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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ (propoxyphene) Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with h/o HTN, HLD, diabetes, moderate aortic stenosis and ___ who presented with dizziness and an episode where he lost consciousness. His story begins last night, when he was eating dinner with his daughter on his way to visit his wife in rehab. On his way, he felt SOB and hot and diaphoretic. When they checked his blood sugar and blood pressure at rehab, they were wnl. He then went home, and sat down on his bed because he felt lightheaded. He remembers his daughter saying she was going to call ___, but the next thing he remembers, he had vomited all over himself and his daughter says his whole body shook for 5 seconds, with his legs going up in the air. He felt fine after this episode, although he has no recollection of the episode itself. During this time, he had no SOB, no CP, nausea, no palpitations. No belly pain aside from a little bit of gas pain. He had been constipated, but no diarrhea. He endorses not drinking much water generally, and preferring coffee and diet coke. He denies incontinence, tongue biting, or a post ictal state. No changes in vision, hearing, sensation, or motor function. No palpitations. After the aforementioned episode, the patient presented to ___, where he had a head CT and a CTA of the chest/abdomen/pelvis. The latter showed a non-occlusive thromboembolic lesion in the proximal SMA. He was started on a heparin drip and the patient was transferred to ___ for treatment for mesenteric ischemia. At ___, troponins were within normal limits, lactate was slightly elevated at 2.3, and glucose was within normal limits. Creatinine was high at 1.3. The patient does endorse baseline SOB with walking, dizziness when he stands up too quickly, and intermittent chest pain (no radiation or associated diaphoresis/SOB) mostly associated with walking that self resolves. No h/o palpitations. No loss of balance. No dysuria, recent illnesses, or sick contacts. No fevers or chills. No h/o seizures. Only previous episode that may have been like this was when he was ~___ and was digging for clams, and forgot where he was briefly. He does report "slowing down" in the past few years and reports mild R leg swelling in the setting of a recent Achilles' tendon injury. The patient was transferred to ___ due to concern for SMA thrombus and initially was admitted to the vascular service. The vascular team reviewed the imaging and felt that the presentation may have been more consistent with SMA dissection. They recommended keeping the patient NPO and keeping heparin gtt. The patient was transferred to the medicine service for further workup of syncope. Past Medical History: -HTN - treated with enalapril and atenolol -HLD - treated with simvastatin -Hypothyroidism s/p follicular carcinoma of the thyroid - on levothyroxine -BPH - treated with tamsulosin -BCC nose and forehead s/p resection -SCC forehead s/p resection and rads -___ - not treated -Type 2 diabetes - on metformin -Mild to moderate aortic valve stenosis - seen on ___ echo. EF 65% -Aortic root enlargement at 4.3 cm and ascending aortic aneurysm at 3.9 cm - seen on ___ echo -Iron deficiency anemia. Baseline Hgb ___ per PCP notes Social ___: ___ Family History: Father: died at age ___ from heart attack, diabetes, prostate cancer at age ___ Mother: ___, diabetes Paternal uncle: ___ disease No premature CAD in family members Father's youngest bother with ___ disease Physical Exam: Admission Physical Exam ============================== Vitals: T 97.8-98.0, BP 103-110/50-53, HR 72-80, RR 18, 100% on RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI NECK: Supple without LAD, mildly elevated JVD PULM: CTABL no wheezes, rales, rhonchi COR: RRR, ___ holosystolic murmur loudest at the RUSB ABD: Soft, non-tender, non-distended, +BS, no HSM EXTREM: Warm, well-perfused, no ___ edema. + right sided pill rolling tremor NEURO: CN II-XII intact, ___ strength in bilateral extremities, sensation intact bilaterally, cerebellar function wnl. Discharge Physical Exam ============================== Vitals: T 97.4-98.5, BP 119-141/54-64, HR 83-97, 95-97% RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI NECK: Supple without LAD, mildly elevated JVD PULM: CTABL no wheezes, rales, rhonchi COR: RRR, ___ holosystolic murmur loudest at the RUSB ABD: Soft, non-tender, non-distended, +BS, no HSM EXTREM: Warm, well-perfused, no ___ edema. + right sided pill rolling tremor NEURO: CN II-XII grossly intact, motor function grossly intact Pertinent Results: Admission Labs ___ ===================== Coags: ___ PTT-150* ___ CBC: WBC-10.4* RBC-3.59* HGB-11.0* HCT-34.3* MCV-96 MCH-30.6 MCHC-32.1 RDW-12.6 RDWSD-44.3 Diff: NEUTS-88.8* LYMPHS-4.4* MONOS-5.6 EOS-0.5* BASOS-0.2 IM ___ AbsNeut-9.19* AbsLymp-0.46* AbsMono-0.58 AbsEos-0.05 AbsBaso-0.02 BMP: GLUCOSE-192* UREA N-25* CREAT-1.0 SODIUM-135 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16 Lactate: 1.9 VBG: PO2-32* PCO2-40 PH-7.34* TOTAL CO2-23 BASE XS--4 Urinalysis:BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG Discharge Labs ___ ===================== CBC: WBC-8.3 RBC-3.34* Hgb-10.4* Hct-31.0* MCV-93 MCH-31.1 MCHC-33.5 RDW-12.8 RDWSD-43.3 Plt ___ Coags: BLOOD ___ PTT-76.1* ___ BMP: BLOOD Glucose-123* UreaN-8 Creat-0.8 Na-136 K-4.0 Cl-102 HCO3-23 AnGap-15 Calcium-7.7* Phos-2.6* Mg-1.8 Lactate: BLOOD Lactate-1.0 Urine Culture: (Final ___: < 10,000 CFU/mL. Duplex Abd/Pelvis ___: No hemodynamically significant stenosis in either the superior mesenteric artery or celiac artery. There is likely evidence of a prior dissection in the superior mesenteric artery approximately 2-3 cm from the origin of the aorta with demonstration of bidirectional flow. Flow is normal distally to this area and there is no increase in velocity. Echo ___: The left atrial volume index is mildly increased. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = 70 %). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are three aortic valve leaflets. There is severe aortic valve stenosis (valve area <1.0cm2). The aortic valve VTI is 117.9. Mild (1+) aortic regurgitation is seen. Mild to moderate (___) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic stenosis with mild aortic regurgitation. Mild to moderate mitral regurgitation. Normal biventricular cavity size and systolic function. Moderate pulmonary artery systolic hypertension. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Enalapril Maleate 5 mg PO DAILY 4. Simvastatin 20 mg PO QPM 5. Atenolol 50 mg PO DAILY 6. LORazepam 1 mg PO BID:PRN Anxiety 7. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY 8. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___) Weekdays 9. Levothyroxine Sodium 175 mcg PO 2X/WEEK (___) ___ and ___ 10. Tamsulosin 0.4 mg PO DAILY Discharge Medications: 1. Apixaban 10 mg PO BID RX *apixaban [Eliquis] 5 mg ___ tablet(s) by mouth twice a day Disp #*70 Tablet Refills:*0 2. Tamsulosin 0.4 mg PO QHS 3. Aspirin 81 mg PO DAILY 4. Enalapril Maleate 5 mg PO DAILY 5. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY 6. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___) Weekdays 7. Levothyroxine Sodium 175 mcg PO 2X/WEEK (___) ___ and ___ 8. LORazepam 1 mg PO BID:PRN Anxiety 9. Omeprazole 20 mg PO BID 10. Simvastatin 20 mg PO QPM 11. HELD- Atenolol 50 mg PO DAILY This medication was held. Do not restart Atenolol until blood pressure and heart rate is followed up by primary care physician ___: Home Discharge Diagnosis: Primary Diagnoses ================= Orthostatic/vasovagal syncope SMA dissection Secondary Diagnoses ====================== Severe aortic stenosis Hypertension Diabetes ___ Hypothyroidism Benign prostatic hyperplasia Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ? Small thrombus or dissection TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Reference CT torso ___. FINDINGS: Grayscale color and spectral Doppler images were obtained of the mesenteric arteries and veins. The main portal vein is patent with hepatopetal flow. The superior mesenteric vein and splenic vein are both patent with appropriate direction of flow. The celiac artery is patent with a normal waveform and a peak systolic velocity of 97 cm/sec. Evaluation of the superior mesenteric artery demonstrates a visible narrowing proximally with no hemodynamically significant stenosis (maximal velocities of 190-220 cm/sec.). There was likely a dissection at some point approximately 2-3 cm from the origin of the aorta and some bidirectional flow is identified but no increase in velocity. Flow distally to this area is normal. The peak systolic velocity is 220 centimeters/second which is within the normal range. Celiac artery is also normal in appearance and velocity profile. IMPRESSION: No hemodynamically significant stenosis in either the superior mesenteric artery or celiac artery. There is likely evidence of a prior dissection in the superior mesenteric artery approximately 2-3 cm from the origin of the aorta with demonstration of bidirectional flow. Flow is normal distally to this area and there is no increase in velocity. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:01 ___, 10 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, Chest pain Diagnosed with Epigastric pain temperature: 97.5 heartrate: 95.0 resprate: 16.0 o2sat: 98.0 sbp: 132.0 dbp: 69.0 level of pain: 1 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ after you had an episode where you lost consciousness, were shaking, and vomited. You first went to ___, where a CT of your head looked normal but a potential blood clot in the vessels going to your bowel was seen on a CT scan. To treat this, you were transferred to our hospital. When you arrived here, you felt fine, and had no abdominal pain, chest pain, shortness of breath, or lightheadedness. However, your labs did suggest you were dehydrated, so we started you on fluids delivered through your vein. Meanwhile, the vascular surgery team saw you and suggested we start you on a blood thinner delivered through your vein. Because your blood pressure was low initially, we did not give you your blood pressure medications while you were in the hospital. We also got a picture of your heart called an "Echo," which showed that the valve through which blood flows from your heart to your body is severely narrowed. You should follow up with your cardiologist about this. Finally, we got an ultrasound of the vessels in your belly, which showed a small tear in one of the vessels. To avoid a clot forming within this tear, we started you on a blood thinner called XXX.... You should take this medication every day, and follow up with our vascular surgeons in one month about any further testing and whether you need to continue your blood thinners. You should also start taking your aspirin every day. When you go home, you should make sure to stay hydrated. You should also follow up with your primary care doctor and cardiologist. It was a pleasure taking care of you! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Low back pain Major Surgical or Invasive Procedure: Left L4-5 hemilaminectomy with facetectomy & discectomy History of Present Illness: ___ with HIV on HAART who presents with low back pain and left leg pain. Per the patient, he does not chronically have low back pain (however per ED records, does have a h/o of DJD there). He notes that he has had episodes of back pain, but normally doesn't have any at all. This episode started 2 weeks ago with a burning pain in the ___ the low back. It would periodically radiate down the leg in a shooting fashion to the ankle. He also notes numbness in the foot and toes on the left. He thinks lying flat and using motrin sometimes helps. Denies bowel/bladder incontinence, no saddle anesthesia. He does think there is some weakness on the left leg but that it is giveaway weakness ___ pain. Right side if normal as per the patient. Denies any f/c/ns, n/v/d. In the ED, initial vitals were: 98.3 76 140/86 19 100% - Labs were significant for mild anemia hct 39.3 - Imaging revealed: Large eccentric disc bulge posterior to L5 results in effacement of the ventral lateral CSF space and impingement of the exiting L5 nerve root and traversing S1 nerve root on the left. - The patient was given percocet x 4, diazepam 5 mg x 1, 10 mg x 1. Vitals prior to transfer were: 98.0 71 148/83 18 98% RA Upon arrival to the floor, he states back pain is ___ pain and left leg is ___ pain. Admitted to Medicine for trial of conservative management with pain control and steroids. Past Medical History: Glaucoma HIV on HAART Left corneal transplant ___ Social History: ___ Family History: Father's side with diabetes and ___, mother's side with ___ and pancreatic cancer Physical Exam: Admission PE: Vitals: T98.1, BP138/80, HR 71, RR 20, 98/RA General: NAD HEENT: NCAT NECK: supple Heart: RRR, no m/r/g Lungs: ctab, no r/r/w Abdomen: soft, no HSM Genitourinary: no foley Extremities: no c/c/e Neurological: ___ strength in ankle dorsiflexion, ___ plantarflexion. decreased sensation in left ___. RLE and UEs wnl . Discharge PE: Awake, alert, oriented. Appropriately responds to questioning. Decreased sensation in left L5 distribution. ___ strength RLE ___ strength in IP/Q/H in LLE, ___ strength in ___ in LLE. Wound closed with staples, clean/dry/intact with no underlying fluid collection or wound drainage. Pertinent Results: Admission labs: ___ 12:11AM BLOOD WBC-7.2 RBC-4.57* Hgb-13.3* Hct-39.3* MCV-86 MCH-29.1 MCHC-33.8 RDW-15.3 Plt ___ ___ 12:11AM BLOOD Neuts-56.4 ___ Monos-4.0 Eos-3.5 Baso-0.3 ___ 07:40PM BLOOD Glucose-102* UreaN-11 Creat-1.1 Na-143 K-4.0 Cl-105 HCO3-24 AnGap-18 ___ 12:13AM BLOOD ___ PTT-31.7 ___ . >> IMAGING: - MRI L-spine 1. Mild deformity of the left L5 transverse process on axial images suggests a prior fracture. Its chronicity is uncertain as is not included in the field of view of the sagittal STIR images. Please correlate with clinical history and symptoms. 2. Circumscribed oval 6 x 4 x 13 mm cystic appearing structure in the posterior epidural space at L2, abutting the thecal sac without mass effect on the thecal sac, which most likely represents a pseudomeningocele, an arachnoid cyst, or an epidural more 8. A solid lesion is unlikely, but is not completely excluded in the absence of postcontrast images. 3. Multilevel degenerative disease. 4. At L4-5, there is a large disc extrusion with a probable free fragment, compressing the traversing left L5 nerve root, deforming the thecal sac, and crowding the left intrathecal nerve roots. L4-5 neural foramina demonstrate mild to moderate narrowing. 5. Moderate right and moderate to severe left neural foraminal narrowing at L5-S1 with abutment of bilateral exiting L5 nerve roots. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 2. Dolutegravir 50 mg PO DAILY 3. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID to RIGHT eye 4. Vancomycin 25mg/mL Ophth Soln 1 DROP LEFT EYE DAILY 5. ofloxacin 0.3 % ophthalmic DAILY to left eye 6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE TID 7. Psyllium Wafer 1 WAF PO DAILY Discharge Medications: 1. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID to RIGHT eye 2. Dolutegravir 50 mg PO DAILY 3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE TID 5. Psyllium Wafer 1 WAF PO DAILY 6. Vancomycin 25mg/mL Ophth Soln 1 DROP LEFT EYE DAILY 7. ofloxacin 0.3 % ophthalmic DAILY to left eye 8. Acetaminophen 650 mg PO Q8H Take as prescribed. Do not exceed more than 3 grams of Acetaminophen in a 24 hour period. 9. Diazepam 5 mg PO Q6H:PRN spasm Do not drive or drink alcohol while taking this medication. 10. Docusate Sodium 100 mg PO BID 11. Senna 8.6 mg PO BID 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Omeprazole 20 mg PO DAILY ___ discontinue after steroids are stopped unless patient was taking prior to admission. 14. Ondansetron 4 mg IV Q8H:PRN N/V 15. Heparin 5000 UNIT SC TID ___ discontinue once fully ambulatory. 16. Gabapentin 300 mg PO Q8H:PRN Leg pain 17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Do not drive or drink alcohol while taking this medication. 18. Methylprednisolone 4 mg PO DAILY Start Medrol DosePak on discharge per instructions Tapered dose - DOWN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Lower back pain secondary herniated disc 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: Fusion. TECHNIQUE: Two lateral radiographs lumbar spine were acquired intraoperatively for localization purposes. COMPARISON: Lumbar spine MRI from ___. FINDINGS: The first provided radiograph demonstrates localization hardware projecting posterior to the presumed L4 vertebral body. The subsequent radiograph demonstrates localization hardware projecting posterior to the presumed L4 and L5 vertebral bodies with additional retractors present. The vertebral body heights are preserved. There is mild disc space narrowing at L4-5 and L5-S1. There are also small anterior osteophytes at several levels. For additional details, please see the operative report in the ___ medical record. IMPRESSION: As above. Gender: M Race: BLACK/AFRICAN Arrive by WALK IN Chief complaint: Lower back pain Diagnosed with LUMBAR DISC DISPLACEMENT temperature: 98.3 heartrate: 76.0 resprate: 19.0 o2sat: 100.0 sbp: 140.0 dbp: 86.0 level of pain: 10 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you in the hospital. You were admitted with worsening lower back pain. An MRI of your spine showed a herniated disc which is likely causing your pain. You had surgery to remove this disc. Please follow-up at the appointments listed below. Please see the attached list for udpates to your home medications. Please follow these instructions at discharge: - Your dressing may come off on the second day after surgery. - Your incision is closed with staples. You will need staple removal in ___ days. Please keep your incision dry until suture/staple removal. - Do not apply any lotions or creams to the site. - Please avoid swimming for two weeks after suture/staple removal. - 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. ___ try to do too much all at once. - No driving while taking any narcotic or sedating medication. - No contact sports until cleared by your neurosurgeon. Medications - Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. - You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy (___) - showed granulation tissue and thin secretions History of Present Illness: Ms. ___ is a ___ yo F with HTN, DMT2, asthma/COPD not on home oxygen, OSA previously on CPAP, and severe TBM s/p TBP on ___ complicated by persistent severe hypoxemic respiratory failure s/p trach/PEG on ___, now s/p T-tube for cervical tracheal malacia who presented to the ___ today with worsening dyspnea and mucus plugging for the last 3 days. At her IP appointment this AM, she was noted to be dyspneic with RR ___ the ___, and there was concern for mucous plugging. Patient ran out of her Mucomyst today, but feels like these symptoms have been steadily getting worse for last three days. She denies any fevers, chills or change ___ her suction secretions. She denies any sore throat, cough, increased sputum production, chest pain, abdominal pain, changes ___ bowel or bladder habits. Of note, she was recently hospitalized from ___ for COPD exacerbation for which she received steroids and azithromycin. Previous steroid taper per discharge summary: #Prednisone taper schedule: ___: 40mg daily ___ - ___: 30mg daily ___ - ___: 20mg daily ___: 10mg daily ___: return to prednisone 2.5mg daily until directed PCP ___ the ___, initial vitals: 98.6 | 124 | 133/65 | 38 | 94% - Exam notable for: tachypnea - Labs notable for K of 2.6 and WBC of 19.4 - Imaging notable for a CXR with low lung volumes. Bibasilar subsegmental atelectasis with trace right pleural effusion. No definite focal consolidation to suggest pneumonia. - IP was consulted and were able to pass suction catheter down the distal limb and to the carina without difficulty and then up the proximal limb without difficulty. Small amount of mucus aspirated. They recommended unasyn to cover for tracheitis, and admission to medicine. - ___ ___, patient was given 40mEq K @ 250ml/hr and Unasyn 3g. Patient also received Ondansetron 4mg IV, lorazepam 0.5mg, oxycodone 5mg, and Ibuprofin 800mg PO - Vitals prior to transfer: 98.6 | 118 | 151/71 | 16 | 98% RA On the floor, Patient endorses DOE for last three days, associated with a racing heart. She says this feels different than her COPD exacerbation last month ___ that her SOB is worse, and she has had some significant mucus plugging of her T-tub which is frightening for her. Past Medical History: Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on ___, and T-tube placement. HTN Hypercholesterolemia COPD/asthma Moderate obstructive sleep apnea (AHI 29) T2DM GERD RUE DVT ___ Rheumatoid arthritis Restless leg syndrome Depression Polysubstance abuse - Clonazepam, Vicodin, Percocet - s/p inpatient detox Social History: ___ Family History: Mother: Lung cancer, CHF Physical Exam: Admission Exam: ===================== Vital Signs: 98.6 | 144/77 | 113 | 24 | 97 2L General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, but difficult to appreciate. No Lymphadenopathy CV: increased rate, normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Expiratory wheezes diffusely, louded ___ RUL. Crackles at left lower base Abdomen: Soft, non-distended. Some tenderness to deep palpation ___ LUQ. Bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. Discharge Exam: ===================== Vitals: 98.1F BP 124/63 HR 80 RR 20 96% on RA General: NAD. Sitting ___ bed. HEENT: Round face. NC/AT. MMM. Neck: T-tube ___ place. Lungs: Normal respiratory effort. Diffuse scattered rhonchi over bilateral lung fields. CV: RRR with normal S1 + S2. Mildly distant heart sounds. No murmurs, rubs, or gallops. Abdomen: Soft, non-tender, non-distended, normoactive BS. Ext: No ___ edema or erythema. SCDs ___ place. Neuro: A&Ox3. Moves all extremities. Psych: Normal Mood and affect. Pertinent Results: Admission Labs: ================================ ___ 12:00PM BLOOD WBC-19.4*# RBC-4.26 Hgb-11.0* Hct-35.2 MCV-83 MCH-25.8* MCHC-31.3* RDW-15.4 RDWSD-45.9 Plt ___ ___ 12:00PM BLOOD Neuts-77.8* Lymphs-11.5* Monos-9.0 Eos-0.8* Baso-0.3 Im ___ AbsNeut-15.10*# AbsLymp-2.24 AbsMono-1.75* AbsEos-0.16 AbsBaso-0.06 ___ 12:00PM BLOOD Plt ___ ___ 12:00PM BLOOD Glucose-232* UreaN-8 Creat-0.9 Na-138 K-2.6* Cl-96 HCO3-23 AnGap-22* ___ 07:02AM BLOOD ALT-42* AST-39 LD(LDH)-291* AlkPhos-106* TotBili-0.6 ___ 07:02AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 11:21PM BLOOD Calcium-8.0* Phos-3.7 Mg-1.4* ___ 12:00PM BLOOD GreenHd-HOLD ___ 12:00PM BLOOD ___ 12:27PM BLOOD ___ pO2-29* pCO2-46* pH-7.38 calTCO2-28 Base XS-0 Intubat-NOT INTUBA ___ 06:19PM BLOOD K-2.9* Discharge Labs: ================================ ___ 06:19AM BLOOD WBC-12.8* RBC-3.63* Hgb-9.3* Hct-30.3* MCV-84 MCH-25.6* MCHC-30.7* RDW-15.7* RDWSD-47.6* Plt ___ ___ 06:19AM BLOOD Glucose-148* UreaN-19 Creat-0.9 Na-138 K-3.4 Cl-93* HCO3-28 AnGap-20 ___ 06:19AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8 Micro: ================================ ___ 9:06 am SPUTUM Source: Endotracheal. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). ___: Legionella urine Antigen- Negative ___: Urine culture: negative Blood Cultures pending ___ 9:55 am BRONCHIAL WASHINGS GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. RESPIRATORY CULTURE (Final ___: >100,000 CFU/mL Commensal Respiratory Flora. FUNGAL CULTURE (Preliminary): YEAST. OF TWO COLONIAL MORPHOLOGIES. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). RARE GROWTH. Imaging: ======================== CXR ___ Impression: Low lung volumes.Bibasilar subsegmental atelectasis with trace right pleural effusion. No definite focal consolidation to suggest pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. BusPIRone 30 mg PO BID 7. FLUoxetine 80 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. glimepiride 2 mg oral QAM 10. Tiotropium Bromide 1 CAP IH DAILY 11. Diltiazem Extended-Release 360 mg PO DAILY 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Chlorthalidone 12.5 mg PO DAILY 14. CloNIDine 0.2 mg PO Q6H 15. LORazepam 1 mg PO Q8H:PRN Anxiety 16. ARIPiprazole 5 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0 2. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*15 Capsule Refills:*0 3. GuaiFENesin 10 mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL 10 ml by mouth every six (6) hours Refills:*0 4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 5. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB 6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 7. ARIPiprazole 5 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 80 mg PO QPM 10. BusPIRone 30 mg PO BID 11. Chlorthalidone 12.5 mg PO DAILY 12. CloNIDine 0.2 mg PO Q6H 13. Diltiazem Extended-Release 360 mg PO DAILY 14. FLUoxetine 80 mg PO DAILY 15. glimepiride 2 mg oral QAM 16. LORazepam 1 mg PO Q8H:PRN Anxiety 17. Metoprolol Succinate XL 25 mg PO DAILY 18. Omeprazole 40 mg PO DAILY 19. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: #Tracheitis #Shortness of breath Secondary: #Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with shortness of breath with history of tracheobronchoplasty with T tube in place// Pneumonia? TECHNIQUE: Portable upright AP view of the chest COMPARISON: CT trachea ___ and chest radiograph ___ FINDINGS: Tracheostomy tube along with tracheal stent appear to be in standard positions. Patient is rotated. Cardiac silhouette size is moderately enlarged. The mediastinal and hilar contours are grossly unremarkable. Pulmonary vasculature is not engorged. Lung volumes are low with linear atelectasis noted at the lung bases. Minimal blunting of the right costophrenic angle indicates a trace right pleural effusion. No focal consolidation or pneumothorax is seen. No acute osseous abnormalities detected. IMPRESSION: Low lung volumes.Bibasilar subsegmental atelectasis with trace right pleural effusion. No definite focal consolidation to suggest pneumonia. Radiology Report INDICATION: ___ year old woman with TBM and respiratory distress// TBM versus infection TECHNIQUE: Chest PA and lateral COMPARISON: ___ and ___ FINDINGS: Again seen is a region of scarring in the right lateral lower lobe as well as mild adjacent pleural thickening. The lungs are otherwise clear. Heart size is stable. No pneumothorax or pleural effusion visualized. IMPRESSION: No significant change. No new consolidation demonstrated. Radiology Report INDICATION: ___ year old woman with increased work of breathing// Pneumonia; pleural effusion TECHNIQUE: Frontal chest COMPARISON: ___ at 02:07. FINDINGS: No new consolidation pneumothorax or pleural effusion. Heart size is stable. Mild scarring and pleural thickening again noted in the right lateral lower hemithorax. No significant change. IMPRESSION: Stable findings in the thorax. No significant change from the exam done earlier. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Shortness of breath temperature: 98.6 heartrate: 124.0 resprate: 38.0 o2sat: 94.0 sbp: 133.0 dbp: 652.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, Why you were admitted to the hospital: - You came to the hospital with shortness of breath and rapid breathing. What we did why you were here: - Due to your shortness of breath, you spent a brief time ___ the medical ICU before returning to the floor. - You were treated with antibiotics and steroids for possible tracheitis. - You were also given a diuretic (Lasix) to remove fluid and help your breathing. - We managed your diabetes with insulin because the steroids made your blood sugars significantly elevated. What you need to do once you return home: - Please take Augmentin (an antibiotic) until ___. - Please follow-up at your scheduled appointments, especially with your primary care doctor to discuss further management of your diabetes. You should check your blood sugar each morning and call your PCP if it is consistently greater than 250. It was a pleasure taking care of you during this hospitalization. Sincerely, ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ancef / adhesive Attending: ___. Chief Complaint: ___ after kidney transplant Major Surgical or Invasive Procedure: ___: partial Ureteral stent removal (5cm removed) History of Present Illness: ___ h/o ESRD ___ DMII s/p LURT ___ sent to ED for evaluation by transplant nephrologist for outpatient labs demonstrating elevated creatinine and hyperglycemia. Transplant surgery service notified given patient is recent post-op. Regarding patient's post-op course, initially had some decreased UOP on POD1-2 which then improved after changes to patient's immunosuppressive medications and control of blood pressure. The patient was also non-insulin diabetic prior to transplant, but post-op required insulin therapy, thought to be due to her steroid course. Creatinine was 1.9 at time of discharge on POD 5, down to 1.6 on ___ and with lowest reported Cr since txp at 1.24. She had a recent Cr elevation of 2.1. She has also had recent episodes of hyperkalemia with K up to 6.4 on outpatient labs, most recent K 4.7. Patient advised to come to ___ ED from home in ___ after discussion with nephrologist Dr. ___ workup of these lab abnormalities. Patient reports that initially after she was discharged home, she had some decreased appetite, diarrhea and nausea that improved with adjustments in MMF dosing. Per ___ clinic visit note, she was recently admitted at ___ for observation for abnormal labs including ___ with Cr 1.9, K 6.3, glucose 400, Ca ___ - all improved with fluids and insulin. On evaluation in the ED today by Transplant Surgery, patient appears well. She denies any recent symptoms of fevers/chills, malaise/fatigue, lightheadedness/dizziness, nausea/vomiting, abdominal pain. She reports a good appetite, although her weight appears to have decreased from 166 lbs at time of discharge to 152 lbs today. She also reports constipation, last BM 5 days ago, but passing flatus. She reports making large amounts of urine, denies dysuria, hematuria, or changes in frequency. Past Medical History: type 2 diabetes hypertension, end-stage renal disease. . past surgical history: left radiocephalic AV fistula and left forearm loop graft. Peritoneal dialysis catheter Living unrelated kidney transplant ___ Social History: ___ Family History: coronary disease in her mother. father had type 2 diabetes and COPD. Physical Exam: Exam on Admission: Vitals - T 98.0 HR 105 BP 147/69 RR 16 O2 99% RA HEENT: NCAT, EOMI, MMM CV: RRR, no m/r/g Pulm: normal WOB on room air Abd: soft, nontender, nondistended, RLQ transplant incision C/D/I w/ staples still in Ext: WWP, no edema . Exam at Discharge: 24 HR Data (last updated ___ @ 818) Temp: 97.6 (Tm 98.5), BP: 133/69 (112-138/57-75), HR: 85 (74-86), RR: 18 (___), O2 sat: 99% (99-100), O2 delivery: RA Fluid Balance (last updated ___ @ 553) Last 8 hours Total cumulative -1300ml IN: Total 0ml OUT: Total 1300ml, Urine Amt 1300ml Last 24 hours Total cumulative -932ml IN: Total 2123ml, PO Amt 1600ml, IV Amt Infused 523ml OUT: Total 3055ml, Urine Amt 3055ml, Emesis 0ml GENERAL: [x]NAD [x]A/O x 3 CARDIAC: [x]RRR LUNGS: [x]no respiratory distress ABDOMEN: [x]soft [x]Nontender WOUND: [x]CD&I Staples removed EXTREMITIES: [x]abnormal: mild edema b/l Pertinent Results: Labs on Admission: ___ WBC-3.0* RBC-2.97* Hgb-9.1* Hct-27.4* MCV-92 MCH-30.6 MCHC-33.2 RDW-15.8* RDWSD-53.2* Plt ___ PTT-27.5 ___ Glucose-423* UreaN-23* Creat-1.9* Na-132* K-4.6 Cl-99 HCO3-19* AnGap-14 Albumin-3.7 Calcium-10.6* Phos-1.8* Mg-1.3* %HbA1c-7.1* eAG-157* PTH-210* 25VitD-9* tacroFK-10.3 . Labs at Discharge: ___ WBC-2.7* RBC-2.59* Hgb-8.0* Hct-24.5* MCV-95 MCH-30.9 MCHC-32.7 RDW-15.5 RDWSD-54.1* Plt ___ Glucose-184* UreaN-15 Creat-1.6* Na-138 K-5.1 Cl-106 HCO3-18* AnGap-14 Calcium-10.8* Phos-2.3* Mg-1.7 tacroFK-6.9 . ___ 3:10 am URINE Site: CLEAN CATCH **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mycophenolate Mofetil 500 mg PO QID 2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 3. Fluconazole 100 mg PO Q24H 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO QHS:PRN Constipation - First Line 6. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 7. Ciprofloxacin HCl 500 mg PO Q24H 8. Omeprazole 20 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. ValGANCIclovir 450 mg PO DAILY 11. Acetaminophen 650 mg PO Q6H 12. amLODIPine 5 mg PO DAILY 13. Tacrolimus 2 mg PO Q12H 14. Basaglar 5 Units Breakfast Insulin SC Sliding Scale using Novolog Insulin 15. Cinacalcet 60 mg PO DAILY 16. Sodium Bicarbonate 650 mg PO BID 17. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Glargine 6 Units Lunch Insulin SC Sliding Scale using HUM Insulin 3. Senna 8.6 mg PO BID 4. Tacrolimus 2.5 mg PO Q12H 5. Acetaminophen 650 mg PO Q6H Maximum 8 of the 325 mg tablets daily 6. Aspirin 81 mg PO DAILY 7. Cinacalcet 60 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fluconazole 100 mg PO Q24H 10. Mycophenolate Mofetil 500 mg PO QID 11. Omeprazole 20 mg PO DAILY 12. Sodium Bicarbonate 650 mg PO BID Listed as 10 grain 13. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 15. ValGANCIclovir 450 mg PO DAILY 16. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute kidney injury History of kidney transplant Hyperglycemia Retained ureteral stent 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: ___ with recent renal transplant p/w worsening Cr// eval transplant TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Ultrasound from ___ FINDINGS: The right 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. Moderate to severe right hydronephrosis is increased from prior. The tip of the stent is seen within the transplant pelvis and within the bladder. Again seen is a perinephric fluid collection consistent with hematoma superior and medially to the transplant kidney measuring approximately 11.9 x 5.1 x 2.3 cm, previously 4.9 x 1.4 x 5 cm. The resistive index of intrarenal arteries ranges from 0.77 to 0.84, previously 0.77 to 0.78. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 125 centimeters/second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Moderate-to-severe hydronephrosis, increased from prior. A ureteral stent is in place with proximal and distal tip seen within the renal pelvis and within the bladder. 2. Perinephric fluid collection consistent with hematoma measuring up to 11.9 cm, previously 4.9 cm. 3. Elevated resistive indices ranging from 0.77 to 0.84, similar to prior. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. RIGHT INDICATION: ___ year old woman POD ___ from living donor kidney transplant with elevated creatinine and new hydro of transplant kidney// Please assess for continuing evidence of hydro in transplant kidney after placement of Foley catheter TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Renal transplant ultrasound ___ FINDINGS: The right iliac fossa transplant demonstrates moderate hydronephrosis which is slightly decreased compared to prior. A ureteral stent is identified within the renal pelvis and proximal ureter. The bladder is decompressed and the distal tip of the stent and Foley catheter are not well visualized. The renal cortex is of normal thickness and echogenicity, there is no urothelial thickening, and renal sinus fat is normal. A perinephric fluid collection is re-demonstrated measuring 11.3 x 1.2 x 6.9 cm (previously 11.9 x 2.3 x 5.1 cm). The resistive index of intrarenal arteries ranges from 0.70 to 0.78, within the elevated range previously 0.77-0.84. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 137 cm per second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Moderate hydronephrosis is re-demonstrated and slightly decreased compared to prior ultrasound. A ureteral stent is visualized within the renal pelvis, the distal tip is not well-visualized due to the decompressed bladder. 2. Stable perinephric fluid collection. 3. Mildly decreased resistive indices ranging from 0.70-0.78. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Acute kidney failure, unspecified, Acidosis, Kidney transplant status temperature: 98.0 heartrate: 105.0 resprate: 16.0 o2sat: 99.0 sbp: 147.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Please call the transplant clinic at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . Bring your pill box and list of current medications to every clinic visit. . You will have labwork drawn twice weekly as arranged by the transplant clinic, with results to the transplant clinic (Fax ___ . CBC, Chem 10, AST, T Bili, Trough Tacro level, Urinalysis. . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . Please measure and record your urine output in the "hat" and urinal provided until you are instructed by the transplant clinic that you can stop. Bring the record with you to your transplant clinic follow up visits . You may shower. Allow the water to run over your incision and pat area dry. No rubbing, no lotions or powder near the incision. You may leave the incision open to the air. The staples have been removed . No driving if taking narcotic pain medications . Avoid direct sun exposure. Wear protective clothing and a hat, and always wear sunscreen with SPF 30 or higher when you go outdoors. . Drink enough fluids to keep your urine light in color. Your appetite will return with time. Eat small frequent meals, and you may supplement with things like carnation instant breakfast or Ensure. . Check your blood pressure at home. Report consistently elevated values above 160 systolic to the transplant clinic. . Check blood sugars prior to meals as directed. Continue long and short acting insulins per your discharge scales. . Do not increase, decrease, stop or start medications without consultation with the transplant clinic at ___. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. . Consult transplant binder, and there is always someone on call at the transplant clinic with any questions that may arise

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / ciprofloxacin / boceprevir / carbamazepine / clarithromycin / conivaptan / indinavir / itraconazole / ketoconazole / lopinavir / mibefradil / nefazodone / nelfinavir / phenytoin / posaconazole / rifampin / ritonavir / grapefruit / ST ___ Attending: ___. Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: None History of Present Illness: ___ M h/o metastatic melanoma and recent cellulitis, enterobacter bacteremia, and spinal osteomyelitis c/b C diff infection presenting with failure to thrive at home and ongoing diarrhea. The patient has had ongoing failure to thrive that has been gradually worsening since ___ was discharged ___ following a hospitalization for cellulitis/bacteremia and spinal osteomyelitis. It is associated with his back pain which has not changed at all. It was related to his prior long hospitalization and chronic medical issues, outlined below. ___ was apparently discharged home with ___ services despite ___ recommending rehab as no rehab beds became available and the patient reports ___ was "antsy" to go home. ___ elected to go home with services with help from his family. Since returning home, ___ reports that ___ has not been able to get out of bed pretty much at all, and is limited by back pain whenever you tries to move. ___ continues to have diarrhea ___ times daily and usually is incontinent due to inability to get up on his own. The patient's ___ called his ID physician ___ reported that ___ has had ongoing weakness and has remained essentially bedbound since discharge. ___ has had ongoing diarrhea that was identified with acute onset during last hospitalization and got slightly better but is now slightly worse and is related to missing a few doses of po vancomycin. The ___ was unable to provide adequate care for him at home. Dr. ___ bringing the patient into the ED for evaluation of the weakness and rehab placement, which the patient agreed with. In the ED, the patient corroborated the above. ___ reported that the diarrhea has worsened over the past few days and due to his back pain ___ has had difficulty getting to the bedpan in time, leading to multiple accidents at home. ___ reported to the ED that his back pain has not changed in nature and denies any new weakness or neuro deficits. I have personally reviewed his past records and to summarize: The patient has had a long course of metastatic melanoma first diagnosed in ___, s/p chemotherapy, immune therapy, cyberknife, and currently on a study drug through ___. ___ has also had recurrent leg cellulitis, enterobacter bacteremia, and spinal osteomyelitis in the setting of chronic lymphedema. ___ has been on antibiotics as an outpatient and on po vanc for concomitant C. Diff infection. In the ED, The vital signs were stable. Labs were notable for stable pancytopenia, albumin 1.9, chemistry otherwise wnl. CXR was notable for low lung volumes and bibasilar atelectasis without focal consolidation. ___ was given his ertapenem and other home medications as well as 1 L of fluid. Patient was seen by ___ who referenced ___ recommendations from prior admission recommending rehab. Unclear why the patient had returned home. Case management was unable to find a rehab for the patient in the ED so decision was made to admit until placement is confirmed. On the floor, the patient had no new complaints. ___ was quite comfortable at rest but with any movement or lifting his back pain worsens. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Metastatic melanoma s/p chemotherapy, immune therapy, cyberknife, and currently on a study drug through ___ ___. Dx in ___ - RLE lymphedema subsequent to RLE surgical excision of lymph nodes, c/b recurrent cellulitis, most recently admitted ___ for cellulitis complicated by GNR bacteremia. - Recent C. diff infection - Cirrhosis, possibly secondary to NASH, complicated by varicies - DM - HTN - HLD Social History: ___ Family History: No family history of recurrent infections or autoimmune disorders. Physical Exam: PHYSICAL EXAM ON ADMISSION: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert, AOx3, lying flat in bed in NAD. IN visible distress with any movement of his LLE. 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 obese, slightly distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Multiple Telangectasias on his face. RLE w/ significant chronic venous stasis changes and scars from previous ulcerations but no skin breakdowns or evidence of cellulitis. LLE slightly edematous as well with chronic venous stasis changes not as severe as the R. NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, sensation to light touch grossly intact throughout lower extremities. Strength ___ on hip flexoion and knee flexion on the LLE, ___ on the right PSYCH: pleasant, appropriate affect EXAM PRIOR TO DISCHARGE VITALS: 98.0 121 / 64 63 18 96 RA GENERAL: Sleeping, resting comfortably, lying flat in bed GI: Abdomen obese, slightly distended, non-tender to palpation. Bowel sounds present. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs EXT: Bilateral venous stasis changes fairly advanced, no erythema, wrapped Pertinent Results: ADMISSION ___ 02:00AM BLOOD WBC-2.6* RBC-2.70* Hgb-8.6* Hct-26.6* MCV-99* MCH-31.9 MCHC-32.3 RDW-16.8* RDWSD-59.3* Plt ___ ___ 02:00AM BLOOD Glucose-76 UreaN-22* Creat-0.7 Na-137 K-4.7 Cl-106 HCO3-24 AnGap-7* ___ 02:00AM BLOOD ALT-13 AST-40 AlkPhos-148* TotBili-1.1 ___ 02:00AM BLOOD Albumin-1.9* Calcium-7.7* Phos-2.6* Mg-1.7 PRIOR TO DISCHARGE ___ 06:48AM BLOOD WBC-2.8* RBC-2.57* Hgb-8.3* Hct-26.2* MCV-102* MCH-32.3* MCHC-31.7* RDW-17.1* RDWSD-63.7* Plt Ct-83* ___ 06:48AM BLOOD ___ ___ 06:48AM BLOOD Glucose-132* UreaN-19 Creat-0.7 Na-140 K-4.7 Cl-108 HCO3-27 AnGap-5* ___ 06:11AM BLOOD ALT-13 AST-41* LD(LDH)-191 AlkPhos-153* TotBili-0.6 ___ 06:48AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.7 ___ 06:48AM BLOOD CRP-58.6* IMAGING STUDIES MRI L-SPINE 1. Severely limited study due to artifact likely from combination of motion and body habitus. 2. Compression deformities of L2 and L4, likely due to Schmorl's nodes. 3. Moderate spinal canal narrowing at L1-L2 and L3-L4. CXR 1. Right upper extremity PICC tip terminates in the right atrium, approximately 4 cm beyond the cavoatrial junction. Please no redundancy in the PICC in the area of the axilla. 2. Low lung volumes. Bibasilar atelectasis without focal consolidation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Lactulose ___ mL PO BID 3. LOXO-101 Study Med 100 mg PO BID 4. Vancomycin Oral Liquid ___ mg PO QID 5. Nadolol 20 mg PO DAILY 6. Ertapenem Sodium 1 g IV 1X 7. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 3. Gabapentin 600 mg PO QHS 4. Lactulose 30 mL PO TID 5. Nadolol 40 mg PO DAILY 6. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose Every 24 hours for ___ weeks (D1 ___ 7. LOXO-101 Study Med 100 mg PO BID 8. Vancomycin Oral Liquid ___ mg PO QID Take QID for 2 weeks and then transition to BID until 2 weeks after last dose ertapenem Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Osteomyelitis of spine C diff infection Cirrhosis Melanoma on study drug Venous stasis bilateral Morbid obesity Failure to thrive in adult 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 radiograph INDICATION: ___ with osteomyelitis, s/p picc placement for IV abx// eval for picc placement TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior comparisons, most recent from ___ FINDINGS: Right upper extremity PICC tip terminates in the right atrium, approximately 4 cm beyond the cavoatrial junction. Please note redundancy in the PICC in the area of the axilla. Lung volumes are low. Low lung volumes cause resultant bronchovascular crowding and accentuation of the cardiac silhouette. There is patchy bibasilar atelectasis without focal consolidation. IMPRESSION: 1. Right upper extremity PICC tip terminates in the right atrium, approximately 4 cm beyond the cavoatrial junction. Please no redundancy in the PICC in the area of the axilla. 2. Low lung volumes. Bibasilar atelectasis without focal consolidation. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:36 am, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE INDICATION: ___ year old man with known lumbar spinal osteo on long term antibiotics presenting with overall failure to thrive, weakness, and ongoing back pain.// evidence of growing epidural abscess, unstable disc from osteo. evidence of growing epidural abscess, unstable disc from osteo. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. Please note that all images except for the STIR GRE are nondiagnostic. COMPARISON: MRI of the cervical, thoracic and lumbar spine dated ___. FINDINGS: Essentially nondiagnostic exam. There is abnormality at L1-L 2, L3-L4 disc spaces, worrisome for osteomyelitis. Component of compression fractures possible. L1-L2 level abnormality was not definitely seen on MRI ___, although, comparison MRI was also significantly degraded. CT lumbar spine would be helpful in further evaluation. Probably mild central canal narrowing L1-2 level, probably moderate central canal narrowing L3-L4 level. Probable paravertebral edema. Enlarged spleen. Ascites. IMPRESSION: 1. Nondiagnostic exam. 2. Comparison MRI exam is essentially nondiagnostic as well. 3. CT lumbar spine recommended in further evaluation. 4. Abnormal L1-L 2, L3-L4 disc spaces, vertebral bodies, may represent disc space infection. 5. Probably mild L1-L 2, moderate L3-L4 central canal narrowing. RECOMMENDATION(S): CT lumbar spine Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with PICC slightly pulled out// PICC placement? PICC placement? IMPRESSION: The course of the right PICC line is unremarkable, the tip projects over the mid SVC. No complications, no pneumothorax. Lung volumes have decreased. Borderline size of the cardiac silhouette. Radiology Report INDICATION: ___ year old man with PICC, pulled out slightly// PICC placement TECHNIQUE: Portable chest AP COMPARISON: Multiple prior chest radiographs, most recent dated ___. FINDINGS: Low lung volumes, unchanged compared to most recent prior. Unchanged mild pulmonary congestion and mild interstitial edema. Cardiomediastinal silhouette is stable. No pneumothorax or pleural effusion. Right PICC terminates in the mid SVC. IMPRESSION: Right PICC terminates in the mid SVC. No pneumothorax. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Diarrhea, Weakness Diagnosed with Diarrhea, unspecified temperature: 96.0 heartrate: 66.0 resprate: 16.0 o2sat: 98.0 sbp: 114.0 dbp: 47.0 level of pain: 4 level of acuity: 3.0

You were admitted with failure at home after a recent hospital stay for sepsis, osteomyelitis of the spine, and c difficile colitis on the background of your melanoma and cirrhosis history. You were admitted, given some hydration, your usual home medications including antibiotics, and you were provided with nursing care. You improved. You are being discharged to rehab to get stronger so you can go home and take good care of yourself.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Worsening confusion, fluid overload Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old gentleman with history of HFpEF (last LVEF 50% to 55%), atrial fibrillation, and Alzehimer's dementia presenting for altered mental status and volume overload. Per assisted living, patient has been more confused and agitated recently. On routine labs was found to have leukocytosis to 17.1 and concern for volume overload, hence was given additional bumetanide (2 mg qd to 2 mg bid) In the ED, patient was oriented to self only, and was unsure why he was brought in from assisted living. He denied any chest pain, shortness of breath, nausea, vomiting, diarrhea, urinary symptoms. In the ED, initial VS were: 97.0 82 115/48 99% RA Exam notable for: AO x 1 (self), unable to recite days of week backwards, +JVD ~ 9 cm, bibasilar crackles with diffuse/scattered rhonchi. SpO2 intermittently drops to 89%. No focal neurological deficits. Labs showed: WBC 13.4 Hgb 10.4 Plt 114, 67.8% neutrophils Na 144 K 4.0 Cl 109 CO2 21 BUN 30 Cr 1.2 Aniion gap = 14 Troponin 0.05 Lactate 2.1 BNP 8744 U/A w/ 32 WBC, large leuk, neg nitrite Flu A/B negative Imaging showed: - CXR: Probable multifocal pneumonia, pulmonary vascular congestion with severe cardiomegaly. - CT head without contrast: 1. No acute intracranial abnormalities. 2. Hypodensities in the left frontoparietal region, bifrontal lobes, and right temporal lobe likely represent prior infarct. 3. Chronic microangiopathy and age related global atrophy. Patient received: ceftriaxone 1gm, vancomycin 1000 mg, pip/tazo 4.5g, aspirin 324 mg At time of interview patient knows he is in a hospital in ___ but not why he was here and is surprised to hear that he has pneumonia. He denies any fevers, chills, shortness of breath, orthopnea, ___ edema, PND, cough. He notes he is ambulatory with walker at baseline and has not noticed any change in functional status recently although unable to tell me how far he is able to walk. He notes that he lives with friends, and that he is close to his sister ___ who is his HCP. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: - Alzheimer's dementia - Atrial fibrillation, paroxysmal - HFpEF (LVH + EF 55% severe TR and dilated/hypokinetic RV) - Anemia - Glaucoma - Treated latent syphilis (per family report, was treated 2x: one at age ___ in ___, once in his ___ by PCP in ___) - Microhematuria - Incontinence - Venous stasis Social History: Occupation: ___ Living situation: ___, in a memory unit Children: none HCP: ___, sister, ___ Smoking: Remote (2 ppd in ___ and ___, quit in his ___ ETOH: occasional Illicits: none Durable medical equipment: ___ FUNCTIONAL STATUS: ADLs: - Bathing: A - Grooming: A - Dressing: A - Eating: I - Toilet Hygiene: I - Functional Mobility (walking, transfers): with walker IADLs: (I=independent, A=needs assist, D=dependent) - Driving: D - Medication management: D - Food preparation: D - Grocery shopping: D - Cleaning/laundry: D - Finances: D - Telephone: A Family History: Anemias, coronary artery disease, hypertension, colitis, ___ Physical Exam: ========================== ADMISSION PHYSICAL EXAM: ========================== VS: ___ ___ Temp: 98.1 PO BP: 134/65 L Lying HR: 66 RR: 18 O2 sat: 92% O2 delivery: Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, JVD to 5 cm above base of neck at 60 degrees with + hepatojugular reflux HEART: Irregular irregular, prominent S2, ___ holosystolic murmur at ___ LUNGS: Crackles in RUL and bilateral bases without egophony, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, 1+ edema to level of bilateral knees PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused ========================== DISCHARGE PHYSICAL EXAM: ========================== VS: ___ 0802 Temp: 97.9 PO BP: 107/54 HR: 51 RR: 18 O2 sat: 93% O2 delivery: Ra GENERAL: NAD alert to self and hospital NECK: supple, no LAD, enjorged EJ, +TR murmur HEART: Irregular irregular ___ holosystolic murmur ___ LUNGS: bibasilar insp crackles; breathing comfortably on room air without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, soft EXTREMITIES: wwp, no lower extremity edema, right lateral hip with 2cm x 2cm ulceration, no fluctuance or purulence or surrounding erythema, but there is induration NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused Pertinent Results: ============================ LABS ON ADMISSION ============================ ___ 07:05PM BLOOD WBC-13.4*# RBC-3.16* Hgb-10.4* Hct-32.7* MCV-104* MCH-32.9* MCHC-31.8* RDW-15.6* RDWSD-59.3* Plt ___ ___ 07:05PM BLOOD Neuts-67.8 ___ Monos-9.1 Eos-1.8 Baso-0.2 Im ___ AbsNeut-9.07*# AbsLymp-2.77 AbsMono-1.21* AbsEos-0.24 AbsBaso-0.03 ___ 07:22AM BLOOD ___ PTT-29.6 ___ ___ 07:05PM BLOOD Glucose-105* UreaN-30* Creat-1.2 Na-144 K-4.0 Cl-109* HCO3-21* AnGap-14 ___ 07:05PM BLOOD Albumin-3.8 Calcium-9.2 Phos-2.9 Mg-2.4 ___ 07:05PM BLOOD ALT-12 AST-22 AlkPhos-99 TotBili-1.5 ___ 07:05PM BLOOD proBNP-8744* ___ 07:05PM BLOOD cTropnT-0.04* ============================ INTERVAL PERTINENT LABS ============================ ___ 07:05PM BLOOD cTropnT-0.04* ___ 12:10AM BLOOD cTropnT-0.04* ___ 07:22AM BLOOD CK-MB-3 cTropnT-0.04* ___ 07:22AM BLOOD VitB12-369 Folate-10 ============================ LABS ON DISCHARGE ============================ ___ 06:10AM BLOOD Glucose-91 UreaN-27* Creat-1.2 Na-144 K-3.7 Cl-104 HCO3-27 AnGap-13 ___ 06:10AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3 ============================ MICROBIOLOGY ============================ - ___ urine legionella - negative - ___ urine culture - no growth - ___ blood cultures x2 - no growth at time of discharge ___ 7:10 am SEROLOGY/BLOOD RPR w/check for Prozone (Final ___: REACTIVE. Reference Range: Non-Reactive. QUANTITATIVE RPR (Final ___: REACTIVE AT A TITER OF 1:2. Reference Range: Non-Reactive. TREPONEMAL ANTIBODY TEST (Preliminary): SENT TO STATE. ============================ IMAGING ============================ ___ CXR AP upright and lateral views of the chest provided. Severe cardiomegaly is again seen. There is airspace consolidation in the right upper lobe concerning for pneumonia. Additional less confluent areas of opacity in the lower lobes left greater than right may also represent foci of pneumonia. Pulmonary vascular congestion is noted without frank edema. No large effusion or pneumothorax. Mediastinal contour stable. Imaged bony structures are intact. ___ CTH W/O CON 1. No acute intracranial abnormalities. 2. Hypodensities in the left frontoparietal region, bifrontal lobes, and right temporal lobe likely represent prior infarct. 3. Chronic microangiopathy and age related global atrophy ___ ULTRASOUND SOFT TISSUE Transverse and sagittal images were obtained of the superficial tissues of the right posterior thigh. There is induration of the skin and mild subcutaneous fat edema. There are no loculated fluid collection, or masses or nodules seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. AcetaZOLamide 250 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Bumetanide 2 mg PO BID 4. Lactulose 15 mL PO BID 5. Acetaminophen 650 mg PO BID 6. Potassium Chloride 20 mEq PO DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Collagenase Ointment 1 Appl TP DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. AcetaZOLamide 250 mg PO DAILY 3. Bumetanide 2 mg PO BID 4. Collagenase Ointment 1 Appl TP DAILY 5. Lactulose 15 mL PO BID 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Omeprazole 20 mg PO DAILY 8. Potassium Chloride 20 mEq PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis - Community acquired pneumonia Secondary Diagnoses: - Acute on chronic diastolic heart failure - Acute metabolic encephalopathy - Alzheimers dementia - Non healing right thigh ulceration - Serofast state (history of latent syphilis) 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: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with AMS// pt here with AMS, R/o acute ischemia, hemorrhage. non-focal neuro exam 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, 16.5 cm; CTDIvol = 48.7 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: Areas of low-density in the anteromedial bilateral basal frontal lobes, anterior right temporal lobe appear chronic, likely related to posttraumatic encephalomalacia. Chronic infarct left middle frontal gyrus extending into the frontal operculum. Small probably chronic right cerebellar infarct. There is no evidence of acute major vascular territory infarction,hemorrhage,edema, or mass. Mild chronic small vessel ischemic changes. Generalized brain parenchymal atrophy. There is no evidence of fracture. Minimal mucosal thickening is noted in the left maxillary sinus. Mild paranasal sinus disease in the ethmoid sinuses otherwise, the remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormalities. 2. Chronic infarcts right cerebellum, left frontal lobe. Chronic encephalomalacia anterior bilateral frontal and anterior right temporal lobes, likely posttraumatic. 3. Brain parenchymal atrophy. Radiology Report EXAMINATION: US BUTTOCKS, SOFT TISSUE RIGHT INDICATION: ___ year old man with right thigh non healing ulceration// please perform right THIGH u/s at area of ulceration to eval for fluid collection TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the right posterior thigh. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the right posterior thigh. There is induration of the skin and mild subcutaneous fat edema. There are no loculated fluid collection, or masses or nodules seen. IMPRESSION: Induration of the skin and mild subcutaneous fat edema. No focal mass or fluid collection. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with Disorientation, unspecified, Altered mental status, unspecified temperature: 97.0 heartrate: 82.0 resprate: 14.0 o2sat: 99.0 sbp: 115.0 dbp: 48.0 level of pain: 0 level of acuity: 2.0

Dear. Mr. ___, It was a pleasure to be a part of your care team at ___ ___. You were admitted to the hospital with a cough and signs of an infection. You were treated with antibiotics and started to get better. You were able to be discharged home. Please see below for your follow up appointments and medications. Again, it was very nice to meet you, and we wish you the best. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / Cephalosporins Attending: ___. Chief Complaint: Dizziness, confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ y/o man with a PMH of COPD (2.5L home O2), HFpEF, AFib (on warfarin), CKD, and T2DM, recently discharged on ___ after admission for MRSA HCAP, C. difficile colitis, acute on chronic diastolic heart failure, and acute interstitial nephritis treated with prednisone, and recent discharge on ___ for acute CHF exacerbation who presents from ___ clinic to the ED for feeling dizzy during the visit, confused and found to BP of 84/40, HR of 50, and O2 Saturation of 84% on room air. The patient appeared very unsteady, trying to get out of chair. He was taken to the ED. On arrival to the ED his vitals were 0 97.5 74 101/48 24 86% Nasal Cannula. The patient was found to have slightly increased potassium and elevated leukocytosis. The patient improved on Nasal cannula. He was given levofloxacin (cephalosporin allergy) and vancomycin. The patient's potassium was stable for the 24 hrs in the ED. His creatinine was at baseline. Other labs were at baseline. The patient was continued on his home medications except for anti-hypertensives and his diuretics were held. He was found to the evidence of multifocal pneumonia on CT scan. He was given 2 L of NS and tolerated the fluids well. He was admitted to the medicine service. On arrival to the floor the patient's vitals were 97.9 157/59 79 19 100 on 4L. The patient was resting in bed. Able to respond to simple questions. A+O x 2 (name and place). The patient's daughter was at the bedside. Patient unable to perform extensive ROS. REVIEW OF SYSTEMS: Per HPI. Denies chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, rash. Past Medical History: -Moderate-severe obstructive pulmonary disease: Last PFTs ___, FEV1 40% predicted, uses 2.5L O2 at home -? Coronary artery disease: ___ Stress test negative, but frequent atrial irritability. -- MIBI revealed normal myocardial perfusion. -Diastolic congestive heart failure -Recurrent aspiration -Chronic renal insufficiency: baseline creatinine 1.2-1.4 -Diabetes mellitus, type 2 -GERD w/ h/o H.pylori gastritis -Gynecomastia -Hypertension -Dysphagia -Peripheral neuropathy -Dyslipidemia -Right eye blindness ___ eye injury in childhood) -Atrial fibrillation Past Medical History: -Moderate-severe obstructive pulmonary disease: Last PFTs ___, FEV1 40% predicted, uses 2.5L O2 at home -? Coronary artery disease: ___ Stress test negative, but frequent atrial irritability. -- MIBI revealed normal myocardial perfusion. -Diastolic congestive heart failure -Recurrent aspiration -Chronic renal insufficiency: baseline creatinine 1.2-1.4 -Diabetes mellitus, type 2 -GERD w/ h/o H.pylori gastritis -Gynecomastia -Hypertension -Dysphagia -Peripheral neuropathy -Dyslipidemia -Right eye blindness ___ eye injury in childhood) -Atrial fibrillation Social History: ___ Family History: Patient denies pulmonary disease, heart diseases/conditions, diabetes, cancers (though daughter with lung cancer noted in records). Physical Exam: Admission: VITALS: 97.9 157/59 79 19 100 on 4L. GENERAL: Laying in bed, somnelent but arrouses to voice, eyes closed, answers yes/no questions appropriately, in NAD HEENT - NCAT, no conjunctival pallor or scleral icterus, right eye opacified. left pupil round 2 mm, left EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat lying in bed CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. 1+ DP pulses bilaterally PULMONARY: Scattered wheezes posteriorly, decreased BS @ bases, poor expiratory air movement ABDOMEN: NABS, soft, non-tender, non-distended, no organomegaly. GU: foley in place EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing. 1+ edema over anterior shins to knees bilaterally. SKIN: Extensive exam without any lesions or ulcerations visible. NEUROLOGIC: A&Ox2 (self, ___. Follows commands. Moves all extremities to command/spontaneously. Discharge: VS: 98.6 130s-140s/60s ___ 20 100%2L GENERAL: Laying in bed, wide awake, answering most questions appropriately ((improved since admission) HEENT - NCAT, no conjunctival pallor or scleral icterus, right eye opacified. left pupil round 2 mm, left EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP 7-8 cm at 30 degrees CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. 1+ DP pulses bilaterally PULMONARY: Improved wheezing with only mild wheezing throughout. No significant adventitious breath sounds. ABDOMEN: NABS, soft, non-tender, non-distended, no organomegaly. GU: foley in place EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing. 1+ edema over anterior shins to knees bilaterally. SKIN: Extensive exam without any lesions or ulcerations visible. NEUROLOGIC: A&Ox2 (self, ___. Follows commands. Moves all extremities to command/spontaneously. LABS: See below. MICROBIOLOGY: See below. Pertinent Results: Admission: ___ 09:40PM GLUCOSE-212* UREA N-113* CREAT-5.4* SODIUM-138 POTASSIUM-5.2* CHLORIDE-94* TOTAL CO2-31 ANION GAP-18 ___ 09:40PM ALT(SGPT)-41* AST(SGOT)-23 ALK PHOS-108 TOT BILI-0.7 ___ 09:40PM ALBUMIN-3.0* CALCIUM-8.8 PHOSPHATE-4.3 MAGNESIUM-1.8 ___ 09:40PM WBC-21.1* RBC-3.17* HGB-8.0* HCT-25.1* MCV-79* MCH-25.2* MCHC-31.9* RDW-19.0* RDWSD-54.0* ___ 09:40PM NEUTS-82.3* LYMPHS-13.1* MONOS-3.4* EOS-0.0* BASOS-0.1 IM ___ AbsNeut-17.41* AbsLymp-2.76 AbsMono-0.71 AbsEos-0.00* AbsBaso-0.02 ___ 09:40PM PLT COUNT-160 ___ 09:40PM ___ PTT-41.4* ___ ___ 02:45PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 07:05AM ___ O2 FLOW-4 PO2-31* PCO2-60* PH-7.38 TOTAL CO2-37* BASE XS-7 COMMENTS-NASAL ___ ___ 07:05AM O2 SAT-50 ___ 05:45PM URINE HOURS-RANDOM ___ 05:45PM URINE UHOLD-HOLD ___ 05:45PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 05:45PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 ___ 05:45PM URINE HYALINE-1* ___ 05:45PM URINE AMORPH-RARE ___ 04:04PM ___ RATES-/18 O2 FLOW-3 PO2-20* PCO2-54* PH-7.41 TOTAL CO2-35* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-NASAL ___ ___ 04:04PM LACTATE-3.1* K+-5.5* ___ 03:50PM GLUCOSE-265* UREA N-118* CREAT-5.5* SODIUM-139 POTASSIUM-5.6* CHLORIDE-91* TOTAL CO2-27 ANION GAP-27* ___ 03:50PM ALT(SGPT)-63* AST(SGOT)-27 CK(CPK)-38* ALK PHOS-152* TOT BILI-0.9 DIR BILI-0.4* INDIR BIL-0.5 ___ 03:50PM LIPASE-70* ___ 03:50PM CK-MB-3 cTropnT-0.11* ___ ___ 03:50PM ALBUMIN-3.5 CALCIUM-9.5 PHOSPHATE-4.2 MAGNESIUM-1.8 ___ 03:50PM WBC-17.0* RBC-3.92* HGB-9.8* HCT-31.4* MCV-80* MCH-25.0* MCHC-31.2* RDW-18.9* RDWSD-54.2* ___ 03:50PM NEUTS-80.3* LYMPHS-14.2* MONOS-4.7* EOS-0.1* BASOS-0.1 IM ___ AbsNeut-13.67*# AbsLymp-2.42 AbsMono-0.80 AbsEos-0.02* AbsBaso-0.02 ___ 03:50PM PLT COUNT-223 ___ 03:50PM ___ PTT-42.4* ___ Discharge: ___ 07:00AM BLOOD WBC-13.5* RBC-2.95* Hgb-7.3* Hct-23.2* MCV-79* MCH-24.7* MCHC-31.5* RDW-18.6* RDWSD-52.8* Plt ___ ___ 09:40PM BLOOD Neuts-82.3* Lymphs-13.1* Monos-3.4* Eos-0.0* Baso-0.1 Im ___ AbsNeut-17.41* AbsLymp-2.76 AbsMono-0.71 AbsEos-0.00* AbsBaso-0.02 ___ 10:15AM BLOOD ___ PTT-38.7* ___ ___ 07:00AM BLOOD Glucose-147* UreaN-112* Creat-5.3* Na-141 K-5.3* Cl-97 HCO3-29 AnGap-20 ___ 07:00AM BLOOD ALT-31 AST-16 LD(LDH)-190 AlkPhos-110 TotBili-0.5 ___ 07:00AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.7 ___ 07:05AM BLOOD ___ O2 Flow-4 pO2-31* pCO2-60* pH-7.38 calTCO2-37* Base XS-7 Comment-NASAL ___ imaging: CT ABD/PEL W/O CONTRAST IMPRESSION: 1. Partially imaged extensive heterogeneous areas of airspace opacification in both lower lobes, right middle lobe and lingula, concerning for multifocal infection on a background of chronic bronchiectasis and small airways disease. 2. Largest stool burden within the rectum and throughout the colon without evidence of obstruction or inflammatory changes. 3. Severe atherosclerosis. 4. Cholelithiasis. CXR ___: Bibasilar opacities likely in part due to pleural effusions and atelectasis noting that superimposed infection is entirely possible. Nodular opacity projecting over the right lung base for which followup will be necessary and proximally with PA and lateral views if patient is amenable. CXR ___: 1. Compared with the prior radiograph, increased left basilar and mid lung opacification, accompanied by increased pleural fluid. 2. Improved aeration of the right lower lung. 3. Persistent cardiomegaly. CT Head ___: 1. No acute intracranial abnormality. Micro: UCx: negative x1 BCx: pending x2 Sputum culture: pending x1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 2. Amlodipine 5 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Ferrous GLUCONATE 324 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Lovastatin 10 mg oral DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. sevelamer CARBONATE 2400 mg PO TID W/MEALS 9. Tiotropium Bromide 1 CAP IH DAILY 10. Torsemide 20 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Warfarin 3 mg PO DAILY16 13. Ranitidine 150 mg PO DAILY 14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN sob 15. PredniSONE 10 mg PO DAILY Discharge Medications: 1. Linezolid ___ mg PO Q12H Duration: 5 Days RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 3. Ferrous GLUCONATE 324 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lovastatin 10 mg oral DAILY 6. Ranitidine 150 mg PO DAILY 7. sevelamer CARBONATE 2400 mg PO TID W/MEALS 8. Torsemide 20 mg PO EVERY OTHER DAY 9. Warfarin 2 mg PO DAILY16 10. Vitamin D 1000 UNIT PO DAILY 11. Levofloxacin 250 mg PO Q24H Duration: 5 Days 12. Metoprolol Succinate XL 12.5 mg PO DAILY 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN sob 14. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Healthcare associated pneumonia with sepsis, hypoxemia Secondary: Diastolic heart failure without exacerbation, CKD, COPD, recurrent aspiration, CAD, HTN, Afib Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with encephalopathy and AMS on warfarin for Atrial fibrillation. no known Head trauma // ?ICH TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.8 cm; CTDIvol = 47.9 mGy (Head) DLP = 802.7 mGy-cm. 2) Spiral Acquisition 17.7 s, 18.6 cm; CTDIvol = 48.2 mGy (Head) DLP = 896.8 mGy-cm. Total DLP (Head) = 1,700 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and deep white matter hypodensities are nonspecific but likely represent sequela 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. Pthysis bulbi is again noted on the right. IMPRESSION: 1. No acute intracranial abnormality. Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ year old man with COPD, recent admission for CHF exac and MRSA PNA, admitted again for probably pneumonia. Evaluate for progression of airway disease. TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiographs of ___ and ___. Chest CT of ___. FINDINGS: Compared with the prior study, slightly increased opacification of the left mid lung, accompanied by increased size of left pleural effusion. Aeration of the right lower lung has improved. Lungs are persistently hyperinflated. No pneumothorax. Moderate cardiomegaly is unchanged. IMPRESSION: 1. Compared with the prior radiograph, increased left basilar and mid lung opacification, accompanied by increased pleural fluid. 2. Improved aeration of the right lower lung. 3. Persistent cardiomegaly. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Hypoxia Diagnosed with Pneumonia, unspecified organism temperature: 97.5 heartrate: 74.0 resprate: 24.0 o2sat: 86.0 sbp: 101.0 dbp: 48.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, You were admitted to ___ because you became slightly confused, dizzy, and had low blood pressure. When you came in your blood pressure got better when we gave you some IV fluids. You also were found to have a new pneumonia on your chest xray, which is why we discharged you on oral antibiotics, which you will continue to take for five more days. You also had low blood oxygen levels which improved with antibiotics, and will be going home back on your home oxygen. You should call your doctor if you have worsening shortness of breath, fever, confusion, or anything that concerns you. We wish you all the best. Sincerely, Your care team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ACE Inhibitors / eptifibatide / gluten / isosorbide Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: EGD, cardiac cath History of Present Illness: ___ w/ PMH ___, CAD, stable angina, hemorrhoids presented to ___ for chest pain. He had two episodes of usual nonradiating angina pain this AM that resolved with nitro patch and repeated in ___ that resolved with sublingual nitro; then the pain happened again an hour later with diaphoresis which prompted pt to go to ___. At the OSH, EKG found ST depressions in inferior and lateral leads with unremarkable posterior EKG. Additionally, he was hypotensive with SBP in the ___, acute on chronic renal failure with elevated K (5.9), +trop @ 0.31. He was found to be guaiac+ stool and grossly anemic 5.8/20.5, but pt denies frank melena, brbpr, or significant history of GI bleed. Although pt says that his hemorrhoids sometimes bleed with indomethacin. Transfused 1 unit pRBC, CP controlled with 6 mg morphine, and transferred here. Unclear if patient has a hx of liver disease. Patient usually gets care from ___ but was referred to ___ due to ___ having no available space. In the ___ ED, pt's trop elevated, CK-MB flat. And his H/H had not increased from the unit. 2 more units ordered. Albuterol, insulin, and dextrose were given for hyperkalemia. No EKG changes from hyperkalemia. GI paged but has not seen him yet. Past Medical History: CAD s/p stents ___ ___ from contrast Gout Polyarthritis Dupuytren's contracture Social History: ___ Family History: Father: HTN Physical ___: ADMISSION PHYSICAL EXAM: ======================== GENERAL: alert, oriented, NAD, lying comfortably in bed HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, 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 or lesions NEURO: grossly alert and oriented, CNII-XII grossly normal DISCHARGE PHYSICAL EXAM: ======================== VITALS: 97.9PO 128 / 71 93 18 96 Ra GENERAL: alert, oriented, uncomfortable lying in bed flat HEENT: Sclera anicteric, pink conjunctiva, 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, ABD: soft, non-tender, non-distended, normoactive bowel sounds, no rebound tenderness or guarding, no organomegaly EXT: Right hand/digits are swollen, ___ and ___ digits flexed, entire hand tender to palpation but improved since prior exam. Left hand, bilateral knees and ankles improved swelling today, minimal tenderness, allows some passive ROM of knees, ankles, and left hand. All joints non-eryhthematous. Has chronic Dupuytren s contracture and tremor of right hand, ulnar deviation of fingers bilaterally with bony nodules at many PIP and DIP joints. 2+ pulses, no clubbing, cyanosis or pitting edema SKIN: no rashes or lesions NEURO: CNII-XII grossly normal. Moving all extremities spontaneously Pertinent Results: ADMISSION LABS: =============== ___ 02:47AM BLOOD WBC-11.4* RBC-2.62*# Hgb-5.6*# Hct-18.6*# MCV-71*# MCH-21.4*# MCHC-30.1*# RDW-22.0* RDWSD-54.0* Plt ___ ___ 02:47AM BLOOD Neuts-80.4* Lymphs-11.1* Monos-6.0 Eos-0.3* Baso-0.4 NRBC-0.7* Im ___ AbsNeut-9.19* AbsLymp-1.27 AbsMono-0.69 AbsEos-0.03* AbsBaso-0.04 ___ 02:47AM BLOOD ___ PTT-22.6* ___ ___ 02:47AM BLOOD Glucose-110* UreaN-74* Creat-3.7*# Na-137 K-6.4* Cl-101 HCO3-13* AnGap-23* ___ 02:47AM BLOOD CK-MB-9 cTropnT-0.38* ___ 02:47AM BLOOD Albumin-3.4* Calcium-8.4 Phos-5.4* Mg-2.0 ___ 03:06AM BLOOD K-5.8* INTERVAL LABS: =============== ___ 02:47AM BLOOD CK-MB-9 cTropnT-0.38* ___ 10:02AM BLOOD CK-MB-30* cTropnT-0.80* ___ 06:31PM BLOOD CK-MB-27* cTropnT-1.16* ___ 03:05AM BLOOD CK-MB-17* cTropnT-1.12* ___ 04:15PM BLOOD CK-MB-8 cTropnT-1.08* ___ 02:40AM BLOOD CK-MB-1 cTropnT-1.44* ___ 08:20AM BLOOD CK-MB-1 cTropnT-1.13* ___ 05:30PM BLOOD cTropnT-1.07* ___ 05:25AM BLOOD RheuFac-26* ___ CRP-264.9* ___ ESR: 70 DISCHARGE LABS ===============: ___ 05:15AM BLOOD WBC-11.0* RBC-3.17* Hgb-7.7* Hct-24.5* MCV-77* MCH-24.3* MCHC-31.4* RDW-UNABLE TO RDWSD-UNABLE TO Plt ___ ___ 05:15AM BLOOD Plt ___ ___ 05:15AM BLOOD Glucose-138* UreaN-52* Creat-1.8* Na-133* K-4.9 Cl-93* HCO3-23 AnGap-17 ___ 05:15AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2 IMPORTANT MICRO: ================= ___ 8:00 am SEROLOGY/BLOOD **FINAL REPORT ___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). IMPORTANT IMAGING: ================== TTE (___): The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF = 25%) with regional variation as indicated in the bullseye chart. The right ventricular free wall thickness is normal. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. ___ CATH Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is without significant disease. * Left Anterior Descending The LAD is with 70% proximal stent restenosis (?ulceration) followed by mild restenosis beyond. There were serial 50% focal distal lesions. The ___ Diagonal is without significant disease. * Circumflex The Circumflex is tortuous with 50% mid. The ___ Marginal is a branching vessel with patent stent. * Right Coronary Artery The RCA is 100% proximally occluded. There are left-to-right collaterals present. ___ EGD Findings: Esophagus: Normal esophagus. Stomach: Excavated Lesions A single cratered non-bleeding 20 mm ulcer was found in the antrum. Cold forceps biopsies were performed for histology. Duodenum: Protruding Lesions A single 6 mm non-bleeding nodule was found in the second part of the duodenum. Cold forceps biopsies were performed for histology. Impression: Ulcer in the antrum (biopsy) Polyp in the second part of the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum Hand Xray ___ Studies are compromised secondary to patient positioning and technique. Arthritic changes. Mild osteopenia. Knee Xray ___ Joint effusions. Right medial compartment narrowing. Vascular calcification. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Indomethacin Dose is Unknown PO BID 2. Valsartan 80 mg PO DAILY 3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 4. Atorvastatin 20 mg PO QPM 5. OxyCODONE (Immediate Release) Dose is Unknown PO Q8H:PRN Pain - Moderate 6. Aspirin 162 mg PO DAILY 7. Triamterene-HCTZ (37.5/25) 1 CAP PO TID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY Constipation 3. Calcium Carbonate 500 mg PO QID:PRN heartburn, stomach pain 4. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 5. Docusate Sodium 100 mg PO BID 6. HydrALAZINE 25 mg PO TID 7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. PredniSONE 40 mg PO DAILY Duration: 4 Days Last day ___. Sucralfate 1 gm PO QID Duration: 5 Days Last day ___. Aspirin 81 mg PO DAILY 12. Atorvastatin 80 mg PO QPM 13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*12 Tablet Refills:*0 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary ===== Type II NSTEMI Duodenal Polyp Gastric Ulcer Anemia Secondary ========= Polyarthritis New diagnosis of heart failure with reduced 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: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with transaminitis.// r/o cholecystitis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 2 mm. GALLBLADDER: The gallbladder is not distended. There is no pericholecystic fluid. No stones or sludge are identified. The gallbladder wall is mildly edematous and measures up to 5 mm. This finding is somewhat equivocal and could be related to third spacing from fluid overload or underlying liver disease, however in the right clinical setting could suggest cholecystitis. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 9.1 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. No intra extrahepatic biliary dilatation is seen. 2. There are no sonographically specific signs for acute cholecystitis identified. There is mild gallbladder wall edema measuring up to 5 mm. This finding is nonspecific and could be related to third spacing or in the right clinical setting could suggest cholecystitis. Radiology Report INDICATION: Mr ___ is a ___ w/ PMH CKD, CAD, stable angina, hemorrhoids who presented to ___ with chest pain with elevated troponins and NSTEMI on EKG, found to have anemia and was transferred to MICU for hypotension, S/p 3pRBP and now hemodynamically stable. Cards thinks NSTEMI likely ___ demand ischemia from anemia (nothing else to do as inpatient). Patient also found to have ___ on CKD.// Pneumothorax/pneumoperitoneum or pulm edema? TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. Radiology Report EXAMINATION: HAND (PA,LAT AND OBLIQUE) BILATERAL INDICATION: ___ year old man with GIB, NSTEMI, polyarthritis with diffuse joint swelling hands, knees, ankles bilaterally// Effusions? Joint erosions? Effusions? Joint erosions? TECHNIQUE: Frontal, oblique, and lateral view radiographs of both hands FINDINGS: Right hand: The study is compromised secondary to patient positioning. Degenerative changes are seen involving the distal interphalangeal joints of the second and fifth digit. Degenerative changes are seen involving the interphalangeal joint of the first digit. There are minimal degenerative changes involving the first carpometacarpal joint and proximal interphalangeal joints of the third and l possibly fourth digit. The bones are mildly demineralized. There are no soft tissue calcifications. a Right hand: Degenerative changes are seen involving the distal interphalangeal joints of the second and fifth digit, the proximal interphalangeal joints of the second, third and fourth digits as well as the interphalangeal joint of the first digit. There are minimal degenerative changes involving the first carpometacarpal joint. The bones are mildly demineralized. There are no soft tissue calcifications. There may be an erosion adjacent to the proximal interphalangeal joint of the third digit. IMPRESSION: Studies are compromised secondary to patient positioning and technique. Arthritic changes. Mild osteopenia. Radiology Report EXAMINATION: KNEE (2 VIEWS) BILAT INDICATION: ___ year old man with GIB, NSTEMI, polyarthritis with diffuse joint swelling hands, knees, ankles bilaterally// Effusion? joint erosion TECHNIQUE: Frontal, lateral, and sunrise view radiographs of right knee COMPARISON: None FINDINGS: No fracture or dislocation is seen. Moderate sized joint effusions are seen bilaterally. There is normal osseous mineralization. Vascular calcification is evident. There is moderate medial compartment narrowing on the right. IMPRESSION: Joint effusions. Right medial compartment narrowing. Vascular calcification. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal labs, Chest pain Diagnosed with Anemia, unspecified temperature: 98.1 heartrate: 107.0 resprate: 18.0 o2sat: 100.0 sbp: 120.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

Mr. ___, It was a pleasure to take care of you at ___. WHY WAS I HERE? You were admitted to the hospital because you had chest pain and were found to have a very low blood count WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL - You were given blood transfusions to help improve your blood count - You had imaging of your heart which showed that your heart was not pumping that well - You had an upper endoscopy which showed that you had an ulcer and a polyp which may have been the cause of your very low blood count - You had a cardiac catheterization which showed a blockage of one of the arteries around the heart, so a stent was placed and you were started on medications to help keep this artery open. - You had pain and swelling in your joints and were treated with steroids and pain medications. WHAT SHOULD I DO WHEN I GET HOME? 1) Follow up with your Primary Care Doctor and Cardiologist 2) It is very important that you take your aspirin and plavix every day 3) Please do not take indomethacin or any other NSAIDs 4) Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you the best! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Metoclopramide / Bupropion / amlodipine / metoprolol Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: ___ biopsy of cervical spine (___) History of Present Illness: ___ with HTN, CHF, DM2, CAD s/p LAD PCI, ESRD on HD TRSa, seizure disorder, chronic pain, PVD who presents for evaluation of traumatic findings after fall with headstrike. He slid off his toilet last night, struck his head, and lacerated his penis. Was seen at ___, where he had normal NCCT head/cspine. Per OSH records, has been somnolent and "drowsy" since arrival to OSH. Was given TDAP, laceration to dorsal penis was repaired with 3 ethilon sutures, and MRI was obtained. This study was apparently notable for "soft tissue injury with edema around C3, C4" (per call in, MRI disc and report not seen in transfer paperwork). He was transferred here for spine eval. On evaluation at ___, the patient believes he fell because he slipped, and denies that his symptoms were related to antecedent illness. However, he has missed his last 2 dialysis sessions. He reports had been getting progressively swollen, and he has been waking from sleep short of breath. He had nausea and vomiting 2 days ago, which caused him to miss his HD session. In the ED: Initial vital signs were notable for: Yest 11:43 97.9 86 197/97 20 97% RA Past Medical History: CORONARY ARTERY DISEASE: s/p LAD PCI ___ DIASTOLIC CONGESTIVE HEART FAILURE PERIPHERAL VASCULAR DISEASE: s/p toe amputations. DIABETES MELLITUS: Type 1 HYPERTENSION HYPERLIPIDEMIA HEAD TRAUMA SEIZURE DISORDER CHRONIC PAIN DIABETIC RETINOPATHY DIABETIC NEUROPATHY ESRD on HD ANXIETY/DEPRESSION Social History: ___ Family History: Notable for diabetes and CAD Physical Exam: ADMISSION ========= "Constitutional: Comfortable. C-collar in place. Initially, frequently falling asleep during the exam, but then arouses. Head/eyes: NCAT, PERRLA, EOMI. ENT/neck: OP WNL Chest/Resp: Clear to auscultation bilaterally. Cardiovascular: RRR, Normal S1/S2, no murmurs/rubs/gallops. Abdomen: Soft, nondistended. Nontender. Musc/Extr/Back: Extremities are warm and well perfused. There is 2+ pitting edema into the thighs bilaterally, symmetric. Skin: No rash. Warm and dry. Neuro: Speech fluent. Psych: Normal mood. Normal mentation. DISCHARGE ========= GENERAL: Alert and interactive. In no acute distress. NECK: wearing soft collar CARDIAC: RRR, S1+S2, no R/G. ___ systolic murmur throughout precordium LUNGS: CTAB anteriorly, no W/R/C ABDOMEN: non-distended, soft, No rebound or guarding. EXTREMITIES: Warm. Trace ___ edema, LUE fistula with palpable thrill. NEUROLOGIC: AOx3., contractures in b/l hands. Decreased sensation to pinprick and light touch up to hips in ___ and up to shoulder in UE (previously reported to be up to neck, but patient less compliant with exam at that time). ___ strength in b/l upper and lower extremities. Pt was seen ambulating independently in hallway without difficulty on day of discharge. Bicep, brachioradialis, knee reflex 2+, pronator drift negative. Babinski mute. Pertinent Results: ADMISSION ========= ___ 12:55PM BLOOD WBC-4.5 RBC-4.09* Hgb-11.9* Hct-36.7* MCV-90 MCH-29.1 MCHC-32.4 RDW-13.3 RDWSD-43.9 Plt ___ ___ 12:55PM BLOOD Neuts-60.5 ___ Monos-9.7 Eos-7.0 Baso-0.4 Im ___ AbsNeut-2.74 AbsLymp-1.00* AbsMono-0.44 AbsEos-0.32 AbsBaso-0.02 ___ 12:55PM BLOOD Glucose-110* UreaN-32* Creat-3.7* Na-143 K-3.9 Cl-100 HCO3-29 AnGap-14 ___ 12:55PM BLOOD ALT-15 AST-24 CK(CPK)-214 AlkPhos-127 TotBili-0.3 ___ 12:55PM BLOOD CK-MB-10 MB Indx-4.7 cTropnT-0.07* ___ 12:55PM BLOOD Albumin-3.5 ___ 07:22AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.3 ___ 07:01PM BLOOD CRP-4.1 MICRO ===== ___ 4:26 am URINE URINE CULTURE (Preliminary): STAPH AUREUS COAG +. >100,000 CFU/mL. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL. ___ MD (___) REQUESTS SUSCEPTIBLITY TESTING ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Discharge labs: ___ 07:00AM BLOOD WBC-3.5* RBC-4.50* Hgb-13.2* Hct-39.8* MCV-88 MCH-29.3 MCHC-33.2 RDW-13.9 RDWSD-44.9 Plt ___ ___ 07:00AM BLOOD Glucose-322* UreaN-39* Creat-4.0*# Na-133* K-4.5 Cl-89* HCO3-28 AnGap-16 ___ 07:00AM BLOOD hsCRP-1.6 ___ 07:01PM BLOOD CRP-4.1 ___ 07:01PM BLOOD SED RATE- 14 Blood Cx from ___ all remain no growth to date Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 2. Terbinafine 1% Cream 1 Appl TP BID:PRN fungal rash 3. Mupirocin Ointment 2% 1 Appl TP DAILY:PRN infection 4. Gabapentin 600 mg PO TID 5. HydrALAZINE 25 mg PO Q6H 6. ammonium lactate 12 % topical DAILY:PRN 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY 9. Rosuvastatin Calcium 20 mg PO QPM 10. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. urea 40 % topical DAILY:PRN 12. Cyclopentolate 1% 1 DROP BOTH EYES DAILY 13. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp 15. Methadone 15 mg PO TID 16. Clopidogrel 75 mg PO DAILY 17. Sucralfate 1 gm PO TID 18. Omeprazole 20 mg PO BID 19. DULoxetine 40 mg PO DAILY 20. Tamsulosin 0.8 mg PO QHS 21. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN 22. Sumatriptan Succinate 50 mg PO PRN headache 23. Sertraline 200 mg PO DAILY 24. TraZODone 150 mg PO QHS:PRN insomnia 25. Levothyroxine Sodium 112 mcg PO DAILY 26. Vitamin D ___ UNIT PO EVERY OTHER WEEK 27. Movantik (naloxegol) 25 mg oral DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 2. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine [Aspercreme (lidocaine)] 4 % Apply one patch to neck qam Disp #*30 Patch Refills:*0 3. Gabapentin 100 mg PO DAILY RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*14 Capsule Refills:*0 4. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN 6. ammonium lactate 12 % topical DAILY:PRN 7. Cyclopentolate 1% 1 DROP BOTH EYES DAILY 8. DULoxetine 40 mg PO DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. HydrALAZINE 25 mg PO Q6H 11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 12. Levothyroxine Sodium 112 mcg PO DAILY 13. Methadone 15 mg PO TID (no prescription given at discharge) 14. Movantik (naloxegol) 25 mg oral DAILY 15. Mupirocin Ointment 2% 1 Appl TP DAILY:PRN infection 16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp 17. Omeprazole 20 mg PO BID 18. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 19. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY 20. Rosuvastatin Calcium 20 mg PO QPM 21. Sertraline 200 mg PO DAILY 22. Sucralfate 1 gm PO TID 23. Sumatriptan Succinate 50 mg PO PRN headache 24. Tamsulosin 0.8 mg PO QHS 25. Terbinafine 1% Cream 1 Appl TP BID:PRN fungal rash 26. TraZODone 150 mg PO QHS:PRN insomnia 27. urea 40 % topical DAILY:PRN 28. Vitamin D ___ UNIT PO EVERY OTHER WEEK Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis ================== - C3-C4 Discitis/Osteomyelitis Secondary diagnosis ==================== End-stage renal disease on hemodialysis Chronic pain Type 1 diabetes mellitus Hypertension Anxiety Depression 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 chest without intravenous contrast INDICATION: ___ male with fall and head strike. Evaluate thoracic and left anterior ribs for fracture. TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: CTA chest ___ FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The main pulmonary artery is dilated measuring up to 3.3 cm across maximal diameter (2:33), grossly unchanged as compared to CT chest ___. The heart is not enlarged. Coronary arterial calcifications are severe. Aortic root calcifications are mild. There is no pericardial effusion. AXILLA, HILA, AND MEDIASTINUM: There is an enlarged left axillary lymph node measuring 1.5 cm in short axis (02:15), grossly unchanged as compared to ___. There is no mediastinal lymphadenopathy. There is a pericardial recess. No mediastinal mass or hematoma. PLEURAL SPACES: There is a trace right pleural effusion. LUNGS/AIRWAYS: There is dependent atelectasis and subsegmental atelectasis in the bilateral lower lobes. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: The thyroid is unremarkable. ABDOMEN: Patient is status post cholecystectomy. The native kidneys are atrophic. BONES: There are chronic nondisplaced to minimally displaced fractures of the posterior left twelfth rib (301:130), posterior left eleventh rib (301:111), posterolateral left eighth rib (301:76), posterolateral left seventh rib (301:63), lateral left sixth rib (301:64). There are nondisplaced to minimally displaced chronic fractures of the anterolateral right third rib (301:56), anterolateral right fourth rib (301:73), lateral right fifth rib (301:82), and lateral right sixth rib (301:98). There is no acute fracture. There is a sclerotic focus in the lateral aspect of the left fifth rib (301:59), unchanged from ___. There are partially calcified soft tissue foci in the subcutaneous tissues of the anterior abdominal wall which could represent injection granulomas. IMPRESSION: 1. No acute fracture or malalignment. There are multiple chronic bilateral rib fractures, grossly unchanged as compared to CTA chest ___. 2. No acute intrathoracic abnormality. 3. Mildly dilated main pulmonary artery is unchanged as compared to ___, nonspecific in etiology. This can be seen with pulmonary hypertension. 4. Prominent left axial lymph node is unchanged as compared to ___. This is nonspecific in etiology and could be reactive. Radiology Report EXAMINATION: MR ___ SCAN WITH CONTRAST T9412 MR ___ SPINE INDICATION: History: ___ with possible osteomyelitis C3-4IV contrast to be given at radiologist discretion as clinically needed// Osteomyelitis, MRI w/ contrast TECHNIQUE: Sagittal imaging was performed with T1 technique. After administration of 15 mL of Gadoteriodol intravenous contrast, sagittal and axial T1 weighted imaging was performed. COMPARISON: MR cervical spine without contrast from outside hospital dated ___ and CT ___ dated ___ from outside. FINDINGS: Alignment is normal. At C3-C4, there is hyperintense signal at the intervertebral disc and vertebral bodies on postcontrast T1 weighted images, (series 2, image 7) compatible with discitis and osteomyelitis. Additionally, there is enhancement surrounding a previously demonstrated disc protrusion at C3-C4 which contacts the spinal cord better demonstrated on MR cervical spine dated ___. IMPRESSION: 1. At C3-C4 there is evidence of discitis and osteomyelitis. 2. Abnormal peripheral enhancement of a disc bulge at C3-C4 may represent infected disc protrustion, phlegmon or abscess. Radiology Report EXAMINATION: CT guided bone biopsy INDICATION: ___ with hx of DM1, L foot osteo with MRSA in ___, ESRD on HD TRSa found to have C3-C4 cervical vertebraldiscitis/osteomyelitis +/- small epidural phlegmon. Patient was not made NPO, so ate breakfast this am. Will make NPO if you can still perform biopsy today. On vanc/cefepime and plavix// C3-4 biopsy for osteomyelitis COMPARISON: Cervical spine ___ PROCEDURE: CT-guided bone biopsy. OPERATORS: Dr. ___ radiologist performed the Procedure. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table with the head slightly tilted to the left. Limited preprocedure CTscan of the intended biopsy area was performed. Based on the CT findings an appropriate position for the biopsy was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 11 gauge coaxial needle was introduced into the lesion in C3 vertebral body. An 13 gauge core biopsy device was used to obtain two core biopsy specimens, which were sent for pathology. The procedure was tolerated well and there were no immediate post-procedural complications. 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. SEDATION: Moderate sedation was provided by administering divided doses of 2.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 30 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: -Again seen are signs of osteomyelitis with superior and inferior endplates irregularity at the level of C3 and C4. IMPRESSION: Successful C3 vertebral body biopsy with no immediate complication. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with Oth incomplete lesion at C3, init, Oth incomplete lesion at C4, init, Fall on same level, unspecified, initial encounter temperature: 97.9 heartrate: 86.0 resprate: 20.0 o2sat: 97.0 sbp: 197.0 dbp: 97.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you had a fall and imaging showed a possible infection in your spine. WHAT HAPPENED TO ME IN THE HOSPITAL? - We spoke to the radiologists about the imaging of your neck, and they were very concerned for an infection of the bone. - The interventional radiologists performed a bone biopsy. - The infectious disease doctors recommended that ___ leave the hospital without antibiotics at this time. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications as prescribed and follow-up with your appointments (listed below). - It is EXTREMELY important that you follow up with the infectious disease doctors. ___ will discuss the results of your bone biopsy and will determine whether you need antibiotics to treat the possible infection in your neck. - Please return to the hospital IMMEDIATELY if you develop fevers, chills, worsening numbness/loss of sensation/or inability to move your arms or legs, loss of your bowels (bowel incontinence), inability to empty your bladder (urinary retention), as these could be signs of spinal cord damage and would require IMMEDIATE evaluation by the neurosurgeons. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Levofloxacin / gabapentin Attending: ___. Chief Complaint: fall, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female HCV/cirrhosis with encepholopathy, polysubstance abuse, DM2, HTN, cryptococcal meningitis s/p VP shunt in ___ for hydrocephalus presenting with altered mental status and fall this morning. Per patient, she states that she had slip/fall on banana on stairs 3am today. Estimates 5 stairs. Boyfriend ___ found her at bottom of stairs around 3:30, reportedly thought she was not breathing, started chest compressions and patient awoke. Reports dehydration, dry mouth, and headache: x 2 days. Usual headaches are "blinding in right eye," but now different, holocranial, intermittent, worse when upright, like someone hitting head with hammer. Also complains of new chest pain and back pain on left below scapula. This pain started after her fall. The chest pain is L sided and reproducible, directly anterior to back pain. Was initially seen in CHA ED. Hypotensive ___ at ___ for which she received IVFs, saturating well on RA. Labs at ___ signficant for: -Utox: +Cannabinoids -UA: small bili, large blood, 100 protein, neg nit, neg leuk, ___ RBCzs, ___ bacteria, crystals present, ___ coarse granular casts -lactate 2.7 -ammonia 24 -serum tox: +tricyclics -CBC: WBC 20.9 (84.7%PMNs), H/H 13.9/42.2, PLTs 192 -CMP: Na 132, K 6.5, Cl 84, AG 13, CO2 25, BUN 45, Cr 3.1, Alkphos 397, AST 397, bili 0.5 -Trop 4.72 There, noncon head CT showed intact VP shunt from ___ ventricle into soft tissues in posterior neck, bilateral cerebellar hypodensities and mild hypodensity in the pons corresponding to old infarcts, moderate chronic small vessel disease, and no new acute intracranial abnormality, midline shift, or mass effect. EKG at CHA shows NSR, rate 73, normal axis, no ST-T changes concerning for acute MI. Patient was transferred to ___ ED due to patient preference because VP shunt was placed here. In the ED, initial vitals: 98.4 73 ___ 97% 3L NC. Labs in the ED significant for: WBC 16.4, K 5.9, HCO3 21, Cr 2.9, lactate 1.8, Trop 0.54 -->0.52, CK 9173 --> ___, MB 135, MBI 1.5. EKG showed T wave inversion in V1 and V2. Repeat after 3 hours showed widened QRS with RBBB morphology, RSR' in AVR concerning for tricyclic toxicity (patient's UTox positive for tricyclics at ___. 50meq bicarb challenge was given for possible TCA poisoning and QRS narrowed. Was seen by cardiology and neurosurgery in the ED. Neurosurgery tapped VP shunt and noted exposed suture at scalp, may have small stitch abscess. On arrival to the MICU, Alert and orientedx3. complaining of headache and back pain. Past Medical History: polysubstance abuse - recent ED visit w heroin OD diabetes type 2 hypertension hepatitis C (s/p treatment with SVR in ___ s/p CCY meniscal tear of knee OSA on CPAP (not very compliant) COPD (though not on PFTs here in the past) chronic, severe migraines - prev on topamax, dilaudid, seeing pain clinic Cirrhosis (NASH vs HCV vs alcohol) - Liver biopsy from ___: diffuse steatosis, grade 2 inflammation and stage ___ fibrosis Bipolar Affective d/o Chronic vomiting History IVDU - then on methadone -> no longer on methadone maintenance Social History: ___ Family History: Mother: deceased, ___ disease Father: deceased, DM Physical Exam: ADMISSION EXAM Vitals- T:99.1 BP:129/81 P:82 R:17 O2:96 on NC GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, Mild tenderness right occipital area, no apparent hematoma. Dry mucous membranes with white nonadherent plaque on tongue/palate NECK: supple, full ROM LUNGS: Crackles at bases bilaterally CV: Regular rate and rhythm, normal S1 S2, systolic murmur best heard and upper sternal border. 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 MSK: tender below xiphoid and at inferior left costo-sternal junction. NEURO: full strength bilaterally. no astexsis DISCHARGE EXAM Vitals - T 97.7 BP 167-174/60s HR ___ RR 18 98% RA I/O: incontinent GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: Holosytolic murmur, S1/S2, no murmurs, gallops, or rubs. Tenderness to palpation of left chest wall. LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose 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: ___ 04:25PM BLOOD WBC-16.4* RBC-4.59# Hgb-13.3# Hct-41.5# MCV-90 MCH-29.0 MCHC-32.1 RDW-15.2 Plt ___ ___ 04:25PM BLOOD Neuts-88.1* Lymphs-7.5* Monos-4.1 Eos-0.1 Baso-0.1 ___ 04:25PM BLOOD Plt ___ ___ 04:17AM BLOOD ___ PTT-24.6* ___ ___ 04:25PM BLOOD Glucose-120* UreaN-47* Creat-2.9*# Na-137 K-5.9* Cl-98 HCO3-21* AnGap-24 ___ 09:15PM BLOOD ___ ___ 05:55PM BLOOD CK-MB-135* MB Indx-1.5 ___ 05:55PM BLOOD cTropnT-0.54* ___ 04:25PM BLOOD Calcium-8.1* Phos-9.9*# Mg-2.2 ___ 04:17AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:34PM BLOOD Lactate-1.8 ___ 09:36PM BLOOD Glucose-97 Na-135 K-4.8 Cl-96 calHCO3-26 PERTINENT LABS: ___ 07:00AM BLOOD ALT-19 AST-13 CK(CPK)-24* AlkPhos-107* ___ 07:00AM BLOOD PTH-42 DISCHARGE LABS: ___ 08:28AM BLOOD WBC-14.4* RBC-4.23 Hgb-12.6 Hct-37.6 MCV-89 MCH-29.8 MCHC-33.5 RDW-15.4 Plt ___ ___ 08:28AM BLOOD Glucose-101* UreaN-37* Creat-1.7* Na-143 K-4.1 Cl-105 HCO3-21* AnGap-21* ___ 08:28AM BLOOD Calcium-11.1* Phos-4.7* Mg-2.1 IMAGING/DATA: CXR ___: Low lung volumes with streaky bibasilar opacities, likely atelectasis, but infection cannot be completely excluded. ECGStudy Date of ___ 4:01:36 ___ Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing of ___ ST-T wave changes are more diffuse. TRACING #1 IntervalsAxes ___ ___ ECGStudy Date of ___ 11:52:42 AM Sinus rhythm. Prominent voltage in leads I and aVL for left ventricular hypertrophy. There is variation in precordial lead placement as compared with previous tracing of ___. Non-specific inferior ST-T wave changes persist. The Q-T interval has shortened. Otherwise, no diagnostic interim change. IntervalsAxes ___ ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lorazepam 0.5 mg PO BID 2. QUEtiapine Fumarate 25 mg PO QHS 3. Mylanta unknown oral unknown 4. Polyethylene Glycol 17 g PO Frequency is Unknown 5. Sertraline 200 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. TraZODone 50-100 mg PO HS Discharge Medications: 1. Lorazepam 0.25 mg PO BID RX *lorazepam 0.5 mg 0.5 (One half) tablet by mouth twice a day Disp #*7 Tablet Refills:*0 2. TraZODone 25 mg PO HS RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 3. Lidocaine 5% Patch 1 PTCH TD QAM chest wall pain RX *lidocaine [Lidoderm] 5 % (700 mg/patch) 1 patch Daily Disp #*30 Patch Refills:*0 4. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Patch Refills:*0 5. Sertraline 200 mg PO DAILY RX *sertraline 100 mg 2 tablet(s) by mouth Daily Disp #*7 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: Acute kidney injury Secondary diagnoses: Altered Mental Status Rhabdomyolysis Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with HCV, cirrhosis, DM2, HTN, polysubstance abuse presenting with AMS, fall today, leukocytosis, troponin elevation, new ___. // please evaluate heart size and for consolidation TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ at ___ FINDINGS: Heart size is borderline enlarged though this is likely accentuated due to low lung volumes. The mediastinal contour is unremarkable. There is crowding of the bronchovascular structures, without overt pulmonary edema demonstrated. Streaky opacities are noted in both lung bases. No pleural effusion or pneumothorax is present. A VP shunt catheter is partially imaged, projecting over the right chest. IMPRESSION: Low lung volumes with streaky bibasilar opacities, likely atelectasis, but infection cannot be completely excluded. Radiology Report EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i INDICATION: ___ year old woman with fall, new O2 requirement, WBC count // eval for pna? free air? COMPARISON: Chest radiographs ___ IMPRESSION: Lung volumes are lower today, reflected in greater atelectasis in the right lower lung. Pulmonary vasculature is minimally congested although heart size is normal and there is no pulmonary edema. I see no evidence of pneumonia. There is no pneumothorax or appreciable pleural effusion. Radiology Report INDICATION: ___ year old woman with fall, reproducible chest pain // eval for fractures TECHNIQUE: AP chest and bilateral ribs, 5 images total. COMPARISON: Chest radiograph from ___. FINDINGS: There is no displaced rib fracture identified. There is minimal left lower lung atelectasis. Note is made of a ventriculoperitoneal shunt catheter. Aortic calcifications are noted. No pneumothorax. IMPRESSION: No displaced rib fracture. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with rhabdo s/p fall, low urine output // Evaluate for obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Abdominal ultrasound dated ___. FINDINGS: The right kidney measures 10.7 cm. The left kidney measures 11.2 cm. There is a benign appearing renal sinus cyst on the left, with some septations. There is no hydronephrosis, stones, or concerning masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The Foley catheter is seen decompressing the bladder. IMPRESSION: 1. No hydronephrosis. 2. Similar benign appearing renal sinus cyst on the left. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, + TROP Diagnosed with RHABDOMYOLYSIS, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 98.4 heartrate: 73.0 resprate: 16.0 o2sat: 97.0 sbp: 111.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to the ___ because you had lost consciousness. You were found to have levels of a certain antidepressant in your blood that required ICU care for a brief period of time. You also developed kidney dysfunction and you had to be monitored closely. Your kidney function improved. If you are having chest wall pain you may take acetaminophen (Tylenol), please do not take more than 3 grams (3,000mg) in one day. You were given prescriptions for a few days' doses of sertraline, trazadone, and lorazepam. You should have your medications adjusted at your follow up appointments. Please follow up with the appointments that have been set up for you below. You will be called for an appointment to evaluate your liver. Please be sure to take all of your medications as they are prescribed. Thank you for allowing us to participate in your care. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___ Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ============= ___ 01:30PM BLOOD WBC-6.4 RBC-3.42* Hgb-8.7* Hct-28.8* MCV-84 MCH-25.4* MCHC-30.2* RDW-16.0* RDWSD-48.0* Plt ___ ___ 01:30PM BLOOD Neuts-52.7 ___ Monos-7.2 Eos-2.5 Baso-0.5 Im ___ AbsNeut-3.39 AbsLymp-2.37 AbsMono-0.46 AbsEos-0.16 AbsBaso-0.03 ___ 01:30PM BLOOD ___ PTT-35.0 ___ ___ 01:30PM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-141 K-3.6 Cl-109* HCO3-22 AnGap-10 ___ 07:04AM BLOOD ALT-12 AST-17 AlkPhos-70 TotBili-0.4 ___ 01:30PM BLOOD proBNP-2527* ___ 07:04AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.2* ___ 01:30PM BLOOD calTIBC-365 Ferritn-17 TRF-281 ___ 01:30PM BLOOD TSH-1.8 RELEVANT IMAGING =================== CXR ___ Moderate pulmonary vascular congestion. Redemonstrated evidence of interstitial lung disease. ABD US ___ No ascites seen in the abdomen. TTE ___ The left atrial volume index is moderately increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative 3D volumetric left ventricular ejection fraction is 60 % (normal 54-73%). Left Ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with a normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is an eccentric, anteriorly directed jet of mild to moderate [___] mitral regurgitation (could be artifact from aortic flow - but less likely). Due to the Coanda effect, 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 moderate pulmonary artery systolic hypertension. The end-diastolic PR velocity is elevated suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular wall thickness and biventricular cavity sizes and regional/global biventricular systolic function. Likely mild-moderate mitral regurgitation with normal valve morphology. Moderate pulmonary artery systolic hypertension. DISCHARGE LABS =============== ___ 05:40AM BLOOD WBC-6.4 RBC-3.81* Hgb-9.6* Hct-31.9* MCV-84 MCH-25.2* MCHC-30.1* RDW-14.9 RDWSD-45.8 Plt ___ ___ 05:40AM BLOOD Plt ___ ___ 05:40AM BLOOD Glucose-107* UreaN-26* Creat-1.1 Na-136 K-4.6 Cl-101 HCO3-24 AnGap-11 ___ 05:40AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Metoprolol Tartrate 100 mg PO BID 5. Sildenafil 20 mg PO TID 6. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) 7. Warfarin 1.5 mg PO 3X/WEEK (___) 8. MetFORMIN XR (Glucophage XR) 500 mg PO BID 9. Spironolactone 100 mg PO DAILY 10. Torsemide 10 mg PO EVERY 3 DAYS 11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 12. Warfarin 2 mg PO 4X/WEEK (___) Discharge Medications: 1. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap IH once a day Disp #*30 Capsule Refills:*0 2. Torsemide 20 mg PO ___ RX *torsemide 20 mg 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*0 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb IH every 6 hours as needed Disp #*1 Vial Refills:*0 4. 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 5. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID RX *fluticasone propion-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1 250-50 IH twice a day Disp #*1 Disk Refills:*0 7. MetFORMIN XR (Glucophage XR) 500 mg PO BID RX *metformin 500 mg 1 inh by mouth twice a day Disp #*60 Tablet Refills:*0 8. Metoprolol Tartrate 100 mg PO BID RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 9. Sildenafil 20 mg PO TID RX *sildenafil (pulm.hypertension) 20 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 10. Spironolactone 100 mg PO DAILY RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. Vitamin D ___ UNIT PO EVERY 4 WEEKS (MO) 12. Warfarin 1.5 mg PO 3X/WEEK (___) RX *warfarin 3 mg 0.5 (One half) tablet(s) by mouth ___, ___ Disp #*3 Tablet Refills:*0 13. Warfarin 2 mg PO 4X/WEEK (___) RX *warfarin 2 mg 1 tablet(s) by mouth ___, ___ Disp #*12 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Acute heart failure exacerbation Interstitial lung disease Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with hx of CAD s/p CABG with postop afib (___), htn, HLD, ILD with moderate pHTN, HFpEF, CVA without residual deficits, SVT, pw dyspnea, +crackles at bases of lungs bilaterally // ?pulm edema, effusion TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Patient is status post median sternotomy. Cardiac silhouette is mild to moderately enlarged. Mediastinal contours are stable. There is moderate pulmonary vascular congestion. Subtle peripheral basilar reticular opacities are seen, likely related to interstitial lung disease, possibly smoking related. No pleural effusion or pneumothorax is seen. IMPRESSION: Moderate pulmonary vascular congestion. Redemonstrated evidence of interstitial lung disease. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old woman with increased DOE, HF exacerbation. // pls evaluate for ascites TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Liver ultrasound ___ FINDINGS: Limited images of the 4 quadrants of the abdomen were obtained. There is no ascites. IMPRESSION: No ascites seen in the abdomen. Radiology Report EXAMINATION: Chest radiographs, PA and lateral. INDICATION: Heart failure exacerbation. COMPARISON: Prior radiographs from ___. FINDINGS: Patient is status post coronary artery bypass graft surgery. Cardiac, mediastinal and hilar contours appear stable. Fine reticulation in each peripheral lower lung is consistent with previously characterized interstitial lung disease. There is no definite superimposed process. No pleural effusion or pneumothorax. Mild S shaped thoracolumbar curvature. IMPRESSION: Findings consistent with underlying interstitial lung disease, as seen previously on CT without any definite superimposed process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Dyspnea, unspecified temperature: 97.5 heartrate: 62.0 resprate: 21.0 o2sat: 97.0 sbp: 150.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were having shortness of breath WHAT HAPPENED IN THE HOSPITAL? ============================== - You were given medicine to help remove the extra fluid in your body - You were given medicine to manage your atrial fibrillation (irregular heart beat) - You were seen by the pulmonology team who recommended that you start a new inhaler WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor, including your PCP on ___ and your pulmonologist. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare 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: Pericardial drain placement History of Present Illness: Mr. ___ is a ___ year old gentleman with history of QT prolongation, CVA, hypertension, diabetes, who presents for large circumferential pericardial effusion without hemodynamic compromise. Per chart review, patient was diagnosed with RML pneumonia in ___ and was treated with levofloxacin. Repeat CXR on ___ showed cardiomegaly and persistent lingual infiltrate which prompted a CT scan. CT chest showed large pericardial effusion. Pt was referred to cardiology clinic. TTE in clinic revealed a very large concentric pericardial effusion, with flow variation across the tricuspid valve (___) but not the mitral valve, with early tamponade physiology and brief, mild diastolic RV wall invagination. IVC with blunted respirophasic response, suggestive of mildly elevated right atrial pressure and tamponade. There was no significant pulsus paradoxus in clinic and his blood pressure was actually elevated. Pt was admitted for a pericardiocentesis which was done ___. 1L straw color fluid removed during the procedure with an opening pressure was 12, down to mean of 0 after fluid was removed. An Echo was done after, which confirmed drain placement. Pericardial fluid was sent to lab for further studies. Patient was admitted to the CCU for further monitoring. On arrival to the CCU, the patient reports that he is doing well. He has a mild amount of pain around the drain site that is tolerable. Otherwise, he has no specific complaints. Does not report fevers, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain, and changes in bowel or bladder habits. Past Medical History: Hypertension Diabetes History of CVA Obstructive sleep apnea Post traumatic stress disorder Social History: ___ Family History: Patient lives alone near ___. At baseline he is independent of all IADLS, although notes that he doesn't cook much since his stroke and eats mostly sandwiches. Never smoker. 1 drink/ year. In past served in ___ and ___ as an ___ and in ___, but notes that he has forgotten his ___ since stroke. Physical Exam: Admission Physical Exam: GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP undetectable at 90 degrees. CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. Pericardial drain in place draining straw-colored fluid, site c/d/i LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, non-tender, obese. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: Bilateral venous stasis changes in the lower extremities. PULSES: Distal pulses palpable and symmetric. Discharge Exam: 98.6 PO 128 / 67 L Sitting 67 18 96 Ra WEIGHT: 94.8 kg WEIGHT ON ADMISSION: 95 kg GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect eccentric, somewhat tangential. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP undetectable at 90 degrees. CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. Bandaging c/d/i LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, non-tender, obese. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: Bilateral venous stasis changes in the lower extremities. PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admission Labs: ============ ___ 06:25PM BLOOD WBC-7.6 RBC-4.86 Hgb-14.1 Hct-41.7 MCV-86 MCH-29.0 MCHC-33.8 RDW-14.6 RDWSD-46.3 Plt ___ ___ 06:25PM BLOOD ___ PTT-30.0 ___ ___ 06:25PM BLOOD Glucose-155* UreaN-23* Creat-1.0 Na-141 K-5.4* Cl-99 HCO3-29 AnGap-13 ___ 08:10AM BLOOD TSH-1.9 ___ 08:10AM BLOOD Free T4-1.1 ___ 06:55PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:55PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 06:55PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 Pericardial fluid analysis/studies: ======================== ___ 03:57PM OTHER BODY FLUID TNC-3442* RBC-876* Polys-0 Lymphs-75* ___ Mesothe-8* Macro-14* Other-3* ___ 03:57PM OTHER BODY FLUID TotProt-5.8 Glucose-148 LD(LDH)-301 Albumin-4.1 ___ 3:57 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ 3:57 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERICARDIAL FLUID. Fluid Culture in Bottles (Preliminary): NO GROWTH. STUDIES ___ CXR Stable position of the pericardial drain. Stable moderate cardiomegaly. No evidence of pneumothorax. No larger pleural effusions. No pulmonary edema. ___ ECHO Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). There is a moderate (50 mmHg peak) resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is systolic anterior motion of the mitral valve leaflets. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion most prominent (1.5cm) inferolateral and lateral to the left ventricle and very mild (<0.5 cm) elsewhere.. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Small to moderate pericardial effusion without echocardiographic evidence for hemodynamic compromise. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Moderate resting LVOT obstruction/gradient. Mildly dilated aortic sinus. Compared with the prior study (images reviewed) of ___, the pericardial effusion is now much smaller. Serial evaluation is suggested. ___ ECHO Pre-tap: Severe pericardial effusion without over signs of pericardial tamponade. Post-tap: Small pericardial effusion after removal of 1 L of pericardial fluid. Normal biventricular global systolic function ___ ECHO Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is borderline pulmonary artery systolic hypertension. There is a small to moderate sized circumferential pericardial effusion. Stranding is visualized within the pericardial space c/w organization. No right atrial or right ventricular diastolic collapse is seen. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of ___, the size of the pericardial effusion is similar in limited views. Respiratory variation in the tricuspid valve inflows are noted (prior echo however did not interrogate this region well for adequate comparison). The right ventricle now appears mildly dilated with mild free wall hypokinesis (previously normal). Discharge Labs: =========== ___ 04:02AM BLOOD WBC-6.9 RBC-4.85 Hgb-14.2 Hct-42.2 MCV-87 MCH-29.3 MCHC-33.6 RDW-14.5 RDWSD-46.4* Plt ___ ___ 04:02AM BLOOD Glucose-182* UreaN-25* Creat-1.0 Na-142 K-3.6 Cl-97 HCO3-30 AnGap-15 ___ 04:02AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 ___ 04:02AM BLOOD RheuFac-PND ___ 04:23AM BLOOD ___ CRP-105.4* ___ 04:02AM BLOOD QUANTIFERON-TB GOLD-PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. sAXagliptin 5 mg oral daily 4. amLODIPine 10 mg PO DAILY 5. Metoprolol Tartrate 100 mg PO BID 6. Chlorthalidone 25 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 8. Sertraline 100 mg PO DAILY 9. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY 10. Loratadine 10 mg PO DAILY 11. Aspirin 325 mg PO DAILY Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 3 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2 Tablet Refills:*0 2. Colchicine 0.6 mg PO BID Duration: 3 Months RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Ibuprofen 200 mg PO TID Duration: 1 Dose RX *ibuprofen [___] 200 mg 1 tablet(s) by mouth three times a day Disp #*45 Tablet Refills:*0 4. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 5. amLODIPine 10 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Chlorthalidone 25 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Loratadine 10 mg PO DAILY 11. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY 12. Metoprolol Tartrate 100 mg PO BID 13. sAXagliptin 5 mg oral daily 14. Sertraline 100 mg PO DAILY 15. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis Pericardial effusion Secondary Diagnosis: Pneumonia Obstructive sleep apnea Hypertension Diabetes Mellitus Difficult Foley Placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: ___ with pericardial effusion// eval for cardiomegaly TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. Cardiac silhouette is markedly enlarged, with a globular morphology. There is evidence of an "Oreo Cookie sign" on the lateral view with fluid noted between the anterior mediastinal fat and the pericardial fat suggesting pericardial effusion. Lungs appear clear. No large effusion or pneumothorax. No signs of edema or pneumonia. Bony structures are intact. IMPRESSION: Markedly enlarged cardiac silhouette with probable pericardial effusion. Radiology Report EXAMINATION: Portable AP chest radiograph. INDICATION: ___ year old man with pericardial effusion s/p drain placement.// Evaluate for pericardial effusion and drain placement. TECHNIQUE: AP chest x-ray COMPARISON: Prior chest radiograph ___. FINDINGS: There has been interval placement of a pericardial drain, with interval increase in opacification of the left lower lobe and obscuration of the left heart border. This may represent atelectasis of the left lower lobe, or a local increase in the pericardial or a new pleural effusion. The right sided aspect of the pericardial effusion is markedly improved. No pneumothorax, no pulmonary edema. The mediastinal contour is stable. No fracture or concerning bone findings. IMPRESSION: Interval opacification of the left lower lung, which may be due to atelectasis, a new pleural effusion or a localized increase in the pericardial effusion. No pneumothorax, no pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with pericardial drain// interval eval interval eval IMPRESSION: Stable position of the pericardial drain. Stable moderate cardiomegaly. No evidence of pneumothorax. No larger pleural effusions. No pulmonary edema. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal echo Diagnosed with Pericardial effusion (noninflammatory) temperature: 98.8 heartrate: 103.0 resprate: 18.0 o2sat: 96.0 sbp: 193.0 dbp: 98.0 level of pain: 0 level of acuity: 2.0

====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - There was fluid around your heart What was done for me in the hospital? - The fluid around your heart was drained. - We treated you with antibiotics for an infection in your lungs. - You were evaluated by physical therapy and occupational therapy, and they determined that you are safe to go home with ___ home services. What should I do when I leave the hospital? - Please take all of your medicines and attend all of your follow-up appointments (appointment information below.) We wish you the best of luck in your health! Sincerely, Your ___ Treatment Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mold Extracts Attending: ___. Chief Complaint: left shoulder pain and left arm numbness Major Surgical or Invasive Procedure: none History of Present Illness: ___ M with asthma, ABPA on itraconazole, chronically elevated CK of unknown etiology, and hx of shoulder impingement who presents with left shoulder pain and left arm numbness. He was in his usual state of good health until 530PM on the day of presentation, when he was watching TV and developed a sharp pinching sensation at the left AC joint. Over the next two hours, the pain spread to involve the supraclavicular region and left lateral chest, and was worse with deep inspiration. He also noted numbness and heaviness of the left arm. He also felt cold. He felt that he was mentating normally, and had no visual changes, other weakness or numbness, HA, or facial droop. No CP or dyspnea. He texted a friend, who recommended he come to the ED to r/o stroke. In the ED intial vitals were: ___ 151/81 18 98% ra. Labs significant for CBC ___, ALT 77, AST 97, AP 82, Tbili 0.4, Alb 4.1. Lytes normal with bicarb 21 (gap 11). Trop 0.06 (most recent 0.08 and 0.09 in ___, CRP 2.1. Coags normal. CXR with no acute process. On ROS, he denied trauma to the shoulder or arm. He did lift weights two days prior to presentation, but did not note any pain following his workout. He has had calf pain since 3 days prior to presentation, which started when jumping rope, but no swelling. No recent dyspnea (he endorses about one year of decreased exercise tolerance, but is unsure whether this is due to weakness vs. SOB). Denies fever, cough, sputum production. Past Medical History: - HyperCKemia s/p neuro evaluation and biopsy ___. ?myositis - Chronic troponin and CK elevation s/p negative cardiac evaluation ___ - Allergic bronchopulmonary aspergillosis - Nasal Polyps - Asthma - GERD - Allergic rhinitis - Anxiety - lap bilateral inguinal hernia repair with mesh on ___ Social History: ___ Family History: Father healthy. Patient's mother with hypertension, vertigo, and anxiety. Physical Exam: PHYSICAL EXAM: Vitals 97.5 122/77 R18 95%RA 71.2kg GENERAL: comfortable, well appearing, NAD HEENT: EOMI, PERRL, OP clear. NECK: supple, no LAD, no JVD. No pain on palpation of the c spine. CARDIAC: Regular, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles. +pain on deep inspiration. ABDOMEN: nondistended, +BS, nontender MSK: No deformities or pain on palpation of the AC joint, humerus, clavicle. EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. Strength ___ bilaterally throughout upper extremities. Sensation intact to light touch bilaterally, without extinction. SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 11:00PM BLOOD WBC-13.7*# RBC-4.63 Hgb-15.1 Hct-44.7 MCV-97 MCH-32.6* MCHC-33.7 RDW-12.6 Plt ___ ___ 11:00PM BLOOD Neuts-81.0* Lymphs-9.7* Monos-4.8 Eos-4.4* Baso-0.2 ___ 11:00PM BLOOD Glucose-89 UreaN-17 Creat-0.8 Na-138 K-6.5* Cl-106 HCO3-21* AnGap-18 ___ 11:00PM BLOOD ALT-77* AST-97* AlkPhos-82 TotBili-0.4 ___ 11:00PM BLOOD CK-MB-24* ___ 11:00PM BLOOD Albumin-4.1 ___ 11:00PM BLOOD CRP-2.1 ___ 11:00PM BLOOD D-Dimer-<150 IMAGING: ___. No acute intracranial process. MRI is more sensitive for acute ischemia. 2. Bifrontal cortical atrophy, allowing for the patient's age. 3. Extensive paranasal sinus inflammatory disease, status post sinus surgery, incompletely imaged. ___ CXR: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 2 SPRY NU BID 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 3. azelastine 137 mcg nasal BID 4. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation inhalation BID 5. Itraconazole 300 mg PO Q12H 6. Albuterol Inhaler 2 PUFF IH BID 7. molybdenum (bulk) unknown PO Molybdenum glycinate Daily 8. Probiotic Complex (L.acid-B.bifidum-B.animal-FOS;<br>lactobacillus combo no.6) unknown exact formulary oral daily 9. Aspirin 81 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH BID 2. azelastine 137 mcg nasal BID 3. Fluticasone Propionate NASAL 2 SPRY NU BID 4. Itraconazole 300 mg PO Q12H 5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION BID 6. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation inhalation BID 7. Aspirin 81 mg PO DAILY 8. molybdenum (bulk) 0 1 PO MOLYBDENUM GLYCINATE DAILY as directed 9. Probiotic Complex (L.acid-B.bifidum-B.animal-FOS;<br>lactobacillus combo no.6) 0 1 ORAL DAILY as directed Discharge Disposition: Home Discharge Diagnosis: Left arm numbness Elevated CK Anxiety 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: History: ___ with left arm numbness and b/l nystagmus // r/o ischemic lesion? TECHNIQUE: MDCT data were acquired through the head without intravenous contrast. Images were displayed in multiple planes. DOSE: DLP: 892 mGy-cm CTDI: 54 mGy COMPARISON: Sinus CT ___ FINDINGS: There is no hemorrhage, major vascular territorial infarction, mass, or shift of the normally midline structures. The size and shape of the ventricles and sulci are normal. The differentiation of grey and white matter is preserved. A 7 mm "filling defect " in the left transverse sinus is compatible with an arachnoid granulation. Postsurgical changes to the paranasal sinuses reflect prior uncinectomy, inferior ethmoidectomy and medial antrostomies, and middle turbinectomies. There is extensive mucosal thickening of the bilateral maxillary and ethmoid sinuses, with evidence of chronic osteitis involving the included portion of the maxillary sinus lateral walls. The left sphenoid sinus is completely and the right sphenoid sinus is nearly completely opacified. There are mucus retention cysts in the bilateral frontal sinuses. The visualized mastoid air cells and middle ear cavities are clear. There is no fracture. IMPRESSION: 1. No acute intracranial process. MRI is more sensitive for acute ischemia. 2. Bifrontal cortical atrophy, allowing for the patient's age. 3. Extensive paranasal sinus inflammatory disease, status post sinus surgery, incompletely imaged. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Chest pain, Arm numbness Diagnosed with CHEST PAIN NOS temperature: 99.0 heartrate: 66.0 resprate: 18.0 o2sat: 98.0 sbp: 151.0 dbp: 81.0 level of pain: 8 level of acuity: 2.0

Hello Mr. ___, It was a pleasure taking care you at the ___ ___. You came because of arm pain. In the hospital you received blood tests that ruled out heart, electrolyte or acid-base problems. Furthermore, you received a CT scan of the head which did not show any evidence of a stroke. A chest x-ray also showed no signs of lung infection. This pain is likely due to a self-limited nerve or muscle issue. Please continue seeing your doctors and taking your medications as prescribed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right sided weakness Major Surgical or Invasive Procedure: ___ ___ guided biopsy of L lung lesion History of Present Illness: ___ is a ___ female smoker with no significant past medical history who presents with two week of progressive right side weakness. Patient reports that two weeks ago she started having a pins and needles feeling in her right foot. Then about 7 days ago she was unable to move her right foot. Since that time she has progressed to severe weakness in the RLE. She also reports that over the last two days her right hand has been clenching into a fist. She does not realize this is happening until she looks at her hand. She feels that her hand and arm are a little weak and she has noticed her writing has become worse. Last night, while eating dinner, she noticed she kept dropping her fork. Her son saw her last night and strongly encouraged her to go to the ED for evaluation. She presents today to ___ ED. ___ showed multiple areas of hypodensities, the largest left frontal concerning for underlying lesions. The neurosurgery team was consulted for evaluation. Patient denies vision changes, vomiting, difficulty with speech, or confusion. She does endorse mild headaches, which are normal for her with stress or dehydration. She does not currently have a headache. She also reports an ~30 lb weight loss in the last year, which she attributes to a decrease in appetite. She does have a "smoker's cough" for the last ___ years, which she reports sometimes makes her nauseous. She also reports BUE tremors, which are baseline for many years. Past Medical History: Eczema Social History: ___ Family History: Mother had dementia, with symptoms beginning in her ___, passed away at ___. Father passed away from MI at ___. Three brothers and one sister, who are healthy. Two sons, ___ and ___, healthy. Physical Exam: Admission Exam: =============== PHYSICAL EXAM: O: T: 97.8 BP: 119/75 HR: 102 R 16 O2Sats 95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm EOMs full Neck: Supple. Extrem: RLE cold to touch, palpable pulses. BUE and LLE, 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, to 3-2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Baseline BUE essential tremors. Right downward drift. RUE - delt 3, bicep 4+, tricep 4+, grip 5 LUE - ___ RLE - ___ LLE - ___ Sensation: Intact to light touch. Decreased to pinprick on RLE, feels dull at foot and feels sharper as moves up the leg. Feels sharp pinprick on RUE < LUE. Proprioception intact. Handedness: Right Discharge Exam: =============== Vitals: ___ 0732 Temp: 97.5 PO BP: 130/76 HR: 75 RR: 18 O2 sat: 98% O2 delivery: RA FSBG: 86 GENERAL: NAD, Lying comfortably in bed, fully cooperative with exam. HEENT: AT/NC, MMM NECK: Supple, No LAD CV: RRR, S1/S2, no murmurs PULM: Decreased breath sounds to left lung, mostly LUL, no wheezes, rales, rhonchi, or crackles, breathing comfortably without use of accessory muscles ABD: Abdomen non-distended EXT: wwp, no edema NEURO: AOx3, CN grossly intact, sensation intact to light touch, strength 4+/___ proximal RLE, 3+/5 knee flexion/extension, ___ R foot, sensation intact to light touch. ACCESS: PIV Pertinent Results: IMAGING ======= CT ___ w/o Contrast (___) impression: 1. Multiple brain lesions with edema suggesting metastases. MRI with contrast is recommended for further evaluation. 2. There is mass effect including left frontoparietal sulcal effacement, partial effacement of the left lateral ventricle and approximately 4 mm of left-to-right midline shift. The basilar cisterns appear patent. MR ___ w/o contrast (___) impression: 1. Multiple predominantly left hemispheric ring-enhancing lesions with varying degrees of surrounding vasogenic edema suggestive of metastatic disease, as above. 2. There is mass effect including partial effacement of the left occipital horn and 6 mm left-to-right midline shift. Chest PA & Lat XRay (___) impression: Essentially complete opacification of the left upper lobe. Given that the trachea is shifted toward the right(opposite side), this is worrisome for a space occupying process such as large consolidation and/or mass, with possibly some underlying atelectasis, but the major factor is space-occupying. CT Chest w/Contrast (___) impression: Large 17 cm left mid and upper lobe mass with areas of central necrosis, mediastinal shift towards the right and invasion into the left upper lobe pulmonary artery and bronchi, highly concerning for malignancy with associated lung collapse. Tissue diagnosis is recommended. PET-CT (___) IMPRESSION: 1. 15.3 x 7.5 cm FDG avid left lung necrotic mass involving the left pulmonary artery. Multiple large FDG avid mediastinal nodes and left supraclavicular nodes are consistent with metastasis. 2. Known left lower renal pole hypoattenuating lesion seen on recent CT from ___ demonstrates increased FDG uptake with SUV max of 10.7. Findings again could represent metastasis or primary renal malignancy. Infection is considered less likely. Multiple FDG avid left para-aortic nodes are concerning for metastasis. 3. Two of the known brain lesions are noted with increased peripheral FDG uptake in the left occipital lobe lesion. Left frontal lobe lesion demonstrates possibly faint peripheral increased FDG uptake as well. Both with central necrosis. PATHOLOGY ========= Pleura Biopsy (___) impression: Pleura, biopsy: Lung adenocarcinoma; positive for TTF-1 and Napsin, and negative for p40, PAX-8 and WT-1. MICROBIOLOGY ============ ___ 1:02 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:30 pm URINE Source: Catheter. SPECIMEN NOT PROCESSED DUE TO: Urinalysis had insufficient pyuria (<=10 WBCs/hpf). Please see ___ “UA w/reflex Culture protocol” for more information. If there is a reason why this patient’s urine culture should be run despite the urinalysis findings, and it is within 72 hours from when the specimen was received by the lab, order an “Add-on” urine culture. You will be required to document the reason for overriding the reflex protocol. **NOT PROCESSED** REFLEX URINE CULTURE: ADMISSION LABS ============== ___ 11:31AM BLOOD WBC-7.7 RBC-4.13 Hgb-10.2* Hct-33.1* MCV-80* MCH-24.7* MCHC-30.8* RDW-18.6* RDWSD-54.0* Plt ___ ___ 11:31AM BLOOD Neuts-70.0 Lymphs-18.4* Monos-7.3 Eos-3.5 Baso-0.5 Im ___ AbsNeut-5.36 AbsLymp-1.41 AbsMono-0.56 AbsEos-0.27 AbsBaso-0.04 ___ 11:31AM BLOOD ___ PTT-33.8 ___ ___ 11:31AM BLOOD Glucose-89 UreaN-10 Creat-0.5 Na-129* K-8.6* Cl-94* HCO3-21* AnGap-14 ___ 11:31AM BLOOD ALT-12 AST-52* AlkPhos-140* TotBili-0.4 ___ 11:31AM BLOOD cTropnT-<0.01 ___ 11:31AM BLOOD Albumin-3.6 ___ 01:02PM BLOOD Albumin-3.7 Calcium-9.4 Phos-4.3 Mg-2.2 ___ 01:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 12:12PM BLOOD Lactate-1.9 ___ 01:16PM BLOOD Lactate-1.3 PERTINENT RESULTS ================= ___ 05:40AM BLOOD Trep Ab-NEG ___ 05:40AM BLOOD TSH-0.60 ___ 08:55AM BLOOD Osmolal-284 ___ 05:40AM BLOOD calTIBC-321 VitB12-391 Ferritn-380* TRF-247 ___ 05:40AM BLOOD ALT-28 AST-16 LD(LDH)-709* AlkPhos-104 TotBili-0.3 ___ 08:24AM URINE Hours-RANDOM Creat-57 Na-110 ___ 08:24AM URINE Osmolal-146 DISCHARGE LABS ============== ___ 05:58AM BLOOD WBC-10.3* RBC-4.64 Hgb-11.8 Hct-38.3 MCV-83 MCH-25.4* MCHC-30.8* RDW-24.1* RDWSD-71.4* Plt ___ ___ 05:58AM BLOOD Glucose-111* UreaN-17 Creat-0.5 Na-134* K-4.8 Cl-95* HCO3-25 AnGap-14 ___ 05:58AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.3 Medications on Admission: none Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Dexamethasone 4 mg PO TID Duration: 7 Days Taper: 4mg TID ___ BID ___ 2mg BID ___ onward 3. Famotidine 20 mg PO BID 4. Ramelteon 8 mg PO QPM:PRN insomnia 5. Senna 8.6 mg PO BID 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Metastatic Brain lesions Adenocarcinoma of the lung RLE>RUE paresthesias and weakness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with onset right-sided logic deficits // Intracranial bleed, space-occupying lesion TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is a large hypodense region in the left frontal and parietal lobes with mass effect on the left lateral ventricle, effacement of the left frontoparietal sulci and approximately 4 mm left-to-right midline shift. The left frontoparietal hypodensity is predominantly subcortical with cortical sparing, consistent with vasogenic edema. There is a rounded isointense focus within the high parafalcine left frontal lobe measuring approximately 2.5 cm AP x 2.4 cm TRV x 2.8 cm SI (2:24) as well as a ovoid hyperdense region in the left parietooccipital lobe (2:16), which are suspicious for underlying mass lesions. Additionally, a small ill-defined hypodensity is noted within the right frontal lobe in the region of the gray white interface (2:19). MRI with contrast is recommended for further evaluation, specifically to evaluate for underlying mass lesions/metastatic disease. There is no evidence of hemorrhage, hydrocephalus or infarction. The basilar cisterns are patent. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal. IMPRESSION: 1. Multiple brain lesions with edema suggesting metastases. MRI with contrast is recommended for further evaluation. 2. There is mass effect including left frontoparietal sulcal effacement, partial effacement of the left lateral ventricle and approximately 4 mm of left-to-right midline shift. The basilar cisterns appear patent. RECOMMENDATION(S): MRI brain with gadolinium is recommended to evaluate for underlying mass lesion/metastatic disease. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:41 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD. INDICATION: ___ year old woman with newly found brain mass on CT. // Addendum aspirating/vasogenic or cytotoxic edema. 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: Head CT dated ___. FINDINGS: Multiple ring-enhancing lesions are noted bilaterally with surrounding vasogenic edema suggestive of metastatic disease. The largest of these is centered in the left occipital lobe measuring 5.6 cm AP x 3.3 cm TRV x 3.8 cm SI. The second largest ring enhancing, centrally necrotic lesion is noted in the high left frontoparietal region, which measures 3.7 x 2.3 x 2.9 cm with a 6 mm satellite lesion near its superior margin (6:23). Additional smaller ring-enhancing lesions measure 6 x 6 mm at the left insular gray-white junction (10:98),, 1.0 x 1.0 cm in the left frontal lobe (10:95) and 1.5 x 1.6 cm in the anteroinferior left frontal lobe (10:85), and 5 x 6 mm in the right frontal lobe (10:134). There is mass effect with partial effacement of the left lateral ventricle occipital horn, left parieto-occipital sulcal effacement, and approximately 6 mm of left to right midline shift. The basilar cisterns are patent. Punctate focus of restricted diffusion at the superior aspect of the high left parietal mass likely reflects microvascular compromise (25:302). There is no evidence of acute intracranial hemorrhage or territorial infarction. There is no evidence of hydrocephalus. There is no abnormal enhancement after contrast administration. The orbits and globes appear within normal limits. There are mild ethmoid sinus mucosal inflammatory changes. IMPRESSION: 1. Multiple predominantly left hemispheric ring-enhancing lesions with varying degrees of surrounding vasogenic edema suggestive of metastatic disease, as above. 2. There is mass effect including partial effacement of the left occipital horn and 6 mm left-to-right midline shift. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 8:42 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with c/f metastatic brain disease // rule out lung nodules as primary TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: There is essentially complete opacification of the left upper lobe. Given that the midline structures are not shifted to the left, this is worrisome for a space-occupying process such as large consolidation, mass. Associated loculated pleural effusion would not be excluded. No pleural effusion is seen at the costophrenic angles. The cardiac silhouette is enlarged. IMPRESSION: Essentially complete opacification of the left upper lobe. Given that the trachea is shifted toward the right(opposite side), this is worrisome for a space occupying process such as large consolidation and/or mass, with possibly some underlying atelectasis, but the major factor is space-occupying. Radiology Report EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS INDICATION: ___ year old woman with multiple brain lesions - needs metastatic w/u // ? metastatic disease TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 34.2 cm; CTDIvol = 9.8 mGy (Body) DLP = 335.3 mGy-cm. 2) Spiral Acquisition 5.5 s, 72.2 cm; CTDIvol = 10.8 mGy (Body) DLP = 778.7 mGy-cm. 3) Spiral Acquisition 2.5 s, 33.7 cm; CTDIvol = 9.9 mGy (Body) DLP = 331.5 mGy-cm. 4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 5) Stationary Acquisition 10.8 s, 0.5 cm; CTDIvol = 60.1 mGy (Body) DLP = 30.1 mGy-cm. Total DLP (Body) = 1,477 mGy-cm. COMPARISON: There are no comparison studies listed. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: There are innumerable nonenhancing, multilobulated lesions within the liver. The largest is in segment ___ measuring up to 5.5 cm in diameter. These are most consistent with cysts. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is an ill-defined hypoattenuating lesion at the lower pole of the left kidney measuring 3.0 x 2.5 x 3.5 cm. This could represent a primary or metastatic disease. The kidneys are otherwise of normal and symmetric size with normal nephrogram. There is no perinephric abnormality. GASTROINTESTINAL: A small hiatal hernia. The stomach is otherwise unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder 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: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. There is a hypoattenuating lesion in the lower pole of left kidney which could represent a primary versus metastatic lesion. 2. Multiple hypoattenuating cystic lesions within the liver do not enhance and are most consistent with simple cysts. 3. Please refer dedicated CT chest for further characterization. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with multiple brain lesions - needs metastatic w/u.? Metastatic disease TECHNIQUE: Contiguous axial images were obtained through the chest after intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Chest radiograph dated ___ FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. Mild coronary artery and aortic arch calcifications. Otherwise, the heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy. There is mediastinal lymphadenopathy. A subcarinal lymph node conglomerate measures 5.4 x 2.2 cm (series 302, image 111). Left superior mediastinal lymph node measures 1.8 x 2.8 cm (series 302, image 25). There is shift of the trachea towards the right. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There is a large mass occupying the majority of the left mid to upper hemithorax thorax, which is heterogeneous with areas of low density, which may represent central necrosis and with overall measurements at least 16 x 7.5 x 17 cm. There is collapse and tumor invasion of the lingula and left upper lobe. There is invasion the left upper lobe branches of the pulmonary artery as well as the left upper lobe bronchi. There is bibasilar atelectasis, right greater than left. There are multiple small right pulmonary nodules measuring up to 3 mm (series 302, image 154). BASE OF NECK: The thyroid gland is unremarkable. ABDOMEN: Please refer to separately dictated abdomen and pelvis report for subdiaphragmatic findings. BONES: No suspicious osseous abnormality is seen.? IMPRESSION: Large 17 cm left mid and upper lobe mass with areas of central necrosis, mediastinal shift towards the right and invasion into the left upper lobe pulmonary artery and bronchi, highly concerning for malignancy with associated lung collapse. Tissue diagnosis is recommended. NOTIFICATION: The findings were discussed with ___, NP, by ___, M.D. on the telephone on ___ at 4:10 pm, 20 minutes after discovery of the findings. Radiology Report EXAMINATION: Ultrasound-guided Procedure INDICATION: ___ year old woman with large left lung mass // biopsy required for tissue diagnosis COMPARISON: Prior chest CT from over ___. PROCEDURE: Ultrasound-guided lung 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. 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 right oblique position on the ultrasound scan table. Limited preprocedure ultrasound of the left lung was performed. Based on the ultrasound findings an appropriate position for the biopsy was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under continuous ultrasound guidance, an 18 gauge core biopsy device with a 22 mm throw was used to obtain 3 core biopsy specimens, which were sent for pathology. The procedure was tolerated well and there were no immediate post-procedural complications. SEDATION: None necessary. FINDINGS: Large heterogeneous mass occupying most of the left hemithorax. No evidence of pneumothorax following the procedure. IMPRESSION: Successful ultrasound-guided core biopsy of the left upper lobe mass. RECOMMENDATION(S): Follow-up chest radiograph in 1 hour following the procedure. Order placed in POE. Radiology Report EXAMINATION: Chest radiograph, portable AP upright view. INDICATION: Left upper lobe mass and recent ultrasound-guided biopsy. COMPARISON: Radiographs from ___ and CT dated ___. FINDINGS: No short-term change in a very large left upper lobe mass. No pneumothorax. IMPRESSION: No short-term change in the appearance of the chest. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with metastatic lesions. // ___ year old woman with metastatic lesions. TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: A large left upper lobe mass is unchanged. No consolidation is seen on the right. No pneumothorax or pleural effusion. IMPRESSION: No significant interval change since ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: R Arm numbness, R Weakness Diagnosed with Other specified disorders of brain temperature: 97.8 heartrate: 102.0 resprate: 16.0 o2sat: 95.0 sbp: 119.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were admitted for weakness of the right side of your body with numbness and tingling of your leg WHAT HAPPENED TO ME IN THE HOSPITAL? - We imaged your brain and found brain masses that were biopsied and showed metastatic - We started you on medications and treated the brain masses with radiation - We scheduled follow up with your new primary oncologist whom you will see after rehab (details below) WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! 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: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old healthy man presents with fever, productive cough, and dyspnea on exertion. Symptoms began 5 days ago. Associated vomiting and central chest pain with coughing. Significant anorexia and night sweats. No nasal congestion, sinus pressure, headache, or sore throat. Denies unintentional weight loss, hemoptysis. Traveled to ___ ___ years ago, otherwise no travel outside of country. No h/o incarceration or known TB exposure. HIV negative in ___. No known sick contacts. History of intermittent smoking as a teenager, no smoking currently. No history of asthma. No history of pneumonia in past. In the ED, initial vital signs were 102.3 98 146/85 20 97% RA. Labs notable for WBC 21.4 (81% PMN), lactate 2.7 (improved to 1.0 with 2L fluids), normal chem 7, UA without signs of UTI. CXR showed multifocal consolidating pneumonia. Received levofloxacin 750mg, azithromycin 500mg x1 and 250mg x1, acetaminophen and albuterol/ipratropium nebulizers. He was kept in ED observation overnight, but became tachypneic when walking short distances, so he was admitted. Vitals prior to transfer: 100 82 131/79 16 97%. Upon arrival to the floor, patient is slightly dyspneic, but satting well (99%) on room air. Review of Systems: (+) per HPI (-) per HPI, otherwise denies abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Obesity Social History: ___ Family History: His father died in his ___ with HIV. His mother died at age ___, cardiac arrest, in the hospital from knee surgery. He has had one brother murdered. He has three daughters, one of which had rhabdomyosarcoma resected at age ___ and another who developed chronic lung disease as an infant. No h/o CAD/MI, DM2, other malignancies, or sudden death. Physical Exam: Admission: Vitals- 98.5 154/90 89 16 99% RA General- Alert, oriented, respirations unlabored HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, no LAD Lungs- diffuse crackles posteriorly, occasional rhonchi, occasional expiratory wheeze anteriorly CV- RRR, no M/R/G Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Discharge: Vitals- 98.9 Tm 100 120/60 p75 R16 100RA General- Alert, oriented, respirations unlabored HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, no LAD Lungs- diffuse crackles posteriorly, occasional rhonchi and wheezing CV- RRR, no M/R/G Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: Admission: ___ 10:15PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG ___ 10:15PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 ___ 10:15PM URINE MUCOUS-MOD ___ 09:43PM LACTATE-2.7* ___ 09:15PM GLUCOSE-172* UREA N-10 CREAT-0.9 SODIUM-135 POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-23 ANION GAP-20 ___ 09:15PM estGFR-Using this ___ 09:15PM WBC-20.5*# RBC-4.67 HGB-14.0 HCT-41.9 MCV-90 MCH-30.0 MCHC-33.5 RDW-13.5 ___ 09:15PM NEUTS-85.5* LYMPHS-6.6* MONOS-6.0 EOS-1.5 BASOS-0.3 ___ 09:15PM PLT COUNT-266 Discharge: ___ 06:50AM BLOOD WBC-17.4* RBC-4.12* Hgb-12.2* Hct-37.1* MCV-90 MCH-29.6 MCHC-32.9 RDW-14.0 Plt ___ ___ 06:50AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-140 K-3.9 Cl-103 HCO3-25 AnGap-16 ___ 06:38AM BLOOD Lactate-1.0 CPK ISOENZYMES proBNP ___ 07:49 541 HIV SEROLOGY HIV Ab ___ 07:49 NEGATIVE Micro: ___ 3:30 pm URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: Reported to and read back by ___. ___ ON ___ AT 0550. PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. Clinical correlation and additional testing suggested including culture and detection of serum antibody. ___ 10:15 pm SPUTUM Source: Expectorated. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ URINE URINE CULTURE-NEGATIVE Imaging: Radiology Report CHEST (PA & LAT) Study Date of ___ 8:38 ___ IMPRESSION: Multifocal consolidative opacities concerning for multifocal pneumonia. Followup radiographs after treatment are recommended to ensure resolution of these findings. Radiology Report CHEST (PA & LAT) Study Date of ___ 10:00 AM CHEST, PA and lateral. COMPARISON: ___. Comparison is made with the prior chest x-ray and this shows increased in opacification in both the right upper lobe and the left lung. Costophrenic angles remain sharp. IMPRESSION: Worsening pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 500 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Ibuprofen 400 mg PO Q8H:PRN pain/fever Discharge Medications: 1. Levofloxacin 750 mg PO DAILY Duration: 4 Days RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 2. Calcium Carbonate 500 mg PO DAILY 3. Ibuprofen 400 mg PO Q8H:PRN pain/fever 4. Multivitamins 1 TAB PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN pain or fever RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 6. Guaifenesin ER 600 mg PO Q12H RX *guaifenesin 600 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Shortness of breath. TECHNIQUE: PA and lateral views of the chest. COMPARISON: None. FINDINGS: Heart size is normal. Mediastinal and hilar contours are unremarkable. Pulmonary vascularity is normal. Multifocal consolidative opacities are noted within both upper lobes as well as within the left lower lobe. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Multifocal consolidative opacities concerning for multifocal pneumonia. Followup radiographs after treatment are recommended to ensure resolution of these findings. Radiology Report CLINICAL HISTORY: Pneumonia, evaluate for change. CHEST, PA and lateral. COMPARISON: ___. Comparison is made with the prior chest x-ray and this shows increased in opacification in both the right upper lobe and the left lung. Costophrenic angles remain sharp. IMPRESSION: Worsening pneumonia. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: DYSPNEA Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 102.3 heartrate: 98.0 resprate: 20.0 o2sat: 97.0 sbp: 146.0 dbp: 85.0 level of pain: 10 level of acuity: 3.0

Mr. ___, It was a pleasure taking care of you at ___. You were admitted with a pneumonia and started on antibiotics. You will need to complete a course of antibiotics as prescribed. Recommend an x-ray to make sure it has completely resolved in 6 weeks. Medication changes: Please finish course of Levofloxacin

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Stab wounds Major Surgical or Invasive Procedure: None Skin stitch x3 History of Present Illness: Patient sustained multiple stab wounds and a right upper extremity bite wound during an altercation with his SO. Apparently this is not the first time he has been injuried by this particular individual Past Medical History: none Social History: ___ Family History: NC Physical Exam: T 98.3 P 75 BP 132/74 RR 14 ___ 100RA HEENT: Atraumatic, EOMI, MMM Chest: stab wound in R lateral pec, did not violate fascia. Skin approximated with 3 stitches CV: RRR PULM: CTAB ABD: superfical stab wound, soft, NT, ND, no rebound or guarding EXT: bite wound in R forearm Pertinent Results: ___ 01:20AM BLOOD WBC-14.1* RBC-4.18* Hgb-14.0 Hct-40.2 MCV-96 MCH-33.6* MCHC-35.0 RDW-12.9 Plt ___ CXR ___ IMPRESSION: No evidence of fracture or pneumothorax. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain Do not take more than 4000mg in a single day. Wean as tolerated RX *acetaminophen 325 mg ___ tablet(s) by mouth every ___ hours Disp #*50 Tablet Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Continue for 5 days RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth Three times a day Disp #*15 Tablet Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Do not drive while taking RX *oxycodone 5 mg 1 tablet(s) by mouth Every ___ hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Stab wounds Human bite Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: TRAUMA #3 (PORT CHEST ONLY) INDICATION: Stab wound to the chest. TECHNIQUE: Portable supine chest radiograph COMPARISON: None FINDINGS: The lungs are clear. There is no pleural effusion or pneumothorax. Heart size is enlarged likely secondary to AP projection, supine positioning. No fractures appreciated. As seen on the concurrent outside hospital CT, there is no blunt thoracic injury. IMPRESSION: No evidence of fracture or pneumothorax. Gender: M Race: UNKNOWN Arrive by AMBULANCE Chief complaint: SW Diagnosed with INTRATHORAC INJ NOS-OPEN, ASSAULT-CUTTING INSTR temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

You have three sutures closing your R pectoral wound. Drainage from there is expected, please come back to clinic to have the sutures removed. 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. wound Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the wound 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. *You have sutures, they will be removed at your follow-up appointment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Right pleural thoracentesis History of Present Illness: Ms. ___ is a very pleasant ___ year old female with history of severe TBM, now POD ___ s/p tracheoplasty with mesh, bronchus intermedius and right main-stem bronchus bronchoplasty with mesh, and left main-stem bronchus bronchoplasty with mesh. She tolerated the procedure well and was discharged home on POD8. She reports that she was doing well until three days ago, when she began to have intermittent shortness of breath, which has progressively worsened. She reports air hunger and pleuritic chest tightness today. These symptoms are different from the symptoms she had prior to the procedure. Her chronic dry cough has improved and she reports ther her bilateral pretibial edema is stable. Past Medical History: PAST MEDICAL HISTORY: GERD, migraines, hypothyroidism, nephrolithiasis, asthma, esophageal narrowing, vocal cord dysfunction (R hypomobility, paradoxical motion), hiatal hernia PSH: b/l TKR, R hand surgery, L hand surgery, hysterectomy, ___ tracheoplasty with mesh, bronchus intermedius and right main-stem bronchus bronchoplasty with mesh, and left main-stem bronchus bronchoplasty with mesh Social History: ___ Family History: non contributory - Mother w/ dementia, father w/ MI, offspring: alopecia universalis Physical Exam: AFVSS Gen: AOx3, NAD HEENT: PEERL, EOMI Chest: R chest incision healing well, bandage over thoracentesis site c/d/i CV: RRR no m/r/g Abd: Obest, NT/ND, +BS Extrem: WWP no c/c/e Pertinent Results: ___ 07:40AM BLOOD WBC-10.1 RBC-4.34 Hgb-11.7* Hct-36.8 MCV-85 MCH-26.9* MCHC-31.7 RDW-14.2 Plt ___ ___ 05:45PM BLOOD WBC-12.7* RBC-4.50 Hgb-12.0 Hct-38.2 MCV-85 MCH-26.5* MCHC-31.3 RDW-14.1 Plt ___ ___ 05:45PM BLOOD Neuts-64.6 ___ Monos-5.7 Eos-4.7* Baso-1.4 ___ 07:40AM BLOOD Plt ___ ___ 05:45PM BLOOD Plt ___ ___ 07:40AM BLOOD Glucose-148* UreaN-15 Creat-0.9 Na-141 K-4.2 Cl-103 HCO3-28 AnGap-14 ___ 05:45PM BLOOD Glucose-129* UreaN-15 Creat-1.4* Na-140 K-4.8 Cl-100 HCO3-26 AnGap-19 ___ 12:35AM BLOOD cTropnT-<0.01 ___ 05:45PM BLOOD cTropnT-<0.01 proBNP-33 ___ 07:40AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.1 ___ 06:02PM BLOOD ___ pO2-115* pCO2-39 pH-7.44 calTCO2-27 Base XS-2 ___ 06:02PM BLOOD O2 Sat-98 ___ 5:19 ___ CHEST (PA & LAT) Clip # ___ Reason: eval for pna, effusion, ptx UNDERLYING MEDICAL CONDITION: History: ___ with cough, sob REASON FOR THIS EXAMINATION: eval for pna, effusion, ptx Final Report HISTORY: Cough, shortness of breath. TECHNIQUE: PA and lateral views of the chest. COMPARISON: CT trachea ___. Chest radiographs from ___ through ___. FINDINGS: Low lung volumes are present. The cardiac, mediastinal and hilar contours are unchanged, with the heart size appearing moderately enlarged. There is no pulmonary edema. Atelectatic changes are again seen within both lung bases. There is a persistent small right pleural effusion. No pneumothorax is identified. Small hiatal hernia is better seen on the previous CT. There are mild degenerative changes in the thoracic spine. IMPRESSION: Small right pleural effusion and bibasilar atelectasis. ___ 7:17 ___ BILAT LOWER EXT VEINS Clip # ___ Reason: DVT? UNDERLYING MEDICAL CONDITION: History: ___ with SOB and pleuritic CP REASON FOR THIS EXAMINATION: DVT? CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Shortness of breath and pleuritic chest pain, question DVT. COMPARISON: None available. FINDINGS: There is normal phasicity in the common femoral veins bilaterally. There is normal compression, augmentation and flow in the common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins of the right and left leg. IMPRESSION: No evidence of DVT in the right or left leg. ___ 10:01 ___ CTA CHEST W&W/O C&RECONS, NON- Clip # ___ Reason: PE? Contrast: OMNIPAQUE Amt: 100 UNDERLYING MEDICAL CONDITION: History: ___ with SOB and pleuritic chest tightness REASON FOR THIS EXAMINATION: PE? CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report HISTORY: Shortness-of-breath and pleuritic chest tightness. Question pulmonary embolism. COMPARISON: Prior trachea CT from ___. TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal notch to the upper abdomen in early arterial phase scanning after the administration of Omnipaque IV contrast. Multiplanar reformatted images in coronal, sagittal and oblique axes were generated. FINDINGS: CTA THORAX: The aorta and main thoracic vessels are well opacified. The aorta demonstrates normal caliber throughout the thorax without intramural hematoma or dissection. The pulmonary arteries are opacified to the subsegmental level. There is no filling defect in the main, right, left, lobar or subsegmental pulmonary arteries. However, evaluation is somewhat limited by the timing of bolus contrast. CT OF THE THORAX: The heart size is normal. The airways are patent to the subsegmental level. There are scattered small mediastinal lymph nodes, none of which meet CT size criteria for lymphadenopathy. There is no hilar or axillary lymph node enlargement by CT size criteria. The heart, pericardium and great vessels are within normal limits. As seen on prior CT, there is redemonstration of mild cylindrical bronchiectasis most prominent in the lower lobes. There is a moderate-sized right sided pleural effusion, partially loculated apically, with associated compressive atelectasis in the right lower lobe. Although this study is not designed for assessment of intra-abdominal structures, the liver demonstrates fatty deposition. Note is made of a small hiatal hernia. Otherwise, the visualized solid organs and stomach are unremarkable. OSSEOUS STRUCTURES: No focal osseous lesion concerning for malignancy. IMPRESSION: 1. No pulmonary embolism or acute cardiopulmonary process. 2. Moderate right-sided pleural effusion, partially loculated apically, with associated right lower lobe compressive atelectasis. 3. Redemonstration of mild cylindrical bronchiectasis, most prominent in the lower lobes. 4. Hepatic steatosis. 5. Small hiatal hernia. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. HydrOXYzine 50 mg PO QHS 2. Ranitidine 300 mg PO HS 3. Furosemide 20 mg PO DAILY 4. Codeine Sulfate 30 mg PO Q4H:PRN Cough 5. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID 6. dexlansoprazole 60 mg oral Daily 7. Potassium Chloride 10 mEq PO DAILY 8. Levothyroxine Sodium 175 mcg PO DAILY 9. Amitriptyline 50 mg PO HS Discharge Medications: 1. Amitriptyline 50 mg PO HS 2. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID 3. Codeine Sulfate 30 mg PO Q4H:PRN Cough 4. Ranitidine 300 mg PO HS 5. HydrOXYzine 50 mg PO QHS 6. Furosemide 20 mg PO DAILY 7. Levothyroxine Sodium 175 mcg PO DAILY 8. dexlansoprazole 60 mg oral Daily 9. Potassium Chloride 10 mEq PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report AP CHEST, 5:12 P.M. ON ___ HISTORY: A ___ woman with a right pleural effusion after thoracentesis, rule out pneumothorax. IMPRESSION: AP chest compared to ___: Changing contour of the right lung base is presumably an indication of decreased right pleural effusion due to interval thoracentesis. There is new focal opacity in the right upper chest at the level of the first anterior interspace. This could be loculated pleural fluid seen on the chest CTA ___. I don't see the region well enough to exclude pneumothorax, and therefore when feasible, conventional chest radiographs should be obtained. Heart is normal size. Left hemithorax unremarkable aside from mild basal atelectasis. The right lower lobe lung lesion, probably focal atelectasis, seen on the chest CT is also barely visible. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with RESPIRATORY ABNORM NEC, CHEST PAIN NOS temperature: 97.8 heartrate: 89.0 resprate: 26.0 o2sat: 100.0 sbp: 140.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

You were seen for shortness of breath and fluid in your right lung after your previous surgery. You had a right-sided thoracentesis that removed 600 ml of fluid from your lung. Your symptoms are stable and the thoracic surgery physicians are comfortable with you going home. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * No driving while taking any form of narcotic pain medication. * Take Tylenol in between your narcotic medicine if you still are using narcotic pain medicine. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk ___ times a day and gradually increase your activity as you can tolerate. Call Dr. ___ ___ if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. You should resume taking all home medicines you were taking before being seen in the hospital. You may immediately resume your previous diet. You may immediately resume your former level of activity.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine / lactose Attending: ___. Chief Complaint: hypotension, AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is ___ with history of Hepatitis C, chronic pain on methadone, COPD on and off prednisone, esophageal stricture s/p dilatation ___ who initially presented to ___ with altered mental status. The patient's sister reports that the night prior to admission, he started developing nausea. She heard him in the bathroom, and reports that he had a normal BM. She denies him vomiting, but reports that he kept moaning and couldn't verbalize what was hurting him. Because of this unresponsiveness, the patient's sister called EMS. The patient had been living in ___ with his daughter until this past ___. While in ___, the patient was having difficulty breathing and having COPD flares; his sister reports that he was on and off steroids during this time, as well as being on home oxygen. Since coming to ___, the patient's sister reports that his breathing has been much improved. Since moving to ___, the patient was also complaining of worsening of his chronic back pain. However, the patient's scooter does not fit into his sister's house and he has been walking more than normal. He also has been unable to sleep sitting up like he usually does, and has been sleeping in a bed, also excacerbating his back pain. Of note, the patient also had EGD on ___ that was notable for severe esophageal candidiasis. He was started on fluconazole with the plan to complete a 3 week course. The patient also has a history of cognitive issues at his baseline. He had a massive arrest in the setting of hypoxemia ___ years ago and was in a coma for three months. The patient's sister reports that he was on pressors for a prolonged time and lost his toes during this process. On arrival to OSH, white count was noted to be 20.1 with 23% bandemia. ABG as OSH notable for 7.40/49/46. BNP 751. Tmax 102. The patient was given Vancomycin out of concern for possible cellulitis. He was transiently hypotensive, but was fluid responsive. In the ED, initial vitals: 98.6 ___ 17 93% 6L. Tmax in the ED 101.1. The patient had CTA in the ED that was read as non-diagnostic study, with no filling defect in the R and L pulmonary artery. Lobar, segmental, and subsegmental arteries could not be assessed. Focal consolidations in right upper and bilateral lower lobes were noted that could be due to atelectasis, aspiration, or infection. There was also report of bullous emphysema. LLQ tenderness was noted on exam in the ED, and CT abd/pelvis did not show any acute intraabdominal pathology. On transfer, vitals were: 91 112/53 13 93% Nasal Cannula On arrival to the MICU, the patient is arousable to voice, but intermittently falling asleep while talking. He reports having back pain. Denies any other symptoms, including chest pain. The patient did endorse having L hip pain. Past Medical History: chronic pain alcohol abuse arthritis h/o esophageal stricture COPD diverticulitis GERD HTN Hepatitis C osteoarthritis s/p b/l hip replacements stab wound to chest (no h/o MI) Social History: ___ Family History: Malignant hyperthermia, atrial fibrillation Physical Exam: ADMISSION EXAM: =============== General- lethargic, obese gentleman, nodding off during the interview HEENT- pupils reactive, EOMI, sclera anicteric, missing R ear (from prior avulsion injury during MVA years ago) Neck- supple CV- RRR S1 S2 Lungs- decreased breath sounds at bases b/l, L>R, crackles heard thoughout with inspiration Abdomen- soft, nontender, nondistended, +BS Ext- dopplerable DP pulses b/l, toes amputated on both feet, ___ shiny and hairless c/w chronic venous stasis changes, erythema noted, though not blanching, right heel ulcer without any evidence of drainage or erythema, no fluctuance noted; TTP over the left hip, minimal pain with passive hip extension and flexion Neuro- CN ___ grossly intact, moving all extremities spontaneously, alert, but falling asleep during interview DISCHARGE EXAM: ================ Vitals: 97.7, 75, 139/74, 18, 97% on 2L General: Obese, Alert, oriented, no acute distress, no conversational dyspnea HEENT: Sclera anicteric, MMM, oropharynx clear, missing R ear Neck: supple, JVP not elevated, no LAD Lungs: inspiratory wheezes at bases, rhonchi at bases 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: UE: hands with purple/brown discoloration b/l, ___: brownish/reddish discoloration of skin up to below the knees consistent with venous stasis changes. no pitting edema or warmth; ulcer on right heel not infected Pertinent Results: ADMISSION LABS: ================ ___ 11:25AM BLOOD WBC-20.2* RBC-4.50* Hgb-13.5* Hct-40.8 MCV-91 MCH-30.0 MCHC-33.1 RDW-15.5 Plt ___ ___ 11:25AM BLOOD Neuts-88.8* Lymphs-6.0* Monos-4.4 Eos-0.5 Baso-0.3 ___ 11:25AM BLOOD ___ PTT-28.9 ___ ___ 11:25AM BLOOD Glucose-81 UreaN-40* Creat-1.6* Na-140 K-5.0 Cl-101 HCO3-26 AnGap-18 ___ 11:25AM BLOOD ALT-34 AST-82* AlkPhos-79 TotBili-0.6 ___ 03:28AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.8 ___ 11:25AM BLOOD Albumin-3.5 ___ 11:39AM BLOOD ___ Temp-37.0 pO2-50* pCO2-53* pH-7.37 calTCO2-32* Base XS-3 Intubat-NOT INTUBA ___ 11:32AM BLOOD Lactate-1.3 ___ 11:39AM BLOOD O2 Sat-84 MICRO: ====== - blood cultures: no growth - sputum ___: c/w respiratory flora DISCHARGE LABS: ============== ___ 05:30AM BLOOD WBC-5.3 RBC-4.45* Hgb-13.1* Hct-41.0 MCV-92 MCH-29.4 MCHC-31.9 RDW-15.2 Plt ___ ___ 05:30AM BLOOD Glucose-74 UreaN-18 Creat-1.3* Na-137 K-4.2 Cl-92* HCO3-31 AnGap-18 ___ 05:30AM BLOOD Calcium-9.6 Phos-4.6* Mg-1.7 IMAGING: ============ CTA chest, CT abd/pelvis: IMPRESSION: 1. Nondiagnostic study for pulmonary embolism as the lobar, segmental, and subsegmental pulmonary arteries were not assessed. No pulmonary embolus is seen within the left or right main pulmonary artery. 2. Multifocal consolidations in the right upper and bilateral lower lobes which may be due to aspiration or infection with superimposed scarring in the right lower lobe. 3. Limited assessment of the abdomen secondary to motion. No acute intra-abdominal pathology to explain the patient's left lower quadrant pain. 4. Multiple compression deformities of the thoracic and lumbar vertebrae, which do not appear to be acute. Correlate clinically with history and symptoms. EGD ___ Benign appearing esophageal stricture s/p dilatation moderately severe esophageal candidiasis non-erosive gastritis Barium swallow ___: Some tertiary contractions of the esophagus are noted. No gross mechanical obstruction seen. EKG: NSR ~100 bpm, normal axis, no clear ST-T changes consistent with ischemia Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Oxazepam ___ mg PO HS:PRN spasms 2. Baclofen 20 mg PO DAILY 3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 4. Allopurinol ___ mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Metoprolol Tartrate 50 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Methadone 40 mg PO TID 10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 11. PredniSONE 10 mg PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Xopenex Neb 0.31 mg/3 mL inhalation daily 14. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Methadone 40 mg PO TID RX *methadone 40 mg 1 tab by mouth three times per day Disp #*20 Tablet Refills:*0 6. Metoprolol Tartrate 50 mg PO BID 7. PredniSONE 10 mg PO DAILY 8. Xopenex Neb 0.31 mg/3 mL inhalation daily 9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 10. Furosemide 40 mg PO DAILY 11. Oxazepam 30 mg PO HS RX *oxazepam 30 mg 1 capsule(s) by mouth daily Disp #*10 Capsule Refills:*0 12. Oxazepam 15 mg PO Q8H:PRN anxiety RX *oxazepam 15 mg 1 capsule(s) by mouth every 8 hours Disp #*10 Capsule Refills:*0 13. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea 14. Pantoprazole 40 mg PO Q24H 15. Calcium Carbonate 1000 mg PO DAILY RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 16. Vitamin D 800 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #*60 Capsule Refills:*0 17. Fluconazole 100 mg PO Q24H take until ___ RX *fluconazole 100 mg 1 tablet(s) by mouth daily Disp #*9 Tablet Refills:*0 18. Levofloxacin 750 mg PO DAILY take until ___ RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 19. Baclofen 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. aspiration pneumonia 2. COPD exacerbation *Anticipated rehab course less than 30 days* Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Patient with shortness of breath and left lower quadrant abdominal pain, evaluate for diverticulitis and pulmonary embolism. COMPARISON: None available. TECHNIQUE: Axial helical MDCT scan of the torso was done following the intravenous administration of 100 cc of Visipaque. Multiplanar reformatted images in coronal and sagittal axes were generated. Oblique MIPs were prepared in an independent work station for the chest. DLP: 1637 mGy-cm FINDINGS: CT CHEST: Some hypodense material is noted within the dependent portion of the trachea and right and left main stem bronchus, possibly due to aspiration. The airways are otherwise patent to the subsegmental level. There is no mediastinal, hilar or axillary lymph node enlargement by CT size criteria. Atherosclerotic calcifications are noted in the coronary arteries. There is no pericardial effusion. Lung windows moderate bullous emphysema, predominantly at the apices. There are multiple consolidations seen within the right upper and bilateral lower lobes, which may be due to aspiration or infection. There is also loss of volume in the right lower lobe with a component of scarring at the right lung base. No pleural effusion or pneumothorax is present. CTA CHEST: Limited evaluation due to transient interruption of contrast from influx of non-opacified blood from the IVC. The aorta demonstrates normal caliber throughout the thorax without intramural hematoma or dissection. No filling defect is seen within the right or left main pulmonary artery, but the lobar, segmental, and subsegmental arteries cannot be assessed. CT ABDOMEN: Evaluation of the intra-abdominal organs are limited secondary to motion, but the liver, spleen, pancreas, and adrenals are grossly unremarkable. Patient is status post cholecystectomy. Numerous hypodensities are noted within bilateral kidneys, not fully assessed due to motion, but likely represent cysts. No pelvicaliceal dilatation or perinephric abnormalities are present. The stomach, duodenum and small bowel are within normal limits, without evidence of wall thickening or obstruction. The colon is non-dilated without evidence of obstructive lesions. The appendix is normal. The aorta contains severe atherosclerotic calcification but is of normal caliber without aneurysmal dilatation. The IVC and major abdominal vessels are patent. There is no retroperitoneal or mesenteric lymph node enlargement. No ascites, free air or abdominal wall hernias are noted. PELVIC CT: Evaluation is limited secondary to streak artifact from bilateral hip arthroplasty hardware. Foley catheter is noted within the bladder. No pelvic wall or inguinal lymph node enlargement is seen. OSSEOUS STRUCTURES: There are numerous bilateral rib deformities with dystrophic bridging calcifications. Multiple compression deformities of the thoracic and lumbar vertebrae are noted, which do not appear to be acute. There is also dextroscoliosis of the lumbar ___ at L3 level. No blastic or lytic lesion suspicious for malignancy is present. IMPRESSION: 1. Nondiagnostic study for pulmonary embolism as the lobar, segmental, and subsegmental pulmonary arteries were not assessed. No pulmonary embolus is seen within the left or right main pulmonary artery. 2. Multifocal consolidations in the right upper and bilateral lower lobes which may be due to aspiration or infection with superimposed scarring in the right lower lobe. 3. Mildly limited assessment of the abdomen secondary to motion. No acute intra-abdominal pathology to explain the patient's left lower quadrant pain. 4. Multiple compression deformities of the thoracic and lumbar vertebrae, which do not appear to be acute. Correlate clinically with history and symptoms. Radiology Report AP RADIOGRAPH OF THE PELVIS AND LEFT HIP RADIOGRAPH CLINICAL INDICATION: ___ male with pneumonia, leukocytosis, status post left hip replacement with hip pain. TECHNIQUE: AP radiograph of the pelvis and multiple radiographic views of the left hip. COMPARISON: None. FINDINGS: Bilateral total hip arthroplasties are visualized, the right incompletely. No acute fracture or definite hardware complication is seen. No definite signs of periprosthetic loosening are identified. Mild degenerative changes present within bilateral inferior sacroiliac joints with spurring. Mild-to-moderate degenerative changes present also within the lower lumbar spine with intervertebral disc space narrowing and spurring. IMPRESSION: Left total hip arthroplasty without hardware complication, fracture, or periprosthetic loosening. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Altered mental status Diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS temperature: 98.6 heartrate: 101.0 resprate: 17.0 o2sat: 93.0 sbp: 80.0 dbp: 50.0 level of pain: 13 level of acuity: 1.0

Mr. ___, It was a pleasure taking care of you at ___ ___. You presented to us with altered mental status and difficulty breathing. You were found to have an aspiration pneumonia. We treated you with 7 days of antibiotics. We continued all your home medications. Please take you medications as instructed. Please attend all your follow up appointments.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Crestor / Lipitor Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/PMHx CAD (AMI in ___ w/LAD stent. stenosis of RCA ___. ___ (LAD DES), DM, HTN p/w sudden onset of dull, pressure-like substernal, ___, chest pain for several hours. Started yesterday evening while he was driving his truck. Not alleviated by rest. Patient reports that the discomfort is similar in location to where he has had prior angina. He has difficulty characterizing the pain, however, states that this pain was different from prior MI, and more intense than before. He reports the discomfort was accompanied by some dyspnea and radiated to the back. He has not had any anginal symptoms since his last PCI in ___. Denies N/V, diarrhea, fever, chills, dizziness, diaphoresis or lightheadedness. In the ED, initial vitals were 97.8 68 136/74 18 95%. ECG showed no changes (per ED), troponin negative x 1. Was given 4 SL NG with no relief in pain, and subsequently given IV morphine, which resulted in rapid resolution of symptoms. On the floor this AM patient denies any current chest pain. No shortness of breath, diaphoresis, dizziness, or fatigue. Past Medical History: -Coronary artery disease: He suffered an anterior myocardial infarction in ___ that was treated with an LAD stent. He underwent a subsequent cardiac catheterization for recurrent symptoms in ___. This showed a totally occluded RCA that was unable to be opened percutaneously. In ___ he underwent stenting of the LAD with a drug eluting stent. Echo in ___ showed EF 40%. -AAA -Diabetes -Hypertension -Hypercholesterolemia -Systolic dysfunction -Tobacco use. Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam: VS- T=98 BP=137/80 HR=64 RR=20 O2 sat=96%RA GENERAL- No acute distress. Laying in bed. Conversive and A&Ox3. Appropriate mood/affect HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Injected conjunctiva b/l. MMM No xanthalesma. NECK- Supple with JVP of 5 cm. CARDIAC- RRR. Soft S1&S2. NMRG. LUNGS- CTAB. Distant breath sounds diffusely. Poor air flow. No wheeze/rales/rhonchi ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES- No c/c/e. No femoral bruits. SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. PULSES- Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ . Discharge Exam: Discharged on day of admission Pertinent Results: ADmission Labs: ___ 03:15AM BLOOD WBC-14.1* RBC-5.27 Hgb-16.2 Hct-46.5 MCV-88 MCH-30.7 MCHC-34.8 RDW-12.8 Plt ___ ___ 03:15AM BLOOD Glucose-144* UreaN-18 Creat-1.1 Na-140 K-4.1 Cl-106 HCO3-24 AnGap-14 ___ 10:15AM BLOOD WBC-12.3* RBC-5.35 Hgb-16.1 Hct-48.4 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 Plt ___ ___ 10:15AM BLOOD Glucose-120* UreaN-17 Creat-1.1 Na-142 K-4.3 Cl-105 HCO3-27 AnGap-14 . Pertinent Labs: ___ 03:15AM BLOOD cTropnT-<0.01 ___ 10:15AM BLOOD CK-MB-4 cTropnT-<0.01 . Studies: ___ Stress Echo: The patient exercised for 10 minutes 25 seconds according to a ___ protocol ___ METS) reaching a peak heart rate of 110 bpm and a peak blood pressure of 166/60 mmHg. The test was stopped because of fatigue. This level of exercise represents a good exercise tolerance for age. In response to stress, the ECG showed no diagnostic ST-T wave changes (see exercise report for details). The blood pressure response to exercise was normal. There was a blunted heart rate response to stress [beta blockade]. Resting images were acquired at a heart rate of 56 bpm and a blood pressure of 106/60 mmHg. These demonstrated regional left ventricular systolic dysfunction with apical aneurysm/mild dyskinesis and severe hypokinesis/akinesis of the distal septum, anterior and inferior walls. The remaining segments contracted wel (LVEF = 35-40 %). Right ventricular free wall motion is normal. There is no pericardial effusion. Doppler demonstrated no aortic stenosis, aortic regurgitation or significant mitral regurgitation or resting LVOT gradient. Echo images were acquired within 57 seconds after peak stress at heart rates of 92 - 76 bpm. These demonstrated no new regional wall motion abnormalities. Baseline abnormalities persist with appropriate augmentation of other segments. There was augmentation of right ventricular free wall motion. IMPRESSION: Good functional exercise capacity. Non-specific ECG changes with 2D echocardiographic evidence of prior myocardial infarction (mid-LAD distribution) without inducible ischemia to achieved workload. Blunted heart rate response to physiologic stress. . ___ CXR: Hyperexpanded lungs with increased left lower lobe peribronchial opacities, possible interval aspiration. Medications on Admission: CLOPIDOGREL [PLAVIX] - Plavix 75 mg tablet. 1 Tablet(s) by mouth once a day ECASA - 325 . ONE BY MOUTH EVERY DAY ENALAPRIL MALEATE - enalapril maleate 10 mg tablet. 1 tablet in the morning and 1.5 tablets in the evening - (Prescribed by Other Provider) ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg tablet,extended release 24 hr. 1 Tablet(s) by mouth once a day - (Prescribed by Other Provider: Dr. ___ METFORMIN - metformin 850 mg tablet. 1 Tablet(s) by mouth three times a day - (Prescribed by Other Provider) (Not Taking as Prescribed: notes takes ___ times daily while working, but 3 times daily on weekends) METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. 1 Tablet(s) by mouth once a day PITAVASTATIN [LIVALO] - Livalo 4 mg tablet. 1 Tablet(s) by mouth once a day Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Enalapril Maleate 10 mg PO DAILY 3. Enteric Coated Aspirin *NF* (aspirin) 325 mg Oral daily 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. pitavastatin *NF* 4 mg Oral daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 6. Metoprolol Succinate XL 50 mg PO DAILY 7. MetFORMIN (Glucophage) 850 mg PO TID 1. Clopidogrel 75 mg PO DAILY 2. Enalapril Maleate 10 mg PO DAILY 3. Enteric Coated Aspirin *NF* (aspirin) 325 mg Oral daily 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. pitavastatin *NF* 4 mg Oral daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 6. Metoprolol Succinate XL 50 mg PO DAILY 7. MetFORMIN (Glucophage) 850 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: chest pain Secondary diagnosis: coronary artery disease chronic systolic congestive heart failure hypertension hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ male with chest pain COMPARISON: Chest radiograph from ___ FRONTAL AND LATERAL CHEST RADIOGRAPHS: Increased AP diameter of the chest with flattened hemidiaphragms suggest COPD, unchanged from prior. Bronchiectasis and peribronchial opacities have progressed in the left lower lobe and may reflect aspiration or inflammation. No confluent consolidation is identified. There is no pulmonary edema or pleural effusion. Cardiomediastinal and hilar contours are within normal limits. IMPRESSION: Hyperexpanded lungs with increased left lower lobe peribronchial opacities, possible interval aspiration. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: CHEST PAIN (CARDIAC FEATURES) Diagnosed with INTERMED CORONARY SYND, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 97.8 heartrate: 68.0 resprate: 18.0 o2sat: 95.0 sbp: 136.0 dbp: 74.0 level of pain: 4 level of acuity: 2.0

It was a pleasure caring for you at ___. You were admitted because you had chest pain that was concerning for a heart attack. We looked at your heart's rhythm (electrocardiogram) and determined that there were no changes from your prior study. We also checked blood levels of chemicals that can sometimes be elevated in heart attacks. You did not have any increase in these chemicals. You underwent a stress test that helps to decide whether or not you will get a cardiac catheterization. There was no abnormality on the stress test, and the probability that your chest pain is due to your heart is very low. You do not need a catheterization at this point. There were no medication changes made during this admission 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: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: erythema and drainage from LUE AVF Major Surgical or Invasive Procedure: None History of Present Illness: ___ with CKD V s/p LUE brachiocephalic AVF ___ with Dr. ___ presents with erythema and drainage at his incision. The fistula was created out of concern that he may need dialysis in the near future, however, he has not yet required dialysis. For the past ___ days he has noticed that the incision has been draining and he has subjective fevers and chills. He denies paresthesia or pain of the ipsilateral hand. ROS: (+) per HPI (-) Denies night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: Alport's Syndrome Autoimmune hemolytic anemia Cataracts Chronic Renal Failure, baseline creatinine 3.0 Coronary Artery Disease s/p drug-eluting stents in ___ and ___ Gout Hearing loss Hereditary nephritis, stage IV kidney disease Hyperlipidemia Hypertension Hypothyroid Social History: ___ Family History: Father - died in his ___ of coronary artery disease Mother - history of hemodialysis Brother - history of end-stage renal disease, on hemodialysis Physical Exam: Exam on Admission: Vitals: 99 95 138/49 18 100RA GEN: A&O CV: RRR, No M/G/R PULM: Clear to auscultation ABD: Soft, nondistended, nontender, no rebound or guarding Extremities: LUE AVF with palpable thrill. Incision well healing but with surrounding erythema and induration. No fluctuance noted. ___ cc purulent material expressed from medial incision. . Exam at Discharge: 24-HOUR EVENTS: -erythema much improved; L arm elevated -leukocytosis resolved -drainage becoming serous -dosed vancomycin for low level PHYSICAL EXAMINATION: 24 HR Data (last updated ___ @ 2354) Temp: 98.8 (Tm 98.8), BP: 126/64 (108-162/58-75), HR: 68 (67-83), RR: 18 (___), O2 sat: 96% (95-99), O2 delivery: Ra Fluid Balance (last updated ___ @ 2210) Last 8 hours Total cumulative -380ml IN: Total 120ml, PO Amt 120ml OUT: Total 500ml, Urine Amt 500ml Last 24 hours Total cumulative -400ml IN: Total 600ml, PO Amt 600ml OUT: Total 1000ml, Urine Amt 1000ml GENERAL: [ x]NAD [X]A/O x 3 CARDIAC: [ x]RRR LUNGS: [x ]no respiratory distress ABDOMEN: [x ]soft WOUND: [x ]abnormal, minimal erythema and serous drainage. EXTREMITIES: [ x]palpable thrill. Palpable LUE radial pulse. Pertinent Results: Labs on Admission: ___ WBC-12.5* RBC-2.48* Hgb-8.4* Hct-25.8* MCV-104* MCH-33.9* MCHC-32.6 RDW-13.7 RDWSD-52.0* Plt ___ PTT-29.5 ___ Glucose-91 UreaN-89* Creat-6.2* Na-136 K-7.7* (specimen grossly hemolyzed) Cl-103 HCO3-17* AnGap-16 Calcium-8.4 Phos-5.5* Mg-1.5* Hapto-196 Lactate-1.5 K-5.1 . Labs at Discharge: ___ WBC-8.1 RBC-2.23* Hgb-7.5* Hct-23.2* MCV-104* MCH-33.6* MCHC-32.3 RDW-13.7 RDWSD-51.5* Plt Ct-98* Glucose-91 UreaN-88* Creat-6.6* Na-143 K-4.9 Cl-110* HCO3-18* AnGap-15 Vanco-22.4* (21 hour trough) . ___ 7:30 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. . ___ 8:05 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Calcitriol 0.25 mcg PO DAILY 4. irbesartan 150 mg oral DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Metoprolol Tartrate 25 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 9. Tamsulosin 0.4 mg PO QHS 10. Torsemide 60 mg PO DAILY 11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 12. Nephrocaps 1 CAP PO DAILY 13. FoLIC Acid ___ mg PO DAILY 14. Sodium Bicarbonate 650 mg PO QID 15. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral BID 16. Aspirin 81 mg PO DAILY Discharge Medications: 1. Cephalexin 500 mg PO TID RX *cephalexin 500 mg 1 capsule(s) by mouth every eight (8) hours Disp #*15 Capsule Refills:*0 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. Allopurinol ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. FoLIC Acid ___ mg PO DAILY 8. irbesartan 150 mg oral DAILY 9. Levothyroxine Sodium 88 mcg PO DAILY 10. Metoprolol Tartrate 25 mg PO BID 11. Nephrocaps 1 CAP PO DAILY 12. Omeprazole 20 mg PO DAILY 13. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral BID 14. Sodium Bicarbonate 650 mg PO QID 15. Tamsulosin 0.4 mg PO QHS 16. Torsemide 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: CKD Stage 5 Dialysis access incision infection 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 SOB and fever// eval pna TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Median sternotomy wires and clips as on prior. There is no focal consolidation. No pneumothorax. Atelectasis noted at the left lung base laterally. There is no pleural effusion. The heart size and mediastinal silhouette are stable within normal limits. Chronic right posterior rib fracture is noted. IMPRESSION: No acute cardiopulmonary process. No focal consolidation. Radiology Report EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE LEFT INDICATION: ___ year old man with new left brachiocephalic fistula in preparation for dialysis. Area of fistula placement is hot, swollen, red and with discharge// eval abscess around new fistula site TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the left antecubital fossa and surgical site. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the left antecubital fossa in the area of redness near the surgical site. A patent arteriovenous fistula was demonstrated. In close proximity to the fistula, there is a irregularly-shaped, heterogeneous fluid collection measuring approximately 2.6 x 1.2 x 2.6 cm with minimal intralesional flow. Findings are consistent with a postoperative collection. No evidence of pseudoaneurysm. IMPRESSION: Adjacent to and overlying the fistula, there is a 2.6 x 1.2 x 2.6 cm heterogeneous fluid collection. Findings likely represent postoperative hematoma or seroma. Overlying infection is difficult to exclude. No evidence of pseudoaneurysm. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever, Wound eval Diagnosed with Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init, Exposure to other specified factors, initial encounter, Chest pain, unspecified, Hyp chr kidney disease w stage 5 chr kidney disease or ESRD, Chronic kidney disease, unspecified, Pure hypercholesterolemia, unspecified temperature: 99.0 heartrate: 90.0 resprate: 18.0 o2sat: 100.0 sbp: 138.0 dbp: 49.0 level of pain: 8 level of acuity: 3.0

Please call the access clinic at ___ if you have fevers or chills, yourleft hand has increased pain, is cold, has blue fingers, has numbness or tingling this may be a medical emergency and you should call right away. Please also monitor for increased incisional redness, drainage or bleeding, arm swelling or increased pain or the development of a foul odor on the dressing, at the access site or any other concerning symptoms. . You should check the left arm access daily for a thrill (buzzing sensation) and if this is not present, you should call the access clinic right away. . Keep the left arm elevated on ___ pillows when sitting or lying down to help swelling decrease. . The arm may be gently washed but do not submerge or soak the arm. Keep the arm elevated when you are sitting or laying down to help the swelling decrease. Dressing should be changed daily and more often as needed. Please report increased drainage or bleeding or if the wound develops a foul odor. . Do NOT allow any blood pressures or lab draws from the access arm. No tight or constrictive clothing or jewelry to the access arm and no lifting more than 10 pounds. . Continue home medications, dietary and fluid restrictions as you have been instructed. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Motrin / amoxicillin Attending: ___. Chief Complaint: Hypoglycema/AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with ESRD (on ___ HD, last HD ___, T1DM on insulin, and several other medical problems who presents with symptomatic hypoglycemia, found unresponsive. Per history obtained in the ED, she was brought in by EMS from home after having AMS and found to have glucose "low." Other history was unavailable at that time. Per EMS, FSBG was "low," they could not get IV access, and she was given IM glucagon after having a brief self-terminating GTC in the ambulance. Of note, she has a history of prior presentations with hypoglycemia. Per her ___, low sugars tend to occur if she administers novolog per sliding scale and subsequently doesn't have anything to eat. Patient notes administering novolog 3U evening prior to admission per sliding scale shortly before bed. She underwent recent cataracts surgery in past week, but has been recovering well without evident complications. No fevers, chills, dyspnea, metallic taste in mouth, chest pain, nausea, vomiting, or dysuria. She has not missed any HD sessions leading up to current presentation; most recent session on ___. Initial VS: Temp 97.7, HR 56, BP 121/58, RR 18 SpO2 95% on RA Exam in the ED: General: Agitated, not following commands HEENT: Normal oropharynx, no exudates/erythema Cardiac: RRR , no chest tenderness Pulmonary: Clear to auscultation bilaterally with good aeration, no crackles/wheezes Abdominal/GI: Soft, nondistended Renal: No CVA tenderness MSK: No deformities or signs of trauma, no focal deficits noted Neuro: Alert and oriented x1, moving all 4 extremities Pertinent labs/imaging studies: - Initial fingerstick in ED was 32 - Na 135, K 4.9, Cl 95, Bicarb 25, BUN 41, Cr 7.7 - Ca 9.2, Mg 1.9, Phos 3.7 - Glucose - ALT 10, AST 16, Alk phos 159, Tbili 0.4, Alb 3.8 - WBC 3.5, Hgb 10.5, Hct 33.5, Plt 152 - Troponin T: 0.13 - pH 7.33, pCO2 51, pO2 64 - Lactate 2.6 - Serum ASA, EtOH, acetaminophen, tricyclics negative NCHCT ___: No acute intracranial abnormality. CXR ___: Top normal heart size, otherwise unremarkable. Patient received: L pretibial IO Dextrose x2 Repeat blood sugars stable Mental status improved Transfer VS: Temp 97.6, BP 149/83, HR 70, SpO2 100% on 2L FSBG 131 On arrival to the floor she is feeling better and close to her baseline. She is awake and oriented to person, place and year. She is able to recount a full social history and give numbers for her relatives and ___. On history obtained from her, she reports that she had a FSBG of 407 in the evening on ___, ate macaroni and cheese, gave herself 3 units of novalog and went to bed. She does not remember anything else and woke up in the hospital. ROS: 10 point ROS reviewed and negative other than those stated in HPI. Past Medical History: Hepatitis C (viral load undetected ___ T1DM on insulin ESRD on HD MWF Rheumatoid arthritis HTN GERD Neuropathy CHF Asthma Osteoporosis Right distal tib/fib fracture Grave's disease Hx of stroke Adrenal hyperplasia Cataract surgery in ___ eye ___ Social History: ___ Family History: Type 2 diabetes Maternal Aunt Type 1 diabetes Maternal Aunt ___ cancer Mother Lung cancer Brother Acute myocardial infarction Maternal Aunt Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: Temp 97.6, BP 149/83, HR 70, SpO2 100% on 2L FSBG 131 General: laying in bed on side in no acute distress HEENT: NC/AT, MMM, EOMI, right eye with slight injection ___ recent cataract surgery Neck: no JVD appreciated Lungs: mild expiratory wheezes, otherwise clear to auscultation bilaterally CV: normal rate and regular rhythm, normal S1 and S2, no m/r/g GI: soft, mildly tender to diffuse palpation, nondistended Ext: warm and well perfused, no sensation on plantar surface of feet, left leg with dressing over IO site, right leg with cast in place Neuro: awake and oriented to person, place and year. Fully conversant, can give phone numbers and history. DISCHARGE PHYSICAL EXAM: ======================== VS: 156 / 68, 77, 18, 99% RA General: Older woman in NAD, in HD HEENT: NC/AT, MMM, EOMI Lungs: CTAB CV: RRR, normal S1 and S2, no m/r/g. GI: +BS, S, NT, ND Ext: warm and well perfused, no edema Neuro: Awake, interactive. No asymmetries noted on visual exam. Pertinent Results: ADMISSION LABS =============== ___ 08:35AM BLOOD WBC-3.5* RBC-3.12* Hgb-10.5* Hct-33.5* MCV-107* MCH-33.7* MCHC-31.3* RDW-12.4 RDWSD-48.9* Plt ___ ___ 08:35AM BLOOD Neuts-58.4 ___ Monos-10.5 Eos-1.7 Baso-0.3 Im ___ AbsNeut-2.05 AbsLymp-1.01* AbsMono-0.37 AbsEos-0.06 AbsBaso-0.01 ___ 08:35AM BLOOD ___ PTT-24.8* ___ ___ 08:35AM BLOOD Ret Aut-2.3* Abs Ret-0.07 ___ 08:35AM BLOOD Glucose-324* UreaN-41* Creat-7.7* Na-135 K-4.9 Cl-95* HCO3-25 AnGap-15 ___ 08:35AM BLOOD ALT-10 AST-16 LD(LDH)-304* AlkPhos-159* TotBili-0.4 ___ 08:35AM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.7 Mg-1.9 Iron-67 ___ 08:35AM BLOOD calTIBC-176* VitB12-714 Hapto-131 Ferritn-1231* TRF-135* ___ 08:35AM BLOOD TSH-5.4* ___ 08:35AM BLOOD Free T4-0.9* ___ 08:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS =============== ___ 06:30AM BLOOD WBC-4.7 RBC-2.90* Hgb-9.6* Hct-30.8* MCV-106* MCH-33.1* MCHC-31.2* RDW-12.7 RDWSD-49.6* Plt ___ ___ 06:30AM BLOOD Glucose-516* UreaN-34* Creat-6.2*# Na-123* K-5.2 Cl-84* HCO3-24 AnGap-16 ___ 06:30AM BLOOD Calcium-9.7 Phos-2.5* Mg-1.9 MICRO ===== ___ BCx x2: No growth (final) IMAGING ======== ___ Non-contrast head CT: There is no evidence of acute territorial infarction,hemorrhage,edema,or discrete 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. ___ CXR: Top normal heart size, otherwise unremarkable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 2. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL) subcutaneous DAILY 3. Losartan Potassium 50 mg PO DAILY 4. LOPERamide 4 mg PO BID:PRN diarrhea 5. Labetalol 300 mg PO TID 6. Atorvastatin 10 mg PO QPM 7. Aspirin 81 mg PO DAILY 8. Levothyroxine Sodium 25 mcg PO DAILY 9. sevelamer CARBONATE 1600 mg PO TID W/MEALS 10. Ferric Citrate 420 mg PO TID W/MEALS 11. Montelukast 10 mg PO DAILY 12. Gabapentin 600 mg PO Q6H 13. Vitamin D ___ UNIT PO DAILY 14. Omeprazole 20 mg PO DAILY 15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 16. Torsemide 20 mg PO DAILY 17. amLODIPine 10 mg PO DAILY 18. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea, wheezing 19. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 20. Calcitriol 0.5 mcg PO 3X/WEEK (___) 21. NovoLOG Flexpen U-100 Insulin (insulin aspart U-100) 100 unit/mL (3 mL) subcutaneous DAILY Discharge Medications: 1. Dextromethorphan Polistirex ___ mg PO Q12H:PRN cough RX *dextromethorphan polistirex ___ mg/5 mL 10 ml by mouth twice a day Refills:*0 2. Lidocaine 5% Patch 2 PTCH TD QPM RX *lidocaine 5 % Apply one patch qPM Disp #*30 Patch Refills:*0 3. Gabapentin 600 mg PO BID RX *gabapentin 600 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 4. Tresiba FlexTouch U-100 (insulin degludec) 15 units subcutaneous DAILY 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea, wheezing 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 10 mg PO QPM 9. Calcitriol 0.5 mcg PO 3X/WEEK (___) 10. Ferric Citrate 420 mg PO TID W/MEALS 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 12. Labetalol 300 mg PO TID 13. Levothyroxine Sodium 25 mcg PO DAILY 14. LOPERamide 4 mg PO BID:PRN diarrhea 15. Losartan Potassium 50 mg PO DAILY 16. Montelukast 10 mg PO DAILY 17. NovoLOG Flexpen U-100 Insulin (insulin aspart U-100) 100 unit/mL (3 mL) subcutaneous DAILY 18. Omeprazole 20 mg PO DAILY 19. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 21. sevelamer CARBONATE 1600 mg PO TID W/MEALS 22. Torsemide 20 mg PO DAILY 23. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Hypoglycemia SECONDARY DIAGNOSES: ==================== T1DM ESRD HTN GERD Neuropathy Asthma Grave's disease HFpEF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with hypoglycemic seizure. Infectious work-up TECHNIQUE: Chest AP upright and lateral COMPARISON: None. FINDINGS: Lungs are fully expanded and clear. The heart is top-normal in size. Mediastinal contour is unremarkable. No pneumothorax. No pleural effusion. IMPRESSION: Top normal heart size, otherwise unremarkable. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with hypoglycemic seizure. Trauma evaluation to rule out fracture, bleed. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute territorial infarction,hemorrhage,edema,or discrete 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. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Hypoglycemia Diagnosed with Altered mental status, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: UA level of acuity: 2.0

====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were found unresponsive due to low blood sugar. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given sugar to bring your blood sugar back to normal and briefly had a line into your leg bone because an IV could not be obtained. - You had dialysis while you were in the hospital - You were seen by the ___ team who ultimately recommended the following DISCHARGE INSULIN PLAN: TAKE TRESIBA INSULIN 15 UNITS AT LUNCH TIME TAKE NOVOLOG BEFORE BREAKFAST, LUNCH AND DINNER ACCORDING TO THIS SCALE GLUCOSE BREAKFAST LUNCH DINNER BEDTIME <100 0 0 0 0 101-150 4 4 6 0 151-200 5 5 6 0 ___ 7 7 8 2 301-350 8 8 10 3 351-400 8 8 10 4 >400 10 10 12 5 IMPORTANT TO REMEMBER THE FOLLOWING: 1. CHECK BLOOD GLUCOSE BEFORE EATING BREAKFAST, LUNCH AND DINNER AND AT BEDTIME. 2. IF YOU DO NOT PLAN ON EATING A MEAL USE THE "BEDTIME" INSULIN CHART TO TREAT A BLOOD GLUCOSE THAT IS HIGH, ABOVE 200. 3. DO NOT TAKE NOVOLOG INSULIN SOONER THAN 2 HOURS APART- DOING THIS MAY CAUSE LOW GLUCOSE 4. IF YOUR BLOOD GLUCOSE IS UNDER 100, CHEW ___ GLUCOSE TABLETS OR DRINK 4 OZ. OF FRUIT JUICE. THEN CHECK 15 MINUTES LATER TO CONFIRM YOUR BLOOD GLUCOSE HAS GONE UP. 5. FOLLOW UP AT ___ NEXT WEEK. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you the best! 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: slurred speech Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ yo R-handed man with history of multiple strokes who presents with slurred speech. LKW 0500 when he spoke with his daughter. At 0720 his wife told him she was leaving for work, and he sleepily mumbled 'ok'. He woke up at 0800 and went to restroom before going back to sleep, but didn't speak to anyone. He then woke at 1000 and spoke with his wife, and he and his wife noticed his speech was slurred. No other associated deficits. He feels his speech is slightly improved since 1000. Mr. ___ has had multiple ischemic strokes in the past: ___ with left arm weakness, ___ with right cheek sensory symptoms, ___ with left sided weakness, ___ with dysarthria and gait difficulty, ___, ___ (slurred/'jumbled speech x3 min, MR with ___ frontal infarct). For none of these was he cared for at ___. After the ___ infarct, he was told to add ASA 81 3x/wk to his daily clopidogrel, but when the followed up with ___ Neurology, Dr. ___, in ___, he said this was expected to be of little benefit and stopped the aspirin, continuing on clopidogrel alone. Residual deficits: L facial droop, L arm and leg weakness. Ambulated with four point cane. Does all ADLs. Manages his medication by filling a pill box and taking pills from the pill box with no assitance. Wife took over finances after first 'very large' stroke, which wife thinks was in late ___. At baseline he has cognitive changes nightly, where he has difficulty following the thread of a conversation. No agitation. Some inappropriate crying/laughing. He has had increasing falls over the last year. First ever fall was ___, and recently he has been falling ___ times per month. Seeing ___ without effect, though he isn't compliant with doing exercises at home on a regular basis. He has AFO provided by ___, but does not wear it. Past Medical History: HTN HLD pre-DM gastritis peripheral vascular disease s/p L3-4 disc herniation and decompression erectile dysfunction h/o C. difficile colitis Insomnia centrilobular emphysema. Social History: ___ Family History: Mother with HTN, died of endocarditis after dental infection, c/b multiple strokes Father with DM, HTN MGM with DM brother with stroke Physical Exam: ADMISSION PHYSICAL EXAM: PHYSICAL EXAMINATION Vitals: T: 97.6 HR: 48-60 BP: ___ RR: 16 SaO2: 98% RA General: Awake, cooperative, NAD. HEENT: no scleral icterus, MMM, no oropharyngeal lesions. Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: Skin warm, well-perfused. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history with some supplementation from family. Attentive to exam. Speech fluent, no paraphasic errors. Comprehension intact to complex commands. Normal prosody. -Cranial Nerves: PERRL 3->2. VFF to confrontation. EOMI with ___ beats bilateral end-gaze nystagmus. Facial sensation intact to light touch. Delayed activation L face. Hearing intact to conversation. Palate elevates symmetrically. ___ strength in trapezii bilaterally. Tongue in cheek very weak on R, still able to overcome slightly on left. Moderate gutteral more than lingual dysarthria (<25% of speech is incomprehensible). - Motor: Normal bulk and tone. Unable to fully extend and supinate L arm, drifts downward. No tremor nor asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 4+ ___ ___- 4+ 5 4 4+ R 5 ___ ___ 5 5 4+ 5 -DTRs: Bi Tri ___ Pat Ach Pec jerk Crossed Abductors L 3 2 3 3+ 4 + R 3 2 3 3 2 + ___ beats clonus L ankle. Plantar response was flexor on right, extensor on left. -Sensory: Intact to LT, temp throughout. - Coordination: Ataxia of RUE most prominent with mirroring, very subtle on FTN. Ataxia of LUE slightly out of proportion to weakness. Ataxia RLE as well. - Gait: deferred =============================================== DISCHARGE PHYSICAL EXAM General: NAD HEENT: NCAT ___: ext WWP Pulmonary: No tachypnea or increased WOB Abdomen: Soft, ND Extremities: Warm, no edema NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent. Normal prosody. There are no paraphasic errors. Speech is not dysarthric. Able to follow both midline and appendicular commands -Cranial Nerves: EOMI with ___ sensation intact to light touch. Delayed activation L face. Hearing intact to conversation. Palate elevates symmetrically. ___ strength in trapezii bilaterally. - Motor: Normal bulk and tone. No pronator drift. No tremor nor asterixis. Delt Bic Tri WrE IP Quad Ham L 4+ 5- 4 5 5 5 5 R 5 ___ 5 5 5 -DTRs: deferred -___: Intact to LT throughout. - Coordination: deferred - Gait: deferred Pertinent Results: ADMISSION LABS: ___ 01:40PM BLOOD WBC-6.6 RBC-3.86* Hgb-11.2* Hct-34.5* MCV-89 MCH-29.0 MCHC-32.5 RDW-12.3 RDWSD-40.1 Plt ___ ___ 01:40PM BLOOD Neuts-73.0* Lymphs-15.2* Monos-8.2 Eos-3.0 Baso-0.3 Im ___ AbsNeut-4.78 AbsLymp-1.00* AbsMono-0.54 AbsEos-0.20 AbsBaso-0.02 ___ 01:40PM BLOOD ___ PTT-29.8 ___ ___ 01:40PM BLOOD Plt ___ ___ 01:40PM BLOOD ALT-12 AST-15 AlkPhos-156* TotBili-0.7 ___ 01:40PM BLOOD cTropnT-<0.01 ___ 01:40PM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.8 Mg-1.8 ___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 01:40PM BLOOD GreenHd-HOLD ___ 02:03PM BLOOD Lactate-1.2 PERTINANT OTHER LABS ___ 04:40AM BLOOD WBC-4.2 RBC-3.72* Hgb-10.8* Hct-32.9* MCV-88 MCH-29.0 MCHC-32.8 RDW-12.1 RDWSD-38.9 Plt ___ ___ 04:40AM BLOOD ___ PTT-29.1 ___ ___ 04:40AM BLOOD Plt ___ ___ 04:40AM BLOOD Glucose-89 UreaN-22* Creat-1.1 Na-139 K-3.7 Cl-104 HCO3-23 AnGap-12 ___ 04:40AM BLOOD ALT-10 AST-13 AlkPhos-148* TotBili-0.6 ___ 04:40AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.4 Mg-1.8 Cholest-97 ___ 04:40AM BLOOD %HbA1c-5.7 eAG-117 ___ 04:40AM BLOOD Triglyc-65 HDL-42 CHOL/HD-2.3 LDLcalc-42 ___ 04:40AM BLOOD TSH-1.6 DISCHARGE LABS: IMAGING: CXR (AP and Lat): No focal consolidation to suggest pneumonia. Mild bibasilar atelectasis. CT head: No acute large territorial infarction, hemorrhage, edema, mass or mass effect demonstrated. The ventricles and sulci are age appropriate. CTA head and neck: The vessels of the circle of ___ and its major branches demonstrate no stenosis, occlusion or aneurysm. There is diffuse atherosclerosis within the bilateral carotid and vertebral arteries without significant stenosis by NASCET criteria, occlusion or aneurysm. TTE: Normal biventricular cavity sizes, regional/global systolic function. Mild mitral regurgitation with normal valve morphology. No cardiac source of embolism (e.g.patent foramen ovale/atrial septal defect, intracardiac thrombus, or vegetation) seen. MRI: 1. Single punctate acute infarct in the anterior left frontal lobe. 2. Late subacute punctate infarct right frontal lobe. 3. Innumerable, small chronic infarcts cerebellum, brainstem, basal ganglia, cerebral hemispheres deep white matter. Severe chronic small vessel ischemic changes. Brain parenchymal atrophy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. CloNIDine 0.2 mg PO BID 3. Atenolol 50 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Terazosin 4 mg PO QHS 6. Sildenafil 50-100 mg PO ONCE:PRN intercourse 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 2 Doses RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. CloNIDine 0.2 mg PO BID 6. Lisinopril 40 mg PO DAILY 7. Sildenafil 50-100 mg PO ONCE:PRN intercourse 8. Terazosin 4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute Ischemic Stroke in anterior right frontal lobe deep white matter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with AMS// ? pna ? ICH ? anueurysm TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Cardiac silhouette size is normal. Mediastinal and hilar contours are unremarkable. Pulmonary vasculature is not engorged. Streaky opacities in lung bases likely reflect areas of atelectasis. No focal consolidation, pleural effusion or pneumothorax. No acute osseous abnormality. IMPRESSION: No focal consolidation to suggest pneumonia. Mild bibasilar atelectasis. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK. INDICATION: History: ___ with AMS// ? pna ? ICH ? anueurysm. 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 after the intravenous administration of 70 mL of Omnipaque 350 nonionic contrast. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 29.9 mGy (Body) DLP = 15.0 mGy-cm. 3) Spiral Acquisition 5.3 s, 41.4 cm; CTDIvol = 15.2 mGy (Body) DLP = 629.1 mGy-cm. Total DLP (Body) = 644 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: MR head dated ___, CT head dated ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of large territorial infarction,hemorrhage,edema, mass effectormass. The ventricles and sulci are age-appropriate. Multiple hypodensities within the subcortical and periventricular white matter are nonspecific but likely sequela of chronic microvascular ischemic disease. The bilateral cavernous portions of the internal carotid arteries demonstrate moderate calcified atherosclerosis. A possible left temporal lobe choroidal fissure cyst remains unchanged. The visualized portion of the paranasal sinuses, mastoid air cells,and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is calcified atherosclerosis within the bilateral intracranial internal carotid arteries, and V4 portions of the left vertebral artery without evidence of significant stenosis. The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: The bilateral carotid arteries demonstrate calcified atherosclerosis, the right internal carotid artery demonstrates no stenosis by NASCET criteria. The left internal carotid artery demonstrates 50% stenosis by NASCET criteria, (series 3 image 135-145), however there is no evidence of occlusion. Thevertebral arteries demonstrate calcified atherosclerosis without significant stenosis or occlusion. OTHER: The visualized lungs demonstrate severe centrilobular emphysema and bullous changes. The thyroid is unremarkable. No lymphadenopathy by CT criteria is identified. Multilevel degenerative changes are visualized throughout the cervical spine consistent with anterior and posterior spondylosis, more significant from C4 through C6 levels. IMPRESSION: 1. The left internal carotid artery demonstrates calcified atherosclerosis and 50% stenosis by NASCET criteria. 2. Normal head CTA . 3. No acute intracranial process or hemorrhage. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with history of multiple strokes, new dysarthria.// eval for stroke TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON MRI of the head from ___ and CTA of the head and neck from ___ FINDINGS: Single punctate focus of DWI hyperintensity in the anterior left frontal lobe subcortical white matter (series 4, image 21) with corresponding ADC hypointensity is consistent with an acute infarct. Small late subacute infarct anterior right frontal lobe deep white matter. Innumerable chronic small infarcts involving right greater than left cerebellum, brainstem, right corona radiata, probably left corona radiata, right greater than left basal ganglia, left thalamus. Findings consistent with severe chronic small vessel ischemic changes. Brain parenchymal atrophy. Significant corpus callosum atrophy. Wallerian degeneration right cerebral peduncle. No acute hemorrhage, edema, masses, mass effect or midline shift. There is mild mucosal thickening along the floors of the bilateral maxillary sinuses. Mild partial opacification of the bilateral mastoid air cells, left greater than right. Preserved vascular flow voids. IMPRESSION: 1. Single punctate acute infarct in the anterior left frontal lobe. 2. Late subacute punctate infarct right frontal lobe. 3. Innumerable, small chronic infarcts cerebellum, brainstem, basal ganglia, cerebral hemispheres deep white matter. Severe chronic small vessel ischemic changes. Brain parenchymal atrophy. NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ (neuroradiology fellow) on ___ via telephone at 09:30 am Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: L Weakness, Slurred speech Diagnosed with Cerebral infarction, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 0 level of acuity: 1.0

Dear Mr. ___, You were hospitalized due to symptoms of slurred speech 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, prior history of strokes, family history of strokes, and smoking. Of note, you were also found to have a urinary tract infection and we would like you to take an antibiotic called Ciprofloxacin HCl 250 mg twice for one more day. Otherwise we are not making any changes to your medication at this time. However, you were previously told that you should switch to Plavix and we encourage you to discuss this with Dr. ___ neurologist. 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: Lisinopril / atorvastatin / Bactrim Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: ___ woman with PMHx notable for chronic thoracic myelopathy, recurrent UTIs, infectious endocarditis, diastolic heart failure, diabetes, HTN, HLD who was discharged one day ago after a 10-day admission for MRSA bacteremia with planned 6 week course of vancomycin. She presented from her rehab facility due to fever to 100.7F. She receives monthly steroids for her myelopathy and initially presented on ___ with lower extremity weakness, difficulty transferring and a recent fall at home. It was felt her exam was at baseline and she was found to have MRSA growing in 1 set of blood cultures drawn on admission. It was unclear whether this set was drawn peripherally or from her port, and subsequent sets were negative. ID was consulted who recommended a 6 week course of vancomycin ___, and recommended changing her port. The surgeon who placed her port (___) was concerned about difficulty replacing it due to her anatomy and it was ultimately left in place with vancomycin locks. She underwent a TEE that showed no vegetation and MR ___ given prior L3-L5 decompression and L4-L5 fusion with screws in place that did not show any fluid collection. In discussion with her outpatient neurologist it was decided to hold her monthly steroid injections during her MRSA treatment. In the ED, initial vitals were: 98.3 88 150/79 18 96% RA. Exam notable for bilateral lower extremity weakness that improved. IV/VI systolic murmur. - Labs notable for: Hgb 7.5, WBC 14, lactate 1.1, Flu negative - Imaging was notable for: retrocardiac opacity, more pronounced on the current examination than on the priors, may be compatible with pneumonia in the appropriate clinical context. - Patient was given: Vancomycin and cefepime Upon arrival to the floor, patient reports feeling completely well. Other than the fever (which she did not notice aside from the measurement) she has no complaints today. Specifically denies any subjective fever, chills, chest pain, dyspnea, cough, congestion, abdominal pain, N/V. Ostomy stool output is similar to her baseline right now. Review of systems was negative except as detailed above. Past Medical History: - diastolic heart failure - diabetes - myelopathy (previously on monthly Solumedrol) - thought to be due to prior Zoster infection - T8-9 myelomalacia - paraplegia - AV bacterial endocarditis (E. faecalis) - port-a-cath placed for access needs - aortic valvular disease - hypertension - hyperlipidemia - rectal trauma s/p colostomy - recurrent UTIs - pulmonary hypertension - urinary incontinence - monoclonal gammopathy - anemia - mediastinal lymphadenopathy - ventral hernia - chronic back pain - h/o left gluteal ulcer (___) - h/o possible myositis - lumbar laminectomy with hardware Social History: ___ Family History: - Father with lung cancer - Mother with hypertension and osteoarthritis - Sister with CVA - Sister with lung cancer - Sister with brain cancer - MGF and MGM with "cardiac disease" - Aunts with diabetes Physical Exam: ADMISSION EXAM ======================= VITALS: Temp: 98.5 PO BP: 123/75 HR: 83 RR: 20 O2 sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: Older appearing woman in no acute distress. Comfortable. Wheelchair bound. NEURO: AAOx3. Full strength in upper extremities. Legs with bilateral weakness but able to move, wiggle toes. Speech intact. HEENT: Normocephalic, atraumatic. EOMI. Poor dentition. CARDIAC: Regular rate & rhythm. Normal S1/S2. IV/VI systolic murmur mostly over LUSB. PULMONARY: Clear to auscultation bilaterally. Breathing comfortably on room air. CHEST: Right port site is clean, dry, without surrounding erythema or purulence. ABDOMEN: Soft, non-tender, non-distended. Colostomy bag in place. EXTREMITIES: Warm, 1+ edema to mid-shin. Tender to palpation bilaterally. SKIN: No significant rashes. DISCHARGE EXAM ======================= VITALS: 24 HR Data (last updated ___ @ 1212)Temp: 97.5 (Tm 99.8), BP: 90/61 (90-135/61-70), HR: 83 (83-94), RR: 18, O2 sat: 96% (93-96), O2 delivery: Ra GENERAL: No acute distress. Comfortable. Wheelchair bound. HEENT: Normocephalic, atraumatic. EOMI. Poor dentition. CARDIAC: Regular rate & rhythm. Normal S1/S2. IV/VI systolic murmur mostly over LUSB. PULMONARY: Clear to auscultation bilaterally. Breathing comfortably on room air. CHEST: Right port site is clean, dry, without surrounding erythema or purulence. ABDOMEN: Soft, non-tender, non-distended. Colostomy bag in place. EXTREMITIES: Warm, 1+ edema to mid-shin. Tender to palpation bilaterally. SKIN: No significant rashes. NEURO: AAOx3. Full strength in upper extremities. Legs with bilateral weakness but able to move, wiggle toes. Speech intact. Pertinent Results: ADMISSION LABS ======================= ___ 02:54AM BLOOD WBC-14.4* RBC-3.38* Hgb-7.5* Hct-25.2* MCV-75* MCH-22.2* MCHC-29.8* RDW-18.6* RDWSD-50.2* Plt ___ ___ 02:54AM BLOOD Glucose-159* UreaN-21* Creat-1.0 Na-142 K-4.2 Cl-100 HCO3-32 AnGap-10 ___ 02:54AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.8 ___ 03:01AM BLOOD Lactate-1.1 ___ 03:37AM URINE Color-Straw Appear-Clear Sp ___ ___ 03:37AM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM* ___ 03:37AM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE Epi-0 ___ 06:30AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE PERTINENT STUDIES ======================= CXR (___) Retrocardiac opacity, more pronounced on the current examination than on the priors, may be compatible with pneumonia in the appropriate clinical context. MICRO ======================= ___ Urine culture: pending ___ Flu swab: negative ___ blood cultures x2: pending ___ blood cultures x2: pending DISCHARGE LABS ======================= ___ 05:36AM BLOOD WBC-11.3* RBC-3.32* Hgb-7.4* Hct-25.1* MCV-76* MCH-22.3* MCHC-29.5* RDW-18.3* RDWSD-50.4* Plt ___ ___ 05:36AM BLOOD Glucose-133* UreaN-25* Creat-0.9 Na-141 K-4.2 Cl-98 HCO3-31 AnGap-12 ___ 05:36AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.8 ___ 05:36AM BLOOD Vanco-25.1* Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with fever// Evaluate for pneumonia TECHNIQUE: Chest AP and lateral COMPARISON: ___ FINDINGS: Lung volumes are low. The cardiomediastinal silhouette is unchanged. A left-sided PICC terminates in the proximal SVC, as seen previously. There is no sizable pleural effusion or pneumothorax. Focal retrocardiac opacity, more pronounced on the current examination than on the prior, may be compatible with pneumonia in the appropriate clinical context. Bridging anterior osteophytes are re-demonstrated in the thoracic spine. IMPRESSION: Retrocardiac opacity, more pronounced on the current examination than on the priors, may be compatible with pneumonia in the appropriate clinical context. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Fever Diagnosed with Pneumonia, unspecified organism temperature: 98.3 heartrate: 88.0 resprate: 18.0 o2sat: 96.0 sbp: 150.0 dbp: 79.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at ___. Why you were in the hospital: - fever What was done for you in the hospital: - we obtained blood cultures and an x-ray which did not show any signs of worsening infection - we continued your vancomycin antibiotic course What you should do after you leave the hospital: - Please take your medications as detailed in the discharge papers. If you have questions about which medications to take, please contact your regular doctor to discuss. - Please go to your follow up appointments as scheduled in the discharge papers. Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please monitor for worsening symptoms. If you do not feel like you are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. We wish you the best! Sincerely, Your ___ Care 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, vomiting Major Surgical or Invasive Procedure: Open cholecystectomy on ___ History of Present Illness: Ms. ___ is a ___ year-old Female acute onset RUQ pain, nausea and vomiting since ___ which resolved spontaneously initially. On ___ she had a persistent episode of abdominal pain, fever, and vomiting. Past Medical History: HTN, fibroids, dermatitis Social History: ___ Family History: Mother with breast ___ Physical Exam: Vitals: Temp 98.7 HR 64 BP 147/79 R18 97%Room air Gen: NAD, AOX3 CV: RRR Resp: CTAB Abd: Incision c/d/i. Former ___ site w/ c/d/i dressing ___ place. +BS, soft, NTND Ext: No edema bilat Pertinent Results: ___ Abdominal ultrasound: Final Report INDICATION: Nausea, vomiting, abdominal pain with elevated LFTs and white count, concerning for cholecystitis. COMPARISON: No prior studies available for comparison. FINDINGS: The liver is homogenous ___ echotexture without focal lesion. No intrahepatic biliary ductal dilatation. Main portal vein is patent and with hepatopetal flow. The gallbladder is distended and contains a 1 cm gallstone lodged ___ the neck. Areas of wall thickening on early images were not reproducible on repeated imaging. Large amount ot pericholecystic fluid however is evident. There is a non-mobile 2.4 x 1.5 x 3.1 cm polypoid hyperechoic nonshadowing lesion at the gallbladder fundus. Color doppler analysis demonstrates flow within the lesion which is supported by spectral doppler wave form. The adjacent gallbladder wall is not well seen. The common bile duct is not dilated measuring 5 mm. No pancreatic head mass identified. No pancreatic duct dilatation evident. Demonstrated portions of the right and left kidney are unremarkable. The spleen is not enlarged, measuring 9 cm. No free fluid identified within the abdomen. IMPRESSION: 1. Gallbladder distension with stone lodged ___ the neck and pericholecystic fluid worrisome for acute cholecystitis. 2. 3 cm hyperechoic nonshadowing lesion ___ the gallbladder, could represent mass lesion such as adenoma or malignancy. Alternatively, this may represent an adherent sludgeball with artifact mimicking vascular flow. Findings were discussed with Dr. ___ on ___ at 9:30 pm. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___. ___ ___ CT Abd/Pelvis Final Report CT ABDOMEN PELVIS WITH CONTRAST, ___. HISTORY: ___ female with two days of nausea and vomiting and abdominal pain, increased white blood cell count and LFTs. TECHNIQUE: Contiguous axial images were obtained through the abdomen and pelvis after the administration of intravenous contrast. Coronal and sagittal reformats were reviewed. Correlation is made to prior ultrasound from earlier the same day. FINDINGS: There are dependent regions of consolidation, suggestive of atelectasis. There is no pleural effusion. The gallbladder is distended with pericholecystic fluid and significant surrounding stranding ___ the entire right upper quadrant involving the area surrounding the duodenum and hepatic flexure of the colon. There are focal interruptions of enhancement of the gallbladder wall, both laterally (series 2, image 33) and at the posterior and anterior walls, best seen on sagittal images (series 602B, image 25). These are most concerning for wall necrosis. There is no hyperenhancing mass identified. The common bile duct is normal ___ caliber. There is no focal liver lesion identified. Liver margins appear intact even adjacent to the gallbladder fossa. There is, however hyperattenuation surrounding the gallbladder fossa, potentially secondary to inflammation from the gallbladder inflammation; however, a thromboses portal venous branch ___ this area whic can cause altered perfusion. Spleen, kidneys, adrenal glands, and pancreas are unremarkable. The stomach and small bowel are normal ___ caliber as is the colon. The appendix is unremarkable. Multiple fibroids identified within the uterus. Adnexa are unremarkable. There is a small amount of free fluid layering within the cul-de-sac. The bladder is unremarkable. There is no free intraperitoneal air. There is no adenopathy within the abdomen, specifically ___ the periportal region. Vascular structures are notable for common hepatic artery which arises directly from the aorta. ___ addition, the left portal vein arises from the branch of the right portal vein. Degenerative changes seen at L4-L5. No suspicious osseous lesions detected. IMPRESSION: 1. Findings consistent with acute cholecystitis with multifocal areas of interrupted mucosal enhancement worrisome for wall necrosis. No evidence of hyperenhancing lesion within the gallbladder, however evaluation by ultrasound would be more sensitive for this finding. No visualized adenopathy. 2. Hyperenhancement ___ the liver adjacent to the gallbladder fossa which could be due to adjacent inflammation; however, there is also suggestion of a thrombosed portal venous branch which can cause altered perfusion. 3. Free fluid seen tracking into the cul-de-sac. 4. Multifibroid uterus. Findings were discussed with Dr. ___ at approximately 9:30 p.m. on ___. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___: MON ___ 5:17 ___ ___ 9:25 am BILE Site: GALLBLADDER GALLBLADDER CONTENTS. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Preliminary): GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Procedure date Tissue received Report Date Diagnosed by ___ ___. ___ SURGICAL PATHOLOGY REPORT: Gallbladder, open cholecystectomy: 1.Acute gangrenous cholecystitis with foci of transmural necrosis, associated abscess and serositis with adhesion formation. 2.Scant adherent, cauterized hepatic parenchyma with involvement by acute inflammation, focal necrosis, granulation tissue formation and bile ducts with focally prominent intraductal neutrophils. 3.Cholelithiasis, cholesterol-type. Clinical: Acute cholecystitis. Gross: The specimen is received fresh labeled with the patient's name ___, medical record number and additionally labeled "gallbladder". It consists of a distended gallbladder that measures 9.4 x 4.6 x 1.2 cm. The serosa is focally gangrenous ___ appearance. The serosa is ___ inked blue. The cystic duct margin is identified and is probed patent. A cystic duct lymph node is not identified. The gallbladder is opened to reveal one cholesterol-type gallstone measuring up to 1.4 cm ___ greatest dimension. The mucosa adjacent to the cystic duct margin is ulcerated measuring 6.5 x 3.5 cm. There are also multiple ulcers ___ the fundus measuring up to 2 cm ___ greatest dimension. The gallbladder wall measures up to 1 cm ___ thickness. The gallbladder is sectioned to reveal areas of apparent submucosal necrosis. No masses are seen. The cystic duct margin and a section of the ulcerated area adjacent to the cystic duct is represented ___ cassette A. Additional sections are submitted ___ cassette B. Medications on Admission: Lisinopril-HCTZ ___ mg PO q day Discharge Medications: 1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Take while using narcotic pain medication to prevent constipation. Disp:*60 Capsule(s)* Refills:*2* 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: Nausea, vomiting, abdominal pain with elevated LFTs and white count, concerning for cholecystitis. COMPARISON: No prior studies available for comparison. FINDINGS: The liver is homogenous in echotexture without focal lesion. No intrahepatic biliary ductal dilatation. Main portal vein is patent and with hepatopetal flow. The gallbladder is distended and contains a 1 cm gallstone lodged in the neck. Areas of wall thickening on early images were not reproducible on repeated imaging. Large amount ot pericholecystic fluid however is evident. There is a non-mobile 2.4 x 1.5 x 3.1 cm polypoid hyperechoic nonshadowing lesion at the gallbladder fundus. Color doppler analysis demonstrates flow within the lesion which is supported by spectral doppler wave form. The adjacent gallbladder wall is not well seen. The common bile duct is not dilated measuring 5 mm. No pancreatic head mass identified. No pancreatic duct dilatation evident. Demonstrated portions of the right and left kidney are unremarkable. The spleen is not enlarged, measuring 9 cm. No free fluid identified within the abdomen. IMPRESSION: 1. Gallbladder distension with stone lodged in the neck and pericholecystic fluid worrisome for acute cholecystitis. 2. 3 cm hyperechoic nonshadowing lesion in the gallbladder, could represent mass lesion such as adenoma or malignancy. Alternatively, this may represent an adherent sludgeball with artifact mimicking vascular flow. Findings were discussed with Dr. ___ on ___ at 9:30 pm. Radiology Report CHEST, TWO VIEWS: ___ HISTORY: ___ female with evidence of cholecystitis. Dry cough for last month. FINDINGS: PA and lateral views of the chest. No prior. Linear opacities at the lung bases are suggestive of subsegmental atelectasis. Costophrenic angles are grossly clear. Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. IMPRESSION: Bibasilar atelectasis without definite consolidation or other acute cardiopulmonary process. Radiology Report CT ABDOMEN PELVIS WITH CONTRAST, ___. HISTORY: ___ female with two days of nausea and vomiting and abdominal pain, increased white blood cell count and LFTs. TECHNIQUE: Contiguous axial images were obtained through the abdomen and pelvis after the administration of intravenous contrast. Coronal and sagittal reformats were reviewed. Correlation is made to prior ultrasound from earlier the same day. FINDINGS: There are dependent regions of consolidation, suggestive of atelectasis. There is no pleural effusion. The gallbladder is distended with pericholecystic fluid and significant surrounding stranding in the entire right upper quadrant involving the area surrounding the duodenum and hepatic flexure of the colon. There are focal interruptions of enhancement of the gallbladder wall, both laterally (series 2, image 33) and at the posterior and anterior walls, best seen on sagittal images (series 602B, image 25). These are most concerning for wall necrosis. There is no hyperenhancing mass identified. The common bile duct is normal in caliber. There is no focal liver lesion identified. Liver margins appear intact even adjacent to the gallbladder fossa. There is, however hyperattenuation surrounding the gallbladder fossa, potentially secondary to inflammation from the gallbladder inflammation; however, a thromboses portal venous branch in this area whic can cause altered perfusion. Spleen, kidneys, adrenal glands, and pancreas are unremarkable. The stomach and small bowel are normal in caliber as is the colon. The appendix is unremarkable. Multiple fibroids identified within the uterus. Adnexa are unremarkable. There is a small amount of free fluid layering within the cul-de-sac. The bladder is unremarkable. There is no free intraperitoneal air. There is no adenopathy within the abdomen, specifically in the periportal region. Vascular structures are notable for common hepatic artery which arises directly from the aorta. In addition, the left portal vein arises from the branch of the right portal vein. Degenerative changes seen at L4-L5. No suspicious osseous lesions detected. IMPRESSION: 1. Findings consistent with acute cholecystitis with multifocal areas of interrupted mucosal enhancement worrisome for wall necrosis. No evidence of hyperenhancing lesion within the gallbladder, however evaluation by ultrasound would be more sensitive for this finding. No visualized adenopathy. 2. Hyperenhancement in the liver adjacent to the gallbladder fossa which could be due to adjacent inflammation; however, there is also suggestion of a thrombosed portal venous branch which can cause altered perfusion. 3. Free fluid seen tracking into the cul-de-sac. 4. Multifibroid uterus. Findings were discussed with Dr. ___ at approximately 9:30 p.m. on ___. Radiology Report INDICATION: ___ female with cholecystitis now with fever and increased oxygen requirements, here to evaluate for pulmonary pathology. COMPARISON: Chest radiograph last performed on ___. FINDINGS: Frontal and lateral chest radiographs show decreased inspiratory lung volumes from ___. There is increased opacification at the bilateral lung bases with obscuration of the hemidiaphragm on the left greater than the right consistent with small bilateral pleural effusions, better assessed on the corresponding lateral radiograph with underlying atelectasis. However, in the correct clinical context, superimposed pneumonia should also be considered. No pneumothorax is present. The cardiac silhouette is incompletely assessed but overall unchanged. The mediastinal and hilar contours are within normal limits. IMPRESSION: Small bilateral pleural effusions with underlying atelectasis increased from ___. In the correct clinical context, superimposed pneumonia should also be considered. Gender: F Race: UNABLE TO OBTAIN Arrive by UNKNOWN Chief complaint: ABD PAIN Diagnosed with ACUTE CHOLECYSTITIS, ABDOMINAL PAIN RUQ, ABDOM/PELV SWELL/MASS UNSP SITE temperature: 97.6 heartrate: 82.0 resprate: 18.0 o2sat: 98.0 sbp: 128.0 dbp: 79.0 level of pain: 8 level of acuity: 3.0

Dear Ms. ___, you were admitted for acute cholecystitis, which is an infection of your gall bladder. You underwent an open cholecystectomy, or removal of your gall bladder. You tolerated this well and are ready to recover at home. You can resume a regular diet. Please take your pain medications as indicated. You can take tylenol ___ addition to your pain medications as needed as well. Do not take ___ over 4 grams per day of tylenol. You should continue your regular activity, but do not lift over 10 pounds at least for 3 weeks. You have steri strips (small bandages that help with wound healing) on your wound. These will fall off on their own with time. You may shower as needed. Pat the incision dry. You may leave it open to air. You can start bathing or immersing your wound underwater on ___ if so desired. Your former drain stitch wound will slowly close on its own. It is normal for it to leak a small amount of fluid. You can place a dry dressing or bandaid on the wound until it becomes more dry. Your final pathology is still pending. This will be reviewed at your follow up appointment, when scheduled by you. It was a pleasure to take care of you. We wish you a speedy recovery.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Fish Containing Products Attending: ___ Major Surgical or Invasive Procedure: none attach Pertinent Results: ADMISSION LABS =================== ___ 06:09PM BLOOD WBC-10.9* RBC-3.79* Hgb-10.9* Hct-34.6* MCV-91 MCH-28.8 MCHC-31.5* RDW-16.2* RDWSD-53.0* Plt ___ ___ 06:09PM BLOOD Neuts-71 Bands-15* Lymphs-8* Monos-4* Eos-0* ___ Metas-2* NRBC-1.7* AbsNeut-9.37* AbsLymp-0.87* AbsMono-0.44 AbsEos-0.00* AbsBaso-0.00* ___ 03:07AM BLOOD ___ PTT-28.9 ___ ___ 02:50PM BLOOD Glucose-134* UreaN-46* Creat-1.6* Na-144 K-5.1 Cl-99 HCO3-24 AnGap-21* ___ 03:07AM BLOOD ALT-110* AST-125* LD(LDH)-472* AlkPhos-66 TotBili-0.6 ___ 02:50PM BLOOD ___ ___ 02:50PM BLOOD cTropnT-0.25* ___ 08:37PM BLOOD cTropnT-0.13* ___ 03:07AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.6 ___ 04:00PM BLOOD calTIBC-173* Ferritn-1029* TRF-133* ___ 02:58PM BLOOD ___ pO2-27* pCO2-37 pH-7.46* calTCO2-27 Base XS-1 ___ 02:58PM BLOOD Lactate-5.7* ___ 02:58PM BLOOD O2 Sat-36 ___ 03:34AM BLOOD freeCa-1.11* IMAGING ================ ___ CXR Bilateral ground-glass opacities noted diffusely most suggestive of pulmonary edema though a component of edema not excluded ___ TTE IMPRESSION: Normal left ventricular wall thickness and cavity size and regional/global systolic function. Right ventricular cavity dilation with free wall hypokinesis. At least moderate mitral regurgitation. Mild to moderate pulmonary artery systolic hypertension. Dilated aortic sinus. Mild aortic regurgitation. No prior study available for comparison. CLINICAL IMPLICATIONS: The patient has a mildly dilated ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in ___ year; if previously known and stable, a follow-up echocardiogram is suggested in ___ years. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LevoFLOXacin 500 mg PO Q24H 2. Acidophilus Probiotic (acidophilus-pectin, citrus) 100 million cell-10 mg oral 1 capsule 3. Midodrine 5 mg PO BID 4. Tamsulosin 0.4 mg PO QHS 5. Budesonide 0.5 mg IH BID 6. Gabapentin 100 mg PO TID 7. GuaiFENesin ER 600 mg PO Q12H 8. Finasteride 5 mg PO DAILY 9. Brovana (arformoterol) 15 mcg/2 mL inhalation BID 10. Docusate Sodium 100 mg PO BID 11. DULoxetine ___ 60 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. Furosemide 20 mg PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 16. Donepezil 5 mg PO QHS 17. Heparin 5000 UNIT SC BID 18. melatonin 10 mg oral QHS 19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 20. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 21. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 22. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 23. Senna 8.6 mg PO DAILY:PRN Constipation - First Line 24. Fleet Enema (Mineral Oil) ___AILY:PRN constipation; use only if bisacodyl suppository is ineffective Discharge Medications: 1. LORazepam 0.5 mg PO Q2H:PRN anxiety or pain RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth Every 2 hours as needed Disp #*10 Tablet Refills:*0 2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg PO Q1H:PRN Pain - Moderate RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.1 ml by mouth as needed for shortness of breath Refills:*0 3. Scopolamine Patch 1 PTCH TD Q72H 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 7. Budesonide 0.5 mg IH BID 8. Docusate Sodium 100 mg PO BID 9. DULoxetine ___ 60 mg PO DAILY 10. Gabapentin 100 mg PO TID 11. GuaiFENesin ER 600 mg PO Q12H 12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 13. melatonin 10 mg oral QHS 14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 15. Senna 8.6 mg PO DAILY:PRN Constipation - First Line Discharge Disposition: Home with Service Facility: ___ Discharge Diagnosis: PRIMARY ================================== Aspiration pneumonia SECONDARY ================================== COPD exacerbation MR ___ anemia Hypernatremia Lactic acidosis BPH Dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with respiratory distress, tx for PNA// eval PNA COMPARISON: None FINDINGS: AP portable upright view of the chest. Overlying EKG leads are present. Motion artifact limited exam. There is bilateral diffuse ground-glass opacity which is concerning for pulmonary edema, though a subtle superimposed pneumonia is impossible to exclude. No large effusion is seen. No pneumothorax. Cardiomediastinal the heart size is grossly normal. The mediastinal contour is slightly prominent likely reflecting a slightly tortuous thoracic aorta. Bony structures appear intact. IMPRESSION: Bilateral ground-glass opacities noted diffusely most suggestive of pulmonary edema though a component of edema not excluded. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: Mr. ___ is a ___ male with hx of COPD on 3L of home O2, pHTN, valvular disease, dementia, and recent admission for PNA (treated with levofloxacin), who was admitted to the MICU with acute hypoxic failure and fevers, concerning for COPD exacerbation secondary to pneumonia vs pulmonary edema. After broad antibiosis and diuresis, his respiratory status is now stable for the floor. // Eval for PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.3 s, 30.9 cm; CTDIvol = 5.6 mGy (Body) DLP = 174.1 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 0.9 mGy (Body) DLP = 0.4 mGy-cm. 3) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. Total DLP (Body) = 176 mGy-cm. COMPARISON: None FINDINGS: HEART AND VASCULATURE: No evidence of a pulmonary arterial embolus. Evaluation of small vessels is limited by motion. The ascending aorta is normal in caliber. Aortic arch is mildly ectatic without evidence of aneurysm. Minimal atherosclerotic calcifications are seen along the descending aorta without evidence of aneurysm or mural thrombus. There is no evidence of aortic dissection. The great arch vessels show normal configuration and caliber. The heart is mildly enlarged. There is no pericardial effusion. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No evidence of a mediastinal mass. The esophagus is mildly ectatic. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: The trachea appears patulous, that may relate to tracheobronchomalacia. Mucus impaction is noted in lower lobe bronchi bilateral. There is mild bronchiectasis throughout the lungs. Moderate to severe centrilobular emphysematous changes are present predominantly in the upper and mid lungs. Marked bilateral airspace opacification are noted dependently in the lower lobes as well as to a lesser degree in the dependent aspect of the upper lobes highly suggestive of aspiration/aspiration pneumonia. A cluster of small nodules vs a single lobulated nodule in the right middle lobe (301:139) measures up to 7 mm is most likely infective/inflammatory BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: A 1.4 cm area of low density is identified at the anterior superior aspect of the left hepatic lobe (2:95, 602:41), most likely related to partial volume averaging. Otherwise the included upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? Bridging osteophytes are noted throughout the thoracic spine. There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary arterial embolism. Evaluation of segmental and subsegmental arterial branches is limited by motion artifact. No thoracic aortic aneurysm, dissection or intramural thrombus. 2. Mucous plugging/aspirate in the lower lobe bronchi with associated marked dependent airspace consolidation predominantly in the lower lobes as well as to a lesser degree in the upper lobes with the distribution highly suggestive of massive aspiration/aspiration pneumonia. 3. Moderate centrilobular emphysema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ h/o COPD on 3L of home O2, pHTN, valvular disease, dementia, and recent admission for PNA (treated with levofloxacin), who was admitted to the MICU with acute hypoxic respiratory failure and fever, w/ CT findings c/f aspiration PNA. // ? aspiration vs. acute process TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: Diffuse bilateral airspace opacities are again visualized likely reflecting aspiration/pneumonia. This is superimposed on a background of emphysema. There is no pleural effusion or pneumothorax. The size of the cardiac silhouette is at the upper limits of normal. IMPRESSION: Diffuse bilateral airspace opacities are not significantly changed when compared to the prior CT chest given differences in technique. These are suspicious for aspiration/pneumonia. Gender: M Race: UNKNOWN Arrive by AMBULANCE Chief complaint: Altered mental status, Respiratory distress Diagnosed with Acute respiratory distress temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: u level of acuity: 1.0

Dear Mr. ___, It was a pleasure taking care of you at ___! Why were you admitted to the hospital? ============================= - You were admitted to the ___ due to swallowing something into your lungs, leading to infection of the lungs What was done while you were at the hospital? ============================= - You were admitted to the intensive care unit for this swallowing into your lungs episode - You were started on antibiotics - You underwent a scan of your lungs which showed a big infection of the lungs from swallowing contents into them - You were continued on antibiotics focused on the infection in your lungs - The speech and swallow team also came to see you and determined that there is risk associated with continuing to eat/drink - We had a goals of care discussion with your family, and determined that you would like to be comfort focused care - You will go home with hospice, focused on comfort care What should you do when you leave the hospital? ============================= - Enjoy your time at home with family - We hope you are able to enjoy your 91st birthday with them Yours sincerely, The ___ 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: Shortness of breath, leg swelling, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo man with a hx of ischemic cardiomyopathy (EF 40%) and HTN who presents with ___ weeks of gradually increasing lower extremity edema, dyspnea on exertion, scrotal edema, and abdominal distention. He presented to ___ clinic today to establish care with his new PCP. At that visit noted to be visibly dyspneic. Reporting productive cough with yellow-green phlegm ___ weeks. No fevers/chills. Of note his weight was up to 105.6 kg from 99.7kg last week. (D/c weight from ___. He checks his BP daily and noted to be elevated to the 180s/80-90s. He ran out of his Rx for lisinopril, Lasix, and atorvastatin so has not been taking the past ___ months. Has been taking metoprolol XL 12.5mg po daily and aspirin 81mg po daily. His BP in the office was noted to be 215/115. Exam with significant volume overload. ECG with SR, HR 78, mild V2 ST-E, similar to baseline. He was referred to the ED for further evaluation and treatment of CHF exacerbation. In the ED, initial vitals were: 99.8 96 ___ RA - Exam notable for: bibasilar crackles, abdominal distention, ___ SEM, and 3+ pitting edema - Labs notable for: BNP 2314, Cre 1.0, WBC 14.7, H/H 13.9/42.1, U/A unremarkable - Imaging was notable for: CXR without acute cardiopulmonary process - Patient was given: Furosemide 40 mg IV x 1, labetolol 100mg po x 1 - Decision to admit for CHF exacerbation - Vitals prior to transfer: 92 147/79 20 94% RA Upon arrival to the floor, patient reports that his cough has already improved with diuresis, although still present. Productive yellow sputum. Notes nasal congestion and itchy, watery eyes that generally happen this time of year. Reports noticing leg swelling because his skin felt tight. Feels his breathing and cough worsened over the past ___ days. No fevers/chills. No chest pain. No headaches or changes in vision. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI. Negative for fevers/chills, chest pain, palpitations, PND, orthopnea, focal numbness/weakness, diarrhea, BRBPR, melena. Past Medical History: HTN Ischemic HFrEF (dx ___: EF 40% repeat ___: EF 40% inferior apical hypokinesis) LLE ___ cyst Subclinical Hypothyroidism Dental problems Social History: ___ Family History: Father is deceased from a stroke (age ___, and he also had skin cancer. He died at age ___. Mother died at age ___ and had severe PUD. Family history is otherwise only notable for a brother with migraines, but is negative for other cancers or premature CAD. Of note an uncle had a major complication during heart catheterization. Physical Exam: ================================= ADMISISON PHYSICAL EXAM ================================= Vital Signs: 98.0 136/72 80 18 96%RA Weight on admission: 101.5 kg (223 lbs - reports dry weight of 196 lbs) General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP elevated to the ear. no LAD CV: Regular rate and rhythm. Normal S1+S2, II/VI systolic murmur Lungs: Crackles about half-way up bases bilaterally; no appreciable wheezes Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pitting edema to the thighs bilaterally with overlying erythema LLE>RLE Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. ================================= DISCHARGE PHYSICAL EXAM ================================= - VITALS: T: 98.1 BP: 136/84 (99-150/52-84) HR: 67 (64-79) RR: 18 SO2: 97% (95-99%) RA - Weight: 94.0kg - Weight on admission: 101.5 kg (223 lbs - reports dry weight of 196 lbs, discharge dry weight of 89.1 kg) General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Resolution of mild injection of left eye, resolution of mild tenderness to palpation over maxillary sinus. No preauricular lymphadenopathy. Neck: Supple. JVP flat at ninety degrees. no LAD CV: Regular rate and rhythm. Normal S1+S2, no m/r/g Lungs: CTAB, no respiratory distress Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley, decreasing but still large scrotal edema Ext: Warm, well perfused, trace pitting edema with overlying erythema LLE>RLE Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. Pertinent Results: ================================= ADMISISON LABS ================================= ___ 08:45PM BLOOD WBC-14.7*# RBC-4.42* Hgb-13.9 Hct-42.1 MCV-95 MCH-31.4 MCHC-33.0 RDW-13.0 RDWSD-45.7 Plt ___ ___ 08:45PM BLOOD Neuts-84.5* Lymphs-5.4* Monos-8.4 Eos-1.1 Baso-0.3 Im ___ AbsNeut-12.41*# AbsLymp-0.80* AbsMono-1.23* AbsEos-0.16 AbsBaso-0.05 ___ 02:48AM BLOOD ___ PTT-26.7 ___ ___ 08:45PM BLOOD Glucose-117* UreaN-15 Creat-1.0 Na-139 K-3.9 Cl-102 HCO3-23 AnGap-18 ___ 02:48AM BLOOD ALT-16 AST-17 LD(LDH)-250 AlkPhos-104 TotBili-0.6 ___ 08:45PM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-2314* ___ 02:48AM BLOOD CK-MB-4 cTropnT-0.01 ___ 02:48AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8 Iron-16* Cholest-146 ================================= PERTINENT LABS ================================= ___ 08:45PM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-2314* ___ 02:48AM BLOOD CK-MB-4 cTropnT-0.01 ___ 02:48AM BLOOD Iron-16* ___ 02:48AM BLOOD calTIBC-260 Ferritn-119 TRF-200 ___ 03:02AM BLOOD %HbA1c-5.4 eAG-108 ___ 02:48AM BLOOD Triglyc-64 HDL-73 CHOL/HD-2.0 LDLcalc-60 ___ 08:45PM BLOOD TSH-5.0* ___ 08:45PM BLOOD Free T4-1.0 ================================= IMAGING ================================= CHEST X-RAY ___: No acute cardiopulmonary process. TTE ___: The left atrial volume index is mildly increased. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal inferior/inferolateral hypokinesis. The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Torn mitral chordae are present. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the findings are similar. ================================= DISCHARGE LABS ================================= ___ 07:15AM BLOOD WBC-8.8 RBC-4.24* Hgb-13.3* Hct-41.3 MCV-97 MCH-31.4 MCHC-32.2 RDW-13.0 RDWSD-46.0 Plt ___ ___ 08:45PM BLOOD Neuts-84.5* Lymphs-5.4* Monos-8.4 Eos-1.1 Baso-0.3 Im ___ AbsNeut-12.41*# AbsLymp-0.80* AbsMono-1.23* AbsEos-0.16 AbsBaso-0.05 ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-95 UreaN-68* Creat-1.8* Na-140 K-4.5 Cl-101 HCO3-27 AnGap-17 ___ 07:15AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.7* Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: ___ year old man with hx of CHF has had a cough for 2 days// r/o PNA, CHF TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: The patient is rotated slightly to the right. Given this, no focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac silhouette remains enlarged. The aorta tortuous. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hypertension Diagnosed with Essential (primary) hypertension temperature: 99.8 heartrate: 96.0 resprate: 20.0 o2sat: 96.0 sbp: 251.0 dbp: 118.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ for heart failure and uncontrolled blood pressure. While you were in the hospital: - we gave you IV then oral medications to help remove fluid - we gave you medications to help control your blood pressure - we gave medications to help with your allergies and eye inflammation - you had a repeat ultrasound of your heart that showed decreasing pumping (lower ejection fraction) - After extensive discussion of risk and benefit, you decided you would not want a cardiac catheterization given your reservations about risks associated. A pharmacological stress test showed no reversible defect Now that you are going home: - weigh yourself every day and call your primary care doctor ___ cardiologist) if you gain more than 3 lbs in two days - eat a low salt diet - take your medications every day, if your run out please call your primary care doctor It was a pleasure taking care of you! -Your ___ Inpatient Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Penicillins / albuterol Attending: ___ Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catherization ___ History of Present Illness: This is a ___ yo F with CAD s/p CABG (___) with recurrent admissions due to chest pain with DES placed to LAD and POBA to ostial ___ diagonal artery on ___ who was transfered here from an outside hospital due to chest pain. The patient noted mild, left sided chest pain 2 days prior to admission. The patient has been compliant with her medications including aspirin and plavix. Last night, the pain became worse and woke the patient up from sleep around 1AM. The patient's pain starts under her left breast and radiates above the breast and across the chest. The pain also radiates to the left elbow. The patient describes this pain as the same as her cardiac pain prior to the stent placement. When the patient awaoke, she took 1 nitro with some relief. She awoke again with the same pain and took ___ more nitros. When the pain did not resolve, the patient called the ambulance. The patient says that she had mild nausea, diaphoresis, and palpitations associated with these episodes. She denied SOB. The patient says that the pain was worse with deep breaths but was not positional. At the OSH, the patient was given nitropaste, bloodwork did not reveal any abnormalities, and the EKG was not concerning. The patient was started on a heparin gtt and transfered here for further workup. . Initial VS: 99.2 72 118/48 12 100% 2L nc. On interview, the patient was chest pain free. . REVIEW OF SYSTEMS + recent Stroke On review of systems, no bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Cardiac Risk Factors: Diabetes(+),Dyslipidemia(+),Hypertension(+) # CAD -- s/p MI in ___ (2v CAD on cardiac cath) # CABG -- ___ with mitral valve repair and MAZE # Chronic Diastolic Congestive Heart Failure -- LVEF 50% on ___ with mild regional systolic dysfunction # Paroxysmal atrial fibrillation -- no episodes since MAZE -- no longer on Coumadin # WPW s/p ablation # Pulmonary hypertension # Hypertension # Hyperlipidemia # Diabetes Mellitus Type 2 # Hypothyroidism s/p thyroid irradiation -- previously hyperthyroid many years ago # COPD # Carotid Stenosis # Kidney Stones # Tonsillectomy # H/o viral gastroenteritis # GERD Social History: ___ Family History: # Mother -- heart murmur # Children -- two sons with arrhythmia, one died from MI at age ___, daughter with thyroid cancer # Maternal Grandmother -- diabetes Physical ___: VS: T= 97.4 BP= 128/70 HR= 88 RR= 20 O2 sat= 98% RA GENERAL: Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP not elevated. CARDIAC: Normal sinus rhythm. Nl S1, S2, ___ systolic ejection murmur at RUSB that does not obscure S2, radiation to carotids. no S3, S4 LUNGS: Distant breath sounds. No crackles, wheezes, or consolidations ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: trace ___ edema, left calf tenderness NEURO: CN II-XII tested and intact, strength ___ throughout, sensation grossly normal. Gait not tested. Pertinent Results: ADMISSION LABS: ___ 01:30PM BLOOD WBC-7.9 RBC-4.00* Hgb-12.2 Hct-37.8 MCV-94 MCH-30.4 MCHC-32.3 RDW-13.4 Plt ___ ___ 01:30PM BLOOD Neuts-62.3 ___ Monos-4.2 Eos-1.3 Baso-1.2 ___ 01:30PM BLOOD ___ PTT-31.4 ___ ___ 01:30PM BLOOD Glucose-123* UreaN-24* Creat-1.0 Na-140 K-3.8 Cl-103 HCO3-26 AnGap-15 ___ 01:30PM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-9.6 RBC-3.40* Hgb-10.7* Hct-33.3* MCV-98 MCH-31.4 MCHC-32.2 RDW-13.9 Plt ___ ___ 07:20AM BLOOD ___ PTT-25.1 ___ ___ 07:20AM BLOOD Glucose-115* UreaN-22* Creat-0.9 Na-138 K-3.9 Cl-102 HCO3-30 AnGap-10 ___ 07:20AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.9 Cardiac Enzymes: ___ 01:30PM BLOOD cTropnT-<0.01 ___ 10:00PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 08:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:48PM BLOOD CK-MB-10 ___ 07:20AM BLOOD CK-MB-20* ___ 10:00PM BLOOD CK(CPK)-48 ___ 08:00AM BLOOD CK(CPK)-33 LENIs: No clot ___ ============= Cardiac Cath: See OMR for final report. Not dictated by time of discharge. Medications on Admission: Plavix 75mg Qday Atorvastatin 80mg Qday Nitro SL PRN Lisinopril 2.5mg Qday Tylenol PRN Glimepiride 1mg Qday Levothyroxinw 88mcg Qday Metoprolol XL 100mg Qday Spiriva Qday Colace Ranolazine 500mg Qday Lasix 40mg Qday Protonix 40mg Qday Aspirin 325mg Qday Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Qday (). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 10. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis - Coronary artery disease - Unstable Angina Secondary diagnosis - Pulmonary hypertension - Hypertension - Hyperlipidemia - Diabetes Mellitus Type 2 - Hypothyroidism s/p thyroid irradiation - COPD - GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report PORTABLE CHEST: ___ HISTORY: ___ female with recurrent chest pain and recent stents. Question effusions or CHF. FINDINGS: Single portable view of the chest is compared to previous exam from ___. When compared to prior, there has been slight interval improvement of the left basilar opacity with blunting the left costophrenic angle and suggestive of effusion and possible associated atelectasis. Elsewhere, the lungs are clear. Cardiomediastinal silhouette is stable as are the osseous structures. IMPRESSION: Small persistent left basilar opacity suggestive of small effusion and possible atelectasis. Two-view chest x-ray may offer additional detail if desired. Radiology Report INDICATION: ___ female with chest pain and lower extremity tenderness. ___. FINDINGS: Grayscale and color Doppler sonograms were performed of bilateral lower extremities, demonstrating normal compressibility, color flow, and augmentation in the common femoral, superficial femoral, and popliteal veins. There is also normal color flow in the posterior tibial and peroneal veins. IMPRESSION: No evidence of DVT. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with CAD UNSPEC VESSEL, NATIVE OR GRAFT, CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: 99.2 heartrate: 72.0 resprate: 12.0 o2sat: 100.0 sbp: 118.0 dbp: 48.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You came to our hospital for scheduled catheterization of your coronary arteries. She tolerated the procedure very well. During the procedure, we opened up with a right sided coronary artery with a drug eluting stent. You also underwent an ultrasound of your legs, which did not reveal any blood clots. We continued all your home medications, and you should be able to go home today. . No changes were made to your home medication list. . It has been a pleasure taking care of you here at ___. We wish you a speedy recovery. 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: F Service: MEDICINE Allergies: Luvox / Serzone / Zoloft / Prozac / Bupropion / Lisinopril Attending: ___ Chief Complaint: Fever, nausea/vomiting, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with HTN, depression, abnormal LFTs and obesity who presents with 3 days of N/V, abd pain and fevers. She states that starting approx ___, she had malaise and pain in "every joint." She also began to have nausea and non-bloody non-bilious vomiting. She did not take much PO during this time. She reports that she felt warm, but did not have a thermometer to take her temp, she also endorses chills. No abdminal pain, no diarrhea or constipation. She endorses dysuria for the past day, no frequency or change in color/odor or urine. Lastly, she states she has been having low back pain in the ___ her back during the past few days as well. No coughing or SOB, no chest pain, no bloody of black stools. In the ___, she was hypotensive to the ___ systolic and initially febrile to 100.4F. UA was positive and she received ceftriaxone and 1L NS. Labs were notable for WBC 21, Hct 27, Lactate of 1.6. She was transferred to the ___ ___ because there were no ICU beds there. In the ___ ___, initial VS were 98.3 86 ___ 16 89% ra. CT abd/pelvis showed left perinephric stranding which was thought to be from pyelo vs diverticulitis. She received 2L NS, Flagyl 500mg IV, Zofran 4mg IV and 40mEq KCl. Labs notable for WBC of 19 with left shift, Cr of 1.7, Lactate of 2.6, INR of 1.5 and a grossly positive UA with >182 WBCs. Currently, she is feeling well with minimal complaints. She has mild nausea but no further vomiting. She denies any pain at this time. REVIEW OF SYSTEMS: Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -HTN -Obesity -Depression -H/o elevated LFTs -OA Social History: ___ Family History: Father - CAD and colon CA Maternal aunt - breast CA SOCIAL HISTORY: Single and lives alone, retired. Tobacco - former, quit ___ years ago EtOH - denies Illicits - denies Physical Exam: Admission: VITALS: T 100.0F BP 104/59 HR 94 RR 20 ___ GENERAL: Awake and alert, NAD HEENT: PERRL, EOMI NECK: JVP difficult to assess given habitus LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, obese, NABS, no organomegaly BACK: No CVA tenderness appreciated EXTREMITIES: No c/c/e. 2+ DP pulses bilat. NEUROLOGIC: A+OX3. Moving all extremities, no focal deficits appreciated Discharge: Pertinent Results: I. Labs A. Admission ___ 11:00PM BLOOD WBC-19.6*# RBC-3.64* Hgb-10.5* Hct-31.0* MCV-85 MCH-28.9 MCHC-34.0 RDW-13.7 Plt ___ ___ 11:00PM BLOOD Neuts-89.6* Lymphs-8.2* Monos-2.0 Eos-0 Baso-0.1 ___ 11:00PM BLOOD ___ PTT-34.1 ___ ___ 11:00PM BLOOD Glucose-135* UreaN-39* Creat-1.7* Na-139 K-3.4 Cl-101 HCO3-27 AnGap-14 ___ 11:00PM BLOOD ALT-24 AST-20 AlkPhos-93 TotBili-0.5 ___ 11:00PM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.5* Mg-2.1 ___ 11:11PM BLOOD Lactate-2.6* B. Last set of labs ___ 10:30AM BLOOD WBC-12.5* RBC-3.09* Hgb-8.8* Hct-26.3* MCV-85 MCH-28.5 MCHC-33.5 RDW-14.0 Plt ___ ___ 10:30AM BLOOD Plt ___ ___ 08:42AM BLOOD ___ ___ 10:30AM BLOOD Glucose-116* UreaN-14 Creat-0.9 Na-139 K-4.2 Cl-104 HCO3-24 AnGap-15 ___ 10:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0 II. Microbiology Please see inpatient record for ___ microbiology report ___ URINE URINE CULTURE-FINAL: <10,000 ___ BLOOD CULTURE Blood Culture, Routine-FINAL: no growth ___ BLOOD CULTURE Blood Culture, Routine-FINAL: no growth III. Radiology A. CT Abd/pelvis (___) Final Report HISTORY: ___ female with fever, abdominal pain and hypotension. COMPARISON: None available. TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness. Intravenous contrast was administered. Coronal and sagittal reformations were prepared. CT ABDOMEN WITH INTRAVENOUS CONTRAST: Minimal atelectasis is identified in the left lung base. Additionally, there is a 7-mm pulmonary nodule in the left lower lobe (2:10). No pleural effusion is identified. There is homogeneous enhancement of the liver without suspicious focal lesion. The hepatic veins and portal venous system appear grossly patent. No intra- or extra-hepatic biliary ductal dilatation is identified. The gallbladder is filled with stones; however, no gallbladder wall thickening or pericholecystic fluid is identified. The spleen, pancreas, and adrenal glands appear normal. There is thickening of the left anterior and posterior perirenal fascia with surrounding fat stranding. Additionally, there is a large area of relative ___ of the left kidney as compared to the right. Overall, findings reflect pyelonephritis given the clinical history of recently treated urinary tract infection. The left renal artery appears patent. There is no surrounding fluid collection. There is symmetric excretion of both kidneys without hydronephrosis. No focal mass lesion is identified. There is no abdominal free fluid or free air. The stomach and small bowel loops are normal in caliber and configuration without evidence of obstruction or inflammation. Scattered colonic diverticula. The appendix is not clearly visualized; however, there are no secondary signs of acute appendicitis. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, uterus and adnexa are unremarkable. Foley catheter and a small amount of air are visualized within a decompressed bladder. There is no pelvic free fluid. OSSEOUS STRUCTURES: There is an S-shaped scoliosis of the thoracolumbar spine. Multilevel degenerative changes of the spine are noted with grade 1 retrolisthesis of L5 on S1. There is significant facet arthropathy and severe right hip degenerative changes with axial joint space narrowing, erosions, and medial femoral neck bony buttressing. However, no acute bone destructive lesion is identified. IMPRESSION: 1. Findings consistent with acute left sided pyelonephritis. 2. 7-mm left lower lobe pulmonary nodule. Per ___ ___ guidelines, if patient is a nonsmoker and has low risk for malignancy, followup chest CT at ___ months initially is recommended. However, if patient is a smoker with high risk for malignancy, followup chest CT at 3 to 6 months is recommended. 3. Multiple gallstones. 4. Severe right hip degenerative changes and suggestion of superimposed inflammatory arthropathy. B. CXR (___) CHEST RADIOGRAPH INDICATION: Sepsis from urinary source. New oxygen requirements. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. No pulmonary edema. No pneumonia. No areas of atelectasis. Increased radiodensity over the left basal hemithorax is caused by a different patient position. No pneumothorax. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Amlodipine 5 mg PO DAILY Hold for SBP <100 2. Chlorthalidone 50 mg PO DAILY Hold for SBP <100 3. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 4. Lorazepam 1 mg PO BID 5. Losartan Potassium 100 mg PO DAILY Hold for SBP <100 6. Venlafaxine XR 75 mg PO DAILY 7. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain 8. Ascorbic Acid ___ mg PO DAILY 9. Glucosamine Sulf-Chondroitin *NF* (glucosamine ___ 2KCl-chondroit) 500-400 mg Oral daily Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. Lorazepam 1 mg PO BID 3. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain 4. Venlafaxine XR 75 mg PO DAILY 5. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 6. Amlodipine 5 mg PO DAILY Hold for SBP <100 7. Glucosamine Sulf-Chondroitin *NF* (glucosamine ___ 2KCl-chondroit) 500-400 mg Oral daily 8. Ciprofloxacin HCl 500 mg PO Q12H The last day of medication is ___. RX *Cipro 500 mg 1 Tablet(s) by mouth every 12 hours Disp #*20 Capsule Refills:*0 9. Chlorthalidone 50 mg PO DAILY Hold for SBP <100 Discharge Disposition: Home Discharge Diagnosis: Primary: sepsis from a urinary source (E. coli) with pyelonephritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with fever, abdominal pain and hypotension. COMPARISON: None available. TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness. Intravenous contrast was administered. Coronal and sagittal reformations were prepared. CT ABDOMEN WITH INTRAVENOUS CONTRAST: Minimal atelectasis is identified in the left lung base. Additionally, there is a 7-mm pulmonary nodule in the left lower lobe (2:10). No pleural effusion is identified. There is homogeneous enhancement of the liver without suspicious focal lesion. The hepatic veins and portal venous system appear grossly patent. No intra- or extra-hepatic biliary ductal dilatation is identified. The gallbladder is filled with stones; however, no gallbladder wall thickening or pericholecystic fluid is identified. The spleen, pancreas, and adrenal glands appear normal. There is thickening of the left anterior and posterior perirenal fascia with surrounding fat stranding. Additionally, there is a large area of relative ___ of the left kidney as compared to the right. Overall, findings reflect pyelonephritis given the clinical history of recently treated urinary tract infection. The left renal artery appears patent. There is no surrounding fluid collection. There is symmetric excretion of both kidneys without hydronephrosis. No focal mass lesion is identified. There is no abdominal free fluid or free air. The stomach and small bowel loops are normal in caliber and configuration without evidence of obstruction or inflammation. Scattered colonic diverticula. The appendix is not clearly visualized; however, there are no secondary signs of acute appendicitis. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, uterus and adnexa are unremarkable. Foley catheter and a small amount of air are visualized within a decompressed bladder. There is no pelvic free fluid. OSSEOUS STRUCTURES: There is an S-shaped scoliosis of the thoracolumbar spine. Multilevel degenerative changes of the spine are noted with grade 1 retrolisthesis of L5 on S1. There is significant facet arthropathy and severe right hip degenerative changes with axial joint space narrowing, erosions, and medial femoral neck bony buttressing. However, no acute bone destructive lesion is identified. IMPRESSION: 1. Findings consistent with acute left sided pyelonephritis. 2. 7-mm left lower lobe pulmonary nodule. Per ___ Society guidelines, if patient is a nonsmoker and has low risk for malignancy, followup chest CT at ___ months initially is recommended. However, if patient is a smoker with high risk for malignancy, followup chest CT at 3 to 6 months is recommended. 3. Multiple gallstones. 4. Severe right hip degenerative changes and suggestion of superimposed inflammatory arthropathy. Findings wet read to the ER via electronic dashboard. Radiology Report CHEST RADIOGRAPH INDICATION: Sepsis from urinary source. New oxygen requirements. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. No pulmonary edema. No pneumonia. No areas of atelectasis. Increased radiodensity over the left basal hemithorax is caused by a different patient position. No pneumothorax. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ? UROSEPSIS Diagnosed with URIN TRACT INFECTION NOS, DIVERTICULITIS OF COLON, HYPERTENSION NOS temperature: 98.3 heartrate: 86.0 resprate: 16.0 o2sat: 89.0 sbp: 93.0 dbp: 78.0 level of pain: 0 level of acuity: 1.0

It was a pleasure caring for you during your hospitalization. You were hospitalized for a urinary tract/kidney infection called pyelonephritis. You will need to take an antibiotic called ciprofloxacin until ___. Physical therapy saw you and thought you would benefit from home ___, but you refused. You understood the risks of refusing physical therapy at home. We also found a lung nodule on your CAT scan. You will need to talk to your primary care doctor about ___ repeat CAT scan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Percocet / levofloxacin Attending: ___ ___ Complaint: left knee pain and drainage Major Surgical or Invasive Procedure: ___: left knee revision by ___, MD History of Present Illness: ___ s/p left TKA in ___ and recent PJI in ___, now presents with another PJI and will undergo a left total knee revision on ___ Past Medical History: PMH: OSA (s/p Uvulopalatopharyngoplasty, tonsillectomy in ___, lost 30 lbs ->sx resolved), obesity, Left knee Injuries, Right Fifth Digit Fracture, Left Arm Fracture, right ear tubes PSH: s/p left TKA ___, L TKA manipulation ___ Knee ACL Reconstruction x2, Left Knee Arthroscopies x4, s/p L knee polyliner exchange (___) with recent MRSA prosthetic joint infection in s/p debridement/washout (___) with retention of prosthesis Social History: ___ Family History: non contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Scant serosanguinous drainage on dressing * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rifampin 150 mg PO 3 CAPSULES BY MOUTH TWICE A DAY 2. Sulfameth/Trimethoprim DS 1 TAB PO BID 3. Multivitamins 1 TAB PO DAILY 4. lactobacillus combination ___ billion cell oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #*100 Tablet Refills:*0 2. Daptomycin 750 mg IV Q24H RX *daptomycin 500 mg 1.5 Vials IV every 24 hours Disp #*63 Vial Refills:*0 3. Docusate Sodium 100 mg PO BID Stop taking if having loose stools RX *docusate sodium 100 mg 1 capsule by mouth twice a day Disp #*60 Capsule Refills:*2 4. Enoxaparin Sodium 40 mg SC DAILY Take daily for 28 days RX *enoxaparin 40 mg/0.4 mL 0.4 ml SC daily Disp #*28 Syringe Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain Do not drive or consume alcohol while taking med RX *oxycodone 10 mg ___ tablet(s) by mouth every 3 to 4 hours Disp #*84 Tablet Refills:*0 6. Senna 8.6 mg PO BID Stop taking if having loose stools RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*2 7. lactobacillus combination ___ billion cell oral DAILY 8. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left knee prosthetic joint 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: KNEE (AP, LAT AND OBLIQUE) LEFT INDICATION: History: ___ with left knee pain, atraumatic, swelling// Left knee pain, atraumatic, swelling IMPRESSION: In comparison with the study of ___, there appears to be a new total knee arthroplasty in place, which appears well seated without evidence of hardware-related complication. Radiology Report EXAMINATION: KNEE (2 VIEWS) LEFT INDICATION: ___ year old man s/p explant of left total knee replacement// eval of knee eval of knee TECHNIQUE: Frontal and lateral radiographs of left knee. COMPARISON: ___. IMPRESSION: Status post explant of left knee total arthroplasty. Metallic staple is again seen along the lateral distal femoral metaphysis. Femoral and tibial intramedullary wires are seen. Antibiotic spacers are in place. Soft tissue gas, skin staples, and drains are consistent with perioperative state. Brace is seen overlying the knee. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old man with PICC// Pt had a R PICC,55cm ___ ___ Contact name: ___: ___ TECHNIQUE: Chest, single AP portable view COMPARISON: Chest x-ray from ___ at 16:08 FINDINGS: A right subclavian PICC line is present. The tip lies at the SVC/RA junction. No pneumothorax is detected. Probable mild cardiomegaly with slight unfolding of the aorta, similar to ___. Upper zone redistribution, without overt CHF. Bibasilar atelectasis. No frank consolidation or gross effusion identified. Eventration of the right hemidiaphragm again noted. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L Knee pain Diagnosed with Pain in left knee temperature: 98.9 heartrate: 92.0 resprate: 16.0 o2sat: 100.0 sbp: 133.0 dbp: 106.0 level of pain: 10 level of acuity: 3.0

1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue Lovenox 40mg once daily for 4 weeks. If you were taking Aspirin prior to your surgery, please hold dose until you complete your course of Lovenox injections, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 3 weeks after surgery. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Non weight bearing on the operative extremity. Mobilize with assistive devices (___). ROM ___ degrees in ___ brace at all time. No strenuous exercise or heavy lifting until follow up appointment. 12. ___ CARE: Per protocol 13. WEEKLY LABS: draw on ___ and send result to ID RNs at: ___ R.N.s at ___. - CBC/DIFF - CHEM 7 - LFTS - ESR/CRP **All questions regarding outpatient parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when the clinic is closed. Physical Therapy: non weight bearing ___ brace at all times (ROM ___ degrees) mobilize frequently Treatments Frequency: Aquacel dressing to be removed on POD #7 (___), then DSD prn drainage Ice and elevate *Staples will be removed at your first post-operative visit in three(3)weeks*

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Right internal jugular central line placement (___) and removal (___) History of Present Illness: ___ PMH HTN, CAD, p/w dyspnea, productive cough and fatigue/dizziness for ___ days. He complains of a chronic cough for the past 2 months, which acutely worsened over the past several days. The patient stated that for ___ days he has had dyspnea at rest that is associated with productive cough. He describes the quality as greenish in nature. In addition, the patient is complaining of worsening BLLE swelling (R>L) for the past several years. He denied fevers/chills, chest pain, orthopnea, PND and palpitations. He denies sick contacts and recent travel. Per family at bedside, the patient refuses to go outside during the winter for fear of falling. They were attempting to convince him to visit his PCP for the worsening BLLE, however, he believed that due to his insurance, he was unable to see his PCP. The patient was transported via EMS to the ED. In the emergency department, he was found to be hypotensive and tachycardic, but was saturating at 100%. His exam was notable for bilateral lower extremity edema and bibasilar crackles. A proBNP was significantly elevated to 6766 and was diuresed with IV Lasix. A chest xray was also concerning for a lobar pneumonia and the patient was started on ceftriaxone and azithromycin. Shortly after receiving IV Lasix, the patient developed hypotension, was given a bolus of fluid and started on levophed. Subsequently, the patient developed afib with RVR. Levophed was held, but the patient had persistent hypotension and tachycardia to 150-170's. Cardiology was consulted, the ED and Cards decided to add esmolol for rate control and continue levophed for pressure management. A CT was also performed with concern for PE. It revealed a PNA, but no evidence of PE. In the ED, initial vitals were: Temp 98.3, HR 112, BP 105/70, RR 18 100% RA - Exam notable for: bilateral crackles, BLLE swelling R>L, systolic murmur. - Labs notable for: BUN/Creat 36/1.5, H/H 10.9/33.7, proBNP 6766, trop plateau at 0.03. - Imaging was notable for: CT: -- Right lower lobe bronchus is focally narrowed secondary to diffuse bronchial wall thickening. Bibasilar right greater than left atelectasis with a right lower lobe bronchopneumonia. No evidence of PE. - Patient was given: -ASA 81mg -Losartan Potassium 50mg -Omeprazole 20mg -Prazosin 2mg -Furosemide 40mg -Ceftriaxone 1gm IV -Azithromycin 500mg IV -Norepinephrine 0.03-0.25mcg -Esmolol 50-150mcg/kg/min Upon arrival to the ICU, patient reports significant symptomatic improvement. He denies dyspnea, DOE, chest pain, orthopnea, PND, abdominal pain, and n/v/d/c. Review of systems was negative except as detailed above. Past Medical History: BPH HTN AP Social History: ___ Family History: In siblings: CVA, HTN, CAD, and colon cancer. Physical Exam: ADMISSION EXAM: =============== GENERAL: well appearing elderly male, younger than stated age with RIJ central line in place. HEENT: NC, AT. IMMM. Nares patent. CARDIAC: irregular rhythm, no mgr PULMONARY: bilateral crackles CHEST: non-tender to palpation ABDOMEN: soft, non-tender, no HSM EXTREMITIES: no edema SKIN: intact NEURO: AOx3, cn2-12 intact, strength ___ in all extremities DISCHARGE EXAM: =============== GENERAL: Alert and interactive. In no acute distress. Laying in bed preparing to eat breakfast. Thin male, smiling. HEENT: Sclerae anicteric, MMM. CARDIAC: RRR LUNGS: No increased work of breathing. Crackles and rhonchi in lower lobes bilaterally, improved from yesterday. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No edema. SKIN: Warm. No rash. NEUROLOGIC: No focal deficits. Moving all four limbs spontaneously. Pertinent Results: ADMISSION LABS: =============== ___ 02:50PM BLOOD WBC-7.2 RBC-3.56* Hgb-10.9* Hct-33.7* MCV-95 MCH-30.6 MCHC-32.3 RDW-12.5 RDWSD-43.9 Plt ___ ___ 02:50PM BLOOD Plt ___ ___ 02:57PM BLOOD ___ PTT-25.2 ___ ___ 02:50PM BLOOD Glucose-130* UreaN-36* Creat-1.5* Na-134* K-5.3 Cl-101 HCO3-22 AnGap-11 ___ 02:50PM BLOOD CK(CPK)-137 ___ 02:50PM BLOOD CK-MB-4 proBNP-6766* ___ 02:50PM BLOOD cTropnT-0.02* ___ 08:23PM BLOOD Calcium-9.3 Phos-3.2 Mg-1.8 ___ 08:23PM BLOOD TSH-2.6 ___ 11:06AM BLOOD Digoxin-0.7 ___ 12:41PM BLOOD ___ pO2-28* pCO2-44 pH-7.42 calTCO2-30 Base XS-2 ___ 09:37AM BLOOD Lactate-1.7 ___ 09:14PM BLOOD O2 Sat-46 PERTINENT INTERVAL LABS: ======================== ___ 06:00AM BLOOD Glucose-87 UreaN-31* Creat-1.3* Na-141 K-4.3 Cl-106 HCO3-25 AnGap-10 ___ 06:00AM BLOOD Lactate-2.7* PERTINENT IMAGING: ================== TTE (___): Suboptimal image quality. Probably preserved global left ventricular systolic function (assessment difficult in the setting of beat-to-beat variability - at times appears hyperdynamic). Aortic stenosis seen, not quantified. Mild mitral and tricuspid regurgitation. Normal pulmonary pressure. 1. Study is limited secondary to motion. 2. Within the limitation of the study there is no evidence of pulmonary embolism or aortic abnormality. 3. Right lower lobe bronchus is focally narrowed secondary to diffuse bronchial wall thickening. Bibasilar right greater than left atelectasis with a right lower lobe bronchopneumonia. Repeat CT chest without contrast in 6 weeks is recommended to document resolution. 4. 12 mm left thyroid nodule for which no follow-up is recommended per ACR criteria. RECOMMENDATION(S): 1. Follow-up CT chest without contrast in 6 weeks to document resolution of bronchopneumonia and extensive thickening along the right mainstem bronchus. 2. 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. DISCHARGE LABS: =============== ___ 06:37AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0 ___ 06:37AM BLOOD Glucose-91 UreaN-27* Creat-1.3* Na-140 K-4.5 Cl-105 HCO3-26 AnGap-9* ___ 06:37AM BLOOD WBC-6.5 RBC-3.55* Hgb-11.0* Hct-33.2* MCV-94 MCH-31.0 MCHC-33.1 RDW-12.5 RDWSD-42.9 Plt ___ ___ 06:37AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Furosemide 20 mg PO DAILY 2. LORazepam 1 mg PO QHS 3. Losartan Potassium 50 mg PO DAILY 4. Prazosin 2 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Doxycycline Hyclate 100 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. ipratropium bromide 2 INH IH BID:PRN 10. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID:PRN congestion Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY RX *fluticasone [24 Hour Allergy Relief] 50 mcg/actuation 1 spray nasally Daily Disp #*1 Spray Refills:*0 3. Aspirin 81 mg PO DAILY 4. Doxycycline Hyclate 100 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. ipratropium bromide 2 INH IH BID:PRN 7. LORazepam 1 mg PO QHS 8. Losartan Potassium 50 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID:PRN congestion 12. HELD- Prazosin 2 mg PO DAILY This medication was held. Do not restart Prazosin until you discuss with your PCP and follow up your blood pressures 13.Outpatient Lab Work N17.9: Acute kidney injury Please check chem-7 on ___. Please fax results to Pt's PCP, ___ (___). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: * Community-acquired pneumonia Secondary diagnoses: * Atrial fibrillation with rapid ventricular response * History of 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 eval placement of cvl// cvl placement? TECHNIQUE: Single portable view of the chest. COMPARISON: Chest x-ray and chest CT from ___. FINDINGS: Right-sided central venous catheter seen with tip over the lower SVC. There is no pneumothorax. Streaky right basilar opacity may be due to either atelectasis or infection. Left lung is grossly clear. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: Right-sided central venous catheter line tip projecting over the lower SVC. No pneumothorax. Persistent right basilar opacity. Gender: M Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Dyspnea on exertion, Weakness Diagnosed with Dyspnea, unspecified temperature: 98.3 heartrate: 112.0 resprate: 18.0 o2sat: 100.0 sbp: 105.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

================================================ MEDICINE Discharge Worksheet ================================================ Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for an infection in your lungs ("pneumonia,") that was complicated by abnormal heart rhythms. What was done for me while I was in the hospital? - We gave you antibiotics to treat your infection. - We gave you medicines to slow your heart rate to a manageable speed. - Your medications were adjusted over several days in order to ensure that you were tolerating them well. What should I do when I leave the hospital? - Please note any new medications in your discharge worksheet below. - Please note any appointments in your discharge worksheet below. Sincerely, 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: L foot pain Major Surgical or Invasive Procedure: ___ - Dr ___ - ___ placement, medial plantar fasciotomy ___ - Dr ___ - ___ dehiscence wound left foot History of Present Illness: ___ s/p motorcycle vs deer last night at 2AM going approximately 50 mph. Had his motorcycle fall onto his left side. No headstrike/LOC. Inability to ambulate at scene. Taken to OSH where workup revealed L navicular fx and transferred for further eval. On arrival isolated complaint of left foot pain. No other painful areas. Also complaining of decreased sensation globally to left foot. Past Medical History: denies Social History: ___ Family History: NC Physical Exam: Afebrile, VSS NAD A&Ox3 no respiratory distress LLE: ___ in place without erythema WWP, +DP pulse and good cap refill able to flex/extend toes SILT saph, sural, SPN, DPN, plantar nerves Pertinent Results: ___ 11:00AM URINE HOURS-RANDOM ___ 11:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 11:00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 08:00AM estGFR-Using this ___ 08:00AM GLUCOSE-121* UREA N-19 CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 ___ 08:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:00AM WBC-15.9* RBC-4.58* HGB-14.5 HCT-43.0 MCV-94 MCH-31.6 MCHC-33.7 RDW-12.8 ___ 08:00AM NEUTS-88.0* LYMPHS-6.8* MONOS-4.8 EOS-0.1 BASOS-0.3 ___ 08:00AM PLT COUNT-237 ___ 08:00AM ___ PTT-26.8 ___ Medications on Admission: denies Discharge Medications: 1. Acetaminophen 650 mg PO Q6H standing dose 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks RX *enoxaparin 40 mg/0.4 mL 1 pre-filled syringe once a day Disp #*14 Syringe Refills:*0 4. Gabapentin 800 mg PO Q8H pain RX *gabapentin 800 mg 1 Tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone 2 mg ___ Tablet(s) by mouth every 3 hours Disp #*100 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left foot navicular fracture Discharge Condition: stable alert and oriented ambulatory with crutches Followup Instructions: ___ Radiology Report INDICATION: ___ male with ankle injury. COMPARISON: None available. TECHNIQUE: Three views of the left foot and three views of the left ankle were obtained. FINDINGS: LEFT ANKLE: No acute ankle fracture is detected. The ankle mortise appears preserved. There is soft tissue swelling surrounding the ankle, most severe over the medial malleolus. LEFT FOOT: There is a severely comminuted fracture of the navicular bone with medial displacement of multiple fracture fragments and multi-intra-articular extension. Fracture of the medial cuneiform also seen. Fracture fragment seen adjacent to the cuboid as well. Additional tarsal bone fractures suspected as well but not clearly seen due to multiple overlying fracture fragments from the navicular. There is adjacent soft tissue swelling. IMPRESSION: Severely comminuted and displaced fracture of the left navicular bone with intra-articular extent. Cuboid and medial cuneiform fractures seen and other tarsal fractures suspected. CT could be performed for further evaluation. Orthopedic surgery consult is recommended. Navicular fracture and recommendations were reported to ___ by ___ by telephone at 9:30 a.m. on ___ at the time of discovery of these findings. Radiology Report HISTORY: ___ male with left lower extremity injury. STUDY: CT of the left foot/ankle; images were acquired in soft tissue and bone algorithms. Coronal, sagittal, axial oblique and coronal oblique reformatted images were also generated. COMPARISON: Foot and ankle radiographs from ___. FINDINGS: The visualized portion of the distal tibia and fibula are intact. The talus and calcaneus are intact. There is a markedly comminuted fracture of the navicular with splaying of the two major fragments medially and laterally with a gap of approximately 1.5 cm (400B; 46). There is also a comminuted fracture of the medial base of the medial cuneiform. The visualized portion of the first ray is intact. The middle cuneiform is intact. The visualized portion of the second ray is intact. The lateral cuneiform demonstrates comminuted fracture at its base. There is a small avulsion fracture at base of the third metatarsal with extension into the joint space. There is a fracture involving the lateral aspect of the cuboid. The fracture is also seen through the base of the fourth metatarsal. The visualized portion of the fifth ray demonstrates a transverse fracture through the proximal phalanx (401B; 87 and 402B; 103). There is extensive soft tissue swelling. There does not appear to be neurovascular or tendon entrapment. While the Lisfranc ligament itself is not well-visualized on this study, the Lisfranc interval is intact, and no bony evidence of a Lisfranc ligament injury is present. IMPRESSION: Extensively comminuted fractures involving the mid foot and third and fourth metatarsal bases as described above; transverse fracture of the fifth proximal phalanx. Radiology Report LEFT FOOT, SIX VIEWS REASON FOR EXAM: Intra-op evaluation. Six fluoroscopic views of the foot and ankle taken in the OR were submitted for documentation of placement of an external fixation device for multiple comminuted fractures in the tarsal and metatarsal bones. For more detail of surgical findings, please refer to the OR note. Radiology Report Reason for exam: Status post external fixation for navicular fracture. Comparison is made with prior study ___. There has been interval placement of an external fixation device for a comminuted fracture of the navicular fracture. The multiple fragments are less displaced than before. Other multiple tarsal and metatarsal comminuted fractures are better seen in prior CT from ___. Of note, smaller osseous fragments that were visualized in prior radiograph in the lateral aspect of the mid foot are not longer visualized. For more detail of surgical findings, please refer to the OR note. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: MOTORCYCLE CRASH Diagnosed with FX METATARSAL-CLOSED, MV COLLIS NOS-MOTORCYCL temperature: 100.2 heartrate: 92.0 resprate: 16.0 o2sat: 98.0 sbp: 129.0 dbp: 83.0 level of pain: 4 level of acuity: 2.0

******SIGNS OF INFECTION********** Please return to the emergency department or notify MD if you should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. 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 continued to be non-draining. ******WEIGHT-BEARING******* non weight bearing left lower extremity, ambulate with crutches ******MEDICATIONS*********** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink ___ glasses of water daily and take a stool softener (colace) to prevent this side effect. -Medication refills cannot be written after 12 noon on ___. *****ANTICOAGULATION****** - Take Lovenox for DVT prophylaxis until follow-up with Dr ___. ******FOLLOW-UP********** Please follow up with Dr. ___ in 1 week for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your PCP regarding this admission and any new medications/refills.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Trauma: fall Right rib fractures 3,4 small right pneumothorax right knee pain Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old female without significant past medical history status post 10 foot fall who was transferred by EMS with right knee and ribcage pain. The patient is an internal medicine physician at ___ who was standing on her deck and was leaning on a railing when it gave way and she fell about 10 feet. Patient denies any head strike or loss of conciousness. She fell onto her right side. She has pain along her right ribcage and right knee. She denies any abdominal pain, neck pain, nausea, or vomiting. Timing: Sudden Onset Severity: Moderate to Severe Duration: Hours Location: right side of body Context/Circumstances: status post fall Past Medical History: none Social History: ___ Family History: nc Physical Exam: PHYSICAL EXAMINATION: upon admission ___ Temp: 98.2 HR: 70 BP: 134/94 Resp: 16 O(2)Sat: 96 Constitutional: Comfortable, FAST negative HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Marked tenderness to palpation along the right ribcage Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Extr/Back: Right knee has limited ROM due to tenderness Skin: Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation Pertinent Results: ___ 09:52PM BLOOD WBC-8.8 RBC-4.23 Hgb-14.3 Hct-40.5 MCV-96 MCH-33.9* MCHC-35.4* RDW-13.3 Plt ___ ___ 09:52PM BLOOD Neuts-53.2 ___ Monos-5.1 Eos-1.4 Baso-1.9 ___ 09:52PM BLOOD Plt ___ ___ 09:52PM BLOOD Glucose-104* UreaN-17 Creat-1.1 Na-141 K-3.5 Cl-103 HCO3-26 AnGap-16 ___: cat scan of the c-spine: 1. Partially imaged displaced right posterior third rib fracture with an associated tiny pneumothorax and consolidation, which is likely a combination of hematoma and contusion. 2. No evidence of a cervical spine fracture. 3. Small sclerotic foci in C2 and C5 are likely bone islands or relatedto degenerative changes. ___: x-ray of the right knee: No evidence of a fracture. ___: chest x-ray Displaced fractures of the posterior right third and fourth ribs. No definite evidence of a pneumothorax or pleural fluid. ___: cat scan of the chest: 1. Displaced right posterior ___ and 4th rib fractures. Nondisplaced right posterior 5th rib fracture. No other fracture is identified. 2. Small right pneumothorax, which is predominantly apical. Tiny loculated portions are presents along the posterior pleural surface near the fractures and at the confluence of the major and minor fissures. The apical portion is very slightly increased in size in comparison to the recent cervical spine CT. 3. Small opacity adjacent to the fractures which is likely a combination of hematoma and pulmonary contusion. No dependent layering pleural fluid. 4. Bibasilar opacities, possibly atelectasis, contusion, or a combination of the two. 5. 4 mm left upper lobe pulmonary nodule. Per ___ guidelines, in the absence of specific risk factors, no follow-up is necessary. If risk factors are present, a CT of the chest is recommended in 12 months. 6. Possible small hepatic hypodensity, which may either be a small hepatic cyst or artifact from the low-dose protocol. Consider a non-emergent hepatic ultrasound after recovery. ___: left foot x-ray: Normal left foot radiographs. ___: right elbow x-ray: Normal right shoulder and elbow radiographs. ___: right shoulder x-ray: Normal right shoulder and elbow radiographs. ___: chest x-ray: Stable small right apical pneumothorax. Stable displaced right ___ and 4th rib fractures. No new fracture. Medications on Admission: Klonopin 1 mg qhs prn Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. ClonazePAM 1 mg PO BID:PRN anxiety 3. Docusate Sodium 100 mg PO BID 4. Lidocaine 5% Patch 1 PTCH TD DAILY 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 6. Senna 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: Trauma: fall Right rib fractures 3,4 small right pneumothorax right knee pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Right shoulder pain COMPARISON: None FINDINGS: Three views of the right shoulder were obtained. There is no fracture, malalignment, or degenerative disease. There is no radiopaque foreign body. Three views of the right elbow were obtained. There is no fracture, malalignment, or degenerative disease. There is no joint effusion. IMPRESSION: Normal right shoulder and elbow radiographs. Radiology Report HISTORY: Left foot pain. COMPARISON: None FINDINGS: Three views of the left foot were obtained. There is no fracture, malalignment, or degenerative disease. There is no radiopaque foreign body or degenerative disease. IMPRESSION: Normal left foot radiographs. Radiology Report INDICATION: History of small pneumothorax, rib fractures. Please evaluate. COMPARISONS: Chest CT from ___ and chest radiograph from ___. TECHNIQUE: PA and lateral radiographs of the chest. FINDINGS: Again seen is a small right apical pneumothorax. Note is made of acute displaced right posterior third and fourth rib fractures, better characterized by the CT performed on the previous day. No new fractures are identified. Heart size is normal. The hilar and mediastinal contours are normal. Note is made of mild bibasilar atelectasis, otherwise the lungs are clear. There is a small right pleural effusion. IMPRESSION: Stable small right apical pneumothorax. Stable displaced right ___ and ___ rib fractures. No new fracture. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with FRACTURE TWO RIBS-CLOSED, TRAUM PNEUMOTHORAX-CLOSE, FALL FROM BUILDING temperature: 98.2 heartrate: 70.0 resprate: 16.0 o2sat: 96.0 sbp: 134.0 dbp: 94.0 level of pain: 9 level of acuity: 3.0

___ were admitted to the hospital after a 10 foot fall. ___ sustained right sided rib fractures and a small right pneumothorax. Your rib cage pain with controlled with intravenous analgesia, but later changed to oral agents. ___ also reported right knee pain and there was concern for ligamentous injury. ___ had a brace applied. ___ were evaluated by physical therapy and recommendations made for discharge home with follow-up MRI to your right knee. Your vital signs have been stable. ___ are preparing for discharge home with the following instructions: Your injury caused right sided rib fractures which can cause severe pain and subsequently cause ___ to take shallow breaths because of the pain. * ___ should take your pain medication as directed to stay ahead of the pain otherwise ___ won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk ___ must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * ___ will be more comfortable if ___ use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore ___ should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Additional instructions include: Please call your doctor or return to the emergency room if ___ have any of the following: * ___ experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If ___ are vomiting and cannot keep in 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. * ___ have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern ___ Please follow up with your primary care provider for CT of chest for pulmonary nodule and and recommended ultrasound for ? hepatic cyst.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: ___: Pericardiocentesis and drain placement ___: Intra-Aortic Balloon Pump Placement ___: Coronary artery bypass grafting x 5 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, diagonal artery and sequential reverse saphenous vein graft to the second and third obtuse marginal arteries. History of Present Illness: Mr. ___ is a ___ year old man with hypertension, hyperlipidemia and OSA who presented to ___ with chest pain and dyspnea and was transferred to ___ for higher level of care given concerning ECG changes and an elevated troponin. He is transferred to the CCU for monitoring of a pericardial drain. To briefly review his course, he was in his usual state of health on the day of admission when he developed dyspnea with lifting a 30 pound box of chocolate chips at his bakery. The pressure was constant and non-radiating and he called EMS. On their arrival he was hypoxic to the 80's and transferred to ___. He was found to have an elevated high-sensitivity troponin of 189 that increased to 249, and a NT-proBNP of 6250. He had lateral T-wave inversion on ECG and was given ASA 325mg and two doses of SL nitroglycerin. He was also given 40mg IV Lasix and placed on BiPAP. Of note, patient was recently started on metoprolol tartrate 25mg daily for "tremor", however this was discontinued given severe fatigue associated with it. He was transitioned to propranolol 10mg BID which has been better tolerated. Interestingly, patient believes he is still taking labetalol, in addition to propranolol, however is not ___ sure. Has had lower extremity edema for several years, no worse recently, although was only started on furosemide 20mg daily in early ___ for this. On arrival to ___, he was started on IV heparin gtt for NSTEMI. An echocardiogram on ___ demonstrated a large pericardial effusion with tamponade physiology. He went to the cath lab on ___ for urgent pericardiocentesis with 650 cc serous fluid was drained and sent for studies. He underwent a cardiac catheterization which demonstrates severe multivessel coronary artery disease. Given severe left main disease, and IABP was placed. Cardiac surgery was consulted for revascularization. Past Medical History: Chronic Kidney Disease Deviated Septum Hyperlipidemia Hypertension Obesity Obstructive Sleep Apnea Social History: ___ Family History: Mother died aged ___ and had a history of ___ disease. Father had a history lung cancer and coronary artery disease. Brother had a MI in his ___. Physical Exam: ============================== ADMISSION PHYSICAL EXAMINATION ============================== Pulse:98 Resp:16 O2 sat: 3 L 90% B/P Right: Left: 124/64 IABP 105/69 Height: 5'7" Weight: 90.1 kg General: Awake, alert in NAD, unable to finish sentences completely due to SOB Skin: Dry [x] intact [x] Pericardial drain and Right femoral IABP in place HEENT: PERRLA [] EOMI [] Neck: Supple [] Full ROM [] Chest: Lungs clear bilaterally [] Right basilar crackles Heart: RRR [x] IABP Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] IABP noise Extremities: Warm [x], well-perfused [x] Edema trace Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: IABP Left: + DP Right: + Left: + ___ Right: + Left: + Radial Right: TR band Left: + Carotid Bruit: none Discharge Physical Examination: General: NAD [x] Neurological: A/O x3 [x] non-focal [] HEENT: PEERL [] Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [] Respiratory: CTA [x] No resp distress [] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x] Extremities: Right Upper extremity Warm [x] Edema Left Upper extremity Warm [x] Edema Right Lower extremity Warm [x] Edema 2+ Left Lower extremity Warm [x] Edema 2+ Pulses: DP Right: p Left:p ___ Right: p Left:p Radial Right: Left: Skin/Wounds: Dry [x] intact [] Sternal: CDI [x] no erythema or drainage [] Sternum stable [x] Prevena [] Lower extremity: Right [] Left x[] CDI [x] Pertinent Results: Transthoracic Echocardiogram ___ The left atrial volume index is moderately increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is >15mmHg. There is focal non-obstructive hypertrophy of the basal septum with a moderately increased/dilated cavity. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid to distal anteroseptum, anterior wall, and apex (see schematic) and preserved/normal contractility of the remaining segments. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is 45-50%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a large circumferential pericardial effusion. Stranding is visualized within the pericardial space c/w organization. There is right atrial systolic and right ventricular diastolic collapse c/w increased pericardial pressure/tamponade physiology. IMPRESSION: Large circumferential pericardial effusion with right atrial and right ventricular collapse and IVC plethora c/w pericardial tamponade. Moderate left ventricular basal septal hypertrophy with moderate cavity dilation and mild regional systolic dysfunction c/w CAD in an LAD distribution. Increased PCWP. No definite pathologic valvular flow identified. Indeterminate pulmonary artery systolic pressure. Cardiac Catheterization ___ LMCA: no abnormalities LAD: 99% stenosis in the proximal LAD with TIMI 1 grade flow (penetration without perfusion) into the distal LAD. LCX: 60% stenosis in the mid segment of the LCx that gave rise to three large PL branches without disease. There was a 60% stenosis in the origin of a medium OMB1 and a 80% stenosis of the origin of a larger OMB2. RCA: 90% stenosis in the proximal segment of the RCA, a 80% hazy lesion in the mid portion of the RCA and a 80% stenosis of the origin of a medium to large PDA. There were faint collaterals to the proximal and mid LAD. ___ 05:00AM BLOOD WBC-8.6 RBC-2.84* Hgb-7.8* Hct-25.0* MCV-88 MCH-27.5 MCHC-31.2* RDW-15.5 RDWSD-49.7* Plt ___ ___ 08:30PM BLOOD WBC-10.1* RBC-4.09* Hgb-11.3* Hct-36.1* MCV-88 MCH-27.6 MCHC-31.3* RDW-15.4 RDWSD-50.1* Plt ___ ___ 06:40AM BLOOD ___ ___ 08:30PM BLOOD ___ PTT-28.6 ___ ___ 05:00AM BLOOD Glucose-105* UreaN-53* Creat-3.2* Na-142 K-4.1 Cl-108 HCO3-21* AnGap-13 ___ 08:30PM BLOOD Glucose-110* UreaN-31* Creat-2.4*# Na-143 K-4.0 Cl-106 HCO3-21* AnGap-16 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Propranolol 10 mg PO BID 2. Labetalol 200 mg PO BID 3. Atorvastatin 10 mg PO QPM 4. HydrALAZINE 10 mg PO BID 5. Furosemide 20 mg PO DAILY 6. Potassium Chloride 20 mEq PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob/wheezing 3. Albuterol Inhaler 2 PUFF IH Q6H 4. Aspirin EC 81 mg PO DAILY 5. CefTRIAXone 2 gm IV Q24H Last dose ___ 6. Docusate Sodium 100 mg PO BID 7. Furosemide 40 mg PO BID please reval clinically daily for when to decrease dose to home dose of 20 mg daily 8. Polyethylene Glycol 17 g PO DAILY 9. Ranitidine 150 mg PO DAILY 10. Sarna Lotion 1 Appl TP QID:PRN chest rash 11. Senna 17.2 mg PO DAILY 12. TraMADol 50 mg PO Q12H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 1 tablet(s) by mouth BID prn Disp #*15 Tablet Refills:*0 13. Atorvastatin 80 mg PO QPM 14. HydrALAZINE 10 mg PO Q 12 HR 15. Labetalol 200 mg PO BID 16. Potassium Chloride 20 mEq PO DAILY Hold for >4.5 17. HELD- Propranolol 10 mg PO BID This medication was held. Do not restart Propranolol until reevaluated by Cardiologist Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Coronary Artery Disease Pericardial Effusion with Tamponade Physiology ST Elevation Myocardial Infarction Acute on Chronic Kidney Injury Acute Hypoxic Respiratory Failure Acute Heart Failure with preserved EF Secondary Diagnosis: Chronic Kidney Disease Deviated Septum Hyperlipidemia Hypertension Obesity Obstructive sleep apnea Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxic resp failure, suspected cardiogenic, NSTEMI, tamponade physiology on echocardiogram. Due for pericardiocentesis and possible cath.// pulm edema/pleural effusions IMPRESSION: No previous images. There is marked enlargement of the cardiac silhouette with relatively mild pulmonary vascular congestion. This discordance is consistent with the diagnosis of pericardial effusion. Hazy opacification at the right base with obscuration hemidiaphragm is consistent with pleural fluid and volume loss in the right lower lobe. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with NSTEMI and large pericardial effusion s/p drain// Pericardial drain placement IMPRESSION: In comparison with the study of ___, the there is continued enlargement of the cardiac silhouette with decreasing pulmonary edema. Layering pleural effusion with compressive basilar atelectasis is again seen on the right, with less prominent effusion and atelectasis on the left. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with worsening O2 requirement// ? pulmonary edema TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___. FINDINGS: There is increased hilar congestion and basal predominant pulmonary edema with associated right predominant pleural effusion when compared to prior study. Enlarged heart size is unchanged. IMPRESSION: Worsening pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with NSTEMI now s/p balloon pump placement.// balloon pump placement balloon pump placement IMPRESSION: Comparison to ___, 07:44. The pericardial drain is in stable position. The patient has received a new aortic balloon pump. The tip of the pump projects approximately 28 mm be low the upper most part of the aortic arch. There is a linear lucent zone paralleling the pump. A repeat radiograph within 4 hours should be obtained to monitor this change. The pericardial drain is in stable position. Stable moderate cardiomegaly. Moderate right pleural effusion, minimal left pleural effusion. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old man s/p CABG// FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Contact name: ___: ___ TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: There are postsurgical changes from CABG. The endotracheal tube terminates 2.7 cm above the carina. The enteric tube terminates in the body of the stomach. A right internal jugular Swan-Ganz catheter terminates in the right interlobar pulmonary artery. A left chest tube is in place. The intra-aortic balloon pump terminates in the upper descending aorta, just below the aortic arch. Bilateral pleural effusions (right greater than left), cardiomegaly and mild pulmonary edema are unchanged. There is no focal consolidation or pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p CABG// eval for effusion TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: There are postsurgical changes from CABG. The endotracheal tube terminates 4.4 cm above the carina. The right internal jugular Swan-Ganz catheter terminates in the right interlobar pulmonary artery. The enteric tube terminates in the body of the stomach. Mediastinal drains and a left chest tube are in stable position. The cardiomediastinal silhouette remains enlarged. The small to moderate right pleural effusion and small left pleural effusion are unchanged. Mild central pulmonary vascular congestion and mild pulmonary edema are also unchanged. There is no focal consolidation or pneumothorax. There are no acute osseous abnormalities. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p CABG// eval for effusion IMPRESSION: Comparison with the study of ___, the endotracheal tube and nasogastric tube have been removed. Swan-Ganz catheter again extends to the right pulmonary artery. Left chest tube remains in place and there is no evidence of pneumothorax. The left hemidiaphragmatic contour is now sharply seen, consistent with decreasing pleural effusion and volume loss in left lower lobe, though a more upright position of the patient could contribute to this appearance. Poor definition of the right hemidiaphragmatic contour with opacification at the bases consistent with pleural fluid and compressive atelectasis on this side. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ct removed// eval for ptx IMPRESSION: In comparison with the earlier study of this date, the left chest tube is been removed and there is no evidence of pneumothorax. The Swan-Ganz catheter is also been removed. The cardiomediastinal silhouette is stable. Increasing engorgement of indistinct pulmonary vessels is consistent with increasing elevation of pulmonary venous pressure. Bilateral pleural effusions and compressive atelectasis, more prominent on the right. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with s/p cabg// eval for effusion or infiltrate TECHNIQUE: Portable AP and lateral chest radiographs COMPARISON: Multiple chest radiographs dating back to ___ and most recent dated ___ FINDINGS: Low lung volumes. Cardiac silhouette is moderately enlarged, unchanged since ___. Interval decrease of pulmonary vasculature congestion since ___. The hemidiaphragms are not well demonstrated suggesting high likelihood of small pleural effusions. Retrocardiac and left lower lung zone opacifications are likely to atelectasis. No pneumothorax. Sternal wires are IMPRESSION: 1. Interval decrease of pulmonary vascular congestion since ___. 2. Small pleural effusions are likely, unchanged. 3. Retrocardiac and left lower lung zone airspace opacities are likely due to atelectasis. Radiology Report INDICATION: ___ year old man with s/p CABG// eval pulm edema/pleural effusions/ postop changes COMPARISON: Radiographs from ___ IMPRESSION: Mediastinal wires are seen. There are very low lung volumes. There is cardiomegaly and prominence of the mediastinum. There is mild worsening of the now moderate pulmonary edema. There are bilateral effusions. There are no pneumothoraces. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Chest pain, unspecified temperature: 98.7 heartrate: 86.0 resprate: 24.0 o2sat: 98.0 sbp: 150.0 dbp: 90.0 level of pain: 0 level of acuity: 2.0

Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 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 ___ **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left periprosthetic femur fracture Major Surgical or Invasive Procedure: L proximal femur open reduction internal fixation History of Present Illness: ___ year-old female with h/o EtOH abuse (prior ICU stays for withdrawal), h/o GIB, prior L hip fx s/p hemi and subsequent revision with fixation, presents after mechanical fall under influence of alcohol with L periprosthetic femur fx. Past Medical History: ___: GERD osteoporosis hip fractures Prior 2 hip surgeries complicated by ICU stays for withdrawal H/o multiple GIB - most recent scope was in ___ (___) ___: hip surgery - at ___ for one and ___ for the other Social History: ___ Family History: n/c Physical Exam: Vitals: AVS wnl General: Well-appearing, breathing comfortably LLE: Dsg with posterior strikethrough - serosanguinous Fires ___ SILT s/s/dp/sp/t Palp DP pulse Pertinent Results: ___ 05:35AM BLOOD WBC-11.2* RBC-3.06* Hgb-9.6* Hct-30.3* MCV-99* MCH-31.4 MCHC-31.7* RDW-13.8 RDWSD-50.6* Plt ___ ___ 05:35AM BLOOD Glucose-96 UreaN-6 Creat-0.4 Na-138 K-4.3 Cl-103 HCO3-27 AnGap-8* Medications on Admission: Medications: omeprazole 40 mg daily, alendronate 70mg 1 tab weekly (___) calcium carbonate 1 tab BID cholecalciferol 1000 unit daily folic acid 1 mg daily multivitamin 1 tab daily sucralfate 1 tab TID eye drops: latanoprost .005% 1 drop each eye daily Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN Dyspepsia 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 4. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Days RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth Q12 hours Disp #*2 Tablet Refills:*0 5. Diazepam - CIWA protocol ___ mg PO QHS, Q2 HOURS PRN CIWA Scale Protocol; anxiety, agitation Begin with 5mg and increase to 10 total if needed. HOLD for somnolence, SpO2<92, RR<12 RX *diazepam 5 mg ___ tablet(s) by mouth qhs, q2 hr Disp #*10 Tablet Refills:*0 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 30 mg SC QPM RX *enoxaparin 30 mg/0.3 mL 30 mg at bedtime Disp #*28 Syringe Refills:*0 8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hr PRN Disp #*15 Tablet Refills:*0 9. Thiamine 100 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 40 mg PO DAILY 13. Sucralfate 1 gm PO TID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left periprosthetic femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: FEMUR (AP AND LAT) LEFT INDICATION: History: ___ with trauma// fx fx TECHNIQUE: Frontal and lateral view radiographs of the left femur COMPARISON: None FINDINGS: There is a foreshortened, laterally angulated and displaced obliquely oriented fracture through the midshaft of the left femur just inferior to the femoral component of a left hip prosthesis. No other fractures are identified. No suspicious lytic lesion, sclerotic lesion, or periosteal new bone formation is detected. No soft tissue calcification or radio-opaque foreign bodies are detected. Limited assessment of the knee joint so significant degenerative changes. Vascular calcifications are noted. IMPRESSION: Foreshortened and displaced obliquely oriented fracture of the midshaft of the left femur just inferior to the femoral component of a left hip prosthesis. Radiology Report EXAMINATION: FEMUR (AP AND LAT) LEFT INDICATION: History: ___ with femur fx// post reduction, PORTABLE post reduction, PORTABLE TECHNIQUE: Frontal and lateral view radiographs of left femur. COMPARISON: ___ 03:13 FINDINGS: There has been interval reduction of a obliquely oriented fracture through the midshaft of the left femur, just inferior to the femoral component of a left hip prosthesis, which now appears in nearly anatomic alignment.. No suspicious lytic lesion, sclerotic lesion, or periosteal new bone formation is detected. No soft tissue calcification or radio-opaque foreign bodies are detected. Vascular calcifications are again noted. IMPRESSION: Interval reduction of left midshaft femoral fracture which now appears in anatomic alignment. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with femur fx// post reduction, PORTABLE COMPARISON: None FINDINGS: Supine portable AP view of the chest provided. There is no focal consolidation. There is no pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: PELVIS (AP ONLY) INDICATION: History: ___ with femur fx// fx? TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and frog-leg lateral views of Single supine AP view of the pelvis. COMPARISON: None FINDINGS: The patient is status post bilateral hip total arthroplasty, in overall anatomic alignment. No periarticular fracture is detected, though patient obliquity somewhat limits evaluation. There is no suspicious lytic or sclerotic lesion. There is no soft tissue calcification or radio-opaque foreign body. IMPRESSION: Limited exam without evidence of fracture. Radiology Report INDICATION: Left hip ORIF. COMPARISON: Radiographs from ___ IMPRESSION: Fluoroscopic images demonstrate placement of a large lateral fracture plate stabilizing a periprosthetic fracture of the distal left femur adjacent to the distal femoral stem. There has also been removal of the proximal claw plate. There is a left hip bipolar hemiarthroplasty. The total intraservice fluoroscopic time was 118.7 seconds. Please refer to the operative note for additional details. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ETOH, L Femur fracture, s/p Fall, Transfer Diagnosed with Displaced oblique fracture of shaft of left femur, init, Periprosth fracture around internal prosth l hip jt, init, Fall (on) (from) other stairs and steps, initial encounter temperature: 98.4 heartrate: 91.0 resprate: 16.0 o2sat: 97.0 sbp: 108.0 dbp: 62.0 level of pain: 0 level of acuity: 2.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch down weight bearing left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - You may change DRY STERILE DRESSING daily as needed if any drainage or if saturated. If no drainage may leave open to air after post-operative day 7. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: Touch Down Weight Bearing Left Lower Extremity Treatments Frequency: WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - You may change DRY STERILE DRESSING daily as needed if any drainage or if saturated. If no drainage may leave open to air after post-operative day 7.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: acetaminophen Attending: ___. Chief Complaint: Right femur fracture s/p gun shot wound Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man transferred from OSH with a GSW to the R thigh and R femur fracture. The patient states that on ___ around 8:30PM he was walking into a store when he noticed a car slowing down, followed by gun shots. He heard a loud pop and noted R thigh pain and fell to the ground, unable to bear weight. He was taken to ___ wherehe was found to have a GSW to the R thigh with radiographs demonstrating a femoral shaft fracture. No hard signs of vascular injury. He was given Ancef and morphine, and subsequently transferred to ___ for further evaluation and management. On arrival the patient complains of isolated R thigh pain. No pain in any other anatomic location. No numbness or paresthesias. Past Medical History: None Social History: ___ Family History: non contributory Physical Exam: No acute distress Unlabored breathing Abdomen soft, non-tender, non-distended Right lower extremity: - 1cm wound over lateral midthigh w/ no active bleeding - Tenderness around wound - No deformity, erythema, induration - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*100 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 #*40 Capsule Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*75 Tablet Refills:*0 4. Aspirin 325 mg PO DAILY Duration: 14 Days RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Right femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph. INDICATION: Status post gunshot wound to right thigh. TECHNIQUE: AP views of the chest, pelvis, and right hip. COMPARISON: Reference right femur radiograph dated ___. FINDINGS: CHEST: The lungs are well expanded and clear. There is no lobar consolidation, pleural effusion, or pneumothorax. The right costophrenic angle is excluded on this study. Mild prominence of the right hila is likely projectional. The heart is normal in size. PELVIS/RIGHT HIP: The pelvis is intact and without evidence of fracture or dislocation. Multiple bullet fragments are noted overlying the proximal right femur with adjacent cortical irregularity along the lateral aspect of the proximal right femur. No additional fractures are identified. IMPRESSION: 1. Comminuted proximal right femoral fracture with adjacent bullet fragments. 2. Clear lungs. Radiology Report EXAMINATION: FEMUR (AP AND LAT) RIGHT IN O.R. INDICATION: RT FEMUR FX.ORFI TECHNIQUE: 112 intraoperative fluoroscopic spot images of the right femur were obtained without the radiologist present. Total fluoroscopy time was not reported. COMPARISON: Radiographs of the right femur ___. FINDINGS: Sequential fluoroscopic images demonstrate intramedullary reaming with subsequent placement of a right femoral intramedullary nail with 2 proximal and distal interlocking screws. Shrapnel is again noted projecting adjacent to the proximal femur. IMPRESSION: Intraoperative images from open reduction and internal fixation of a proximal right femoral diaphyseal fracture. Please see the operative report for further details. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: GSW TO LEG Diagnosed with OPEN WND HIP/THIGH-COMPL, ASSAULT-HANDGUN temperature: 99.9 heartrate: 91.0 resprate: 20.0 o2sat: 99.0 sbp: 121.0 dbp: 81.0 level of pain: 1 level of acuity: 1.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch down weight bearing right leg MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Aspirin for 2 weeks. Please ambulate at least 5 times a day with crutches. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Clean dry dressing as needed - changed daily or as solied.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: CC: Concern for seizure Major Surgical or Invasive Procedure: lumbar puncture ___ History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ year old woman with a history of lung adenocarcinoma with mets to her brain currently receiving brain radiation who was referred to the ED for altered mental status. The patient indicates that earlier morning of presentation she was at home, when she felt that her legs became weak. She then "collapsed" to the floor. She reports remembering everything that happened but when probed for specifics she is unable to, she also reports she fell in the bathroom. However, according to her son, and ___ EMS records she was found on the floor of her kitchen incontinent of urine and feces. When awakened she was confused, disoriented and not making sense. She went to an outside hospital (___), where she was found to by hypothermic and confused. Rectal temperature reportedly was 93.0 initially. She was warmed and temperature improved to 95.6. Received 1L NS and Keppra 500mg IV at OSH. She was also found to have elevated Troponin (Trop I 1.37). She was transferred to ___ for further evaluation. In the ED, initial vitals were: 94.2 92 100/66 16 95% RA. She was found to be A&Ox3 but forgetful, unable to recall certain treatments or details of her diagnosis. Respiratory effort easy and unlabored. Abdomen soft and no pain on palpation. Temperature 94.2 (temporal) in triage. Slightly tachycardic to 104bpm. Labs were notable for WBC of 12.4, elevations in AST and ALT, Trop of 0.14. EKG was sinus rhythm, 98, normal axis, QTC 488, ST segment elevation in leads V1, V2, ST depression in lead 2, aVF. Cardiology consulted felt likely demand ischemia in setting of presumed seizure. Oncology was consulted who deferred to medicine because primary oncologist is at ___ though she receives radiation oncology here. On the floor, she currently feels well but reports weakness, she is gernally independent with ambulation and plays gold 3 times per week but now feels her legs are weak and is having difficulty standing. She denies any headache no chest pain, shortness of breath, abdominal pain, nausea, vomiting. Of note, on ___, she received at L3-4 epidural injection for chronic LBP. 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, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Otherwise ROS is negative. Past Medical History: - Adenocarcinoma of the lung with brain mets (Small Right Frontal and Right Cerebellar s/p 3 sessions of cyberknife) followed by ___, MD - Latent Tb s/p INH - HTN - HLD Surgical history - Multiple prior spine surgery - TAH-BSO - Appendectomy - Tonsillectomy Social History: ___ Family History: Mother with breast cancer Father and two brothers with heart disease Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Afebrile, aVSS Pain Scale: ___ General: Patient appears overall well, she is alert, pleasant and conversant but slightly confused. She compensates well for confusion, she is oriented to person and place but to time she thinks the months is ___ but got day of the week and year correct. Able to complete days of week in reverse but paused several times, made jokes to compensate for not knowing, made errors but quickly corrected herself. HEENT: Sclera anicteric, dentures 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: soft, non-tender, non-distended, normoactive bowel sounds throughout, no rebound or guarding Ext: Many skin tears, excoriations and abrasions to bilateral LEs, most notably over bilateral knees and proximal lower legs Neuro: CN2-12 grossly in tact, motor and sensory function grossly intact in bilateral UE and ___, symmetric DISCHARGE PHYSICAL EXAM: VS: 97.8 89 18 109/72 96%RA General: Well appearing, sitting in bed in NAD Eyes: PERLL, EOMI, sclera anicteric ENT: MMM, oropharynx clear without exudate or lesions Respiratory: CTAB without crackles, wheeze, rhonchi. Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or gallops Gastrointestinal: Soft, nontender, nondistended, +BS, no masses or HSM Extremities: Warm and well perfused, no peripheral edema Skin: warm, numerous abrasions/skin tears on distal lower extremities bilaterally in various stages of healing. Neurological: Alert and oriented x3, motor and sensory exam grossly intact Pertinent Results: Admission Labs: ___ 05:38PM BLOOD WBC-12.7* RBC-5.39* Hgb-16.0* Hct-48.3* MCV-90 MCH-29.7 MCHC-33.1 RDW-13.5 RDWSD-43.7 Plt ___ ___ 05:38PM BLOOD Neuts-86.1* Lymphs-8.0* Monos-3.9* Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.93* AbsLymp-1.02* AbsMono-0.49 AbsEos-0.01* AbsBaso-0.03 ___ 05:38PM BLOOD Glucose-70 UreaN-17 Creat-0.5 Na-135 K-4.3 Cl-93* HCO3-27 AnGap-19 ___ 05:38PM BLOOD ALT-82* AST-77* CK(CPK)-816* AlkPhos-60 TotBili-0.9 ___ 05:38PM BLOOD CK-MB-46* MB Indx-5.6 ___ 05:38PM BLOOD cTropnT-0.14* ___ 05:38PM BLOOD Albumin-3.7 ___ 05:54PM BLOOD Lactate-2.5* Discharge labs: ___ 06:50AM BLOOD WBC-12.0* RBC-5.03 Hgb-15.1 Hct-45.2* MCV-90 MCH-30.0 MCHC-33.4 RDW-13.9 RDWSD-44.9 Plt ___ ___ 06:50AM BLOOD Glucose-90 UreaN-20 Creat-0.5 Na-140 K-4.2 Cl-102 HCO3-26 AnGap-16 ___ 06:10AM BLOOD ALT-63* AST-40 CK(CPK)-377* AlkPhos-54 TotBili-0.5 ___ 06:10AM BLOOD CK-MB-21* MB Indx-5.6 cTropnT-0.05* ___ 06:50AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1 ___ 07:15AM BLOOD Valproa-60 ___ 05:57PM URINE Color-Straw Appear-Clear Sp ___ ___ 05:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 03:55PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-0 Polys-1 ___ ___ 03:55PM CEREBROSPINAL FLUID (CSF) TotProt-65* Glucose-62 MICRO: None Imaging: CXR PA/LAT: ___ Left hilar enlargement with perihilar opacity and left suprahilar mass likely reflect the patient's known lung cancer with partial left upper lobe collapse and probable post treatment changes. Nonspecific hazy opacity in the right upper lobe could reflect an area of inflammation or infection. Right basilar atelectasis. MRI Head w and w/o con ___ IMPRESSION: 1. Decreased 17 x 18 mm right frontal lesion and improved surrounding vasogenic edema. 3 mm cortical focus of enhancement posterior to this lesion seen on the prior study is no longer present. 2. 4 mm enhancing lesion in the right cerebellar hemisphere is stable without associated edema. 3. No new enhancing intracranial lesions identified. EEG ___ IMPRESSION: This is a mildly abnormal continuous ICU monitoring study because of excess generalized slowing in the awake state, consistent with a mild encephalopathy, nonspecific with regards to etiology . No seizures, epileptiform discharges or pushbutton activations are recorded. CYTOLOGY: CSF pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dexamethasone 2 mg PO QAM 2. Dexamethasone 2 mg PO Q1400 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 4. Losartan Potassium 100 mg PO DAILY 5. LevETIRAcetam 250 mg PO BID 6. Diazepam 5 mg PO Q12H:PRN Pain 7. Celecoxib 200 mg oral DAILY 8. Ranitidine 150 mg PO DAILY 9. Simvastatin 10 mg PO QPM 10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 11. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Medications: 1. Divalproex (DELayed Release) 750 mg PO BID RX *divalproex ___ mg 1.5 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 3. Celecoxib 200 mg oral DAILY 4. Dexamethasone 2 mg PO QAM 5. Dexamethasone 2 mg PO Q1400 6. Diazepam 5 mg PO Q12H:PRN Pain 7. Losartan Potassium 100 mg PO DAILY 8. Nystatin Oral Suspension 5 mL PO QID 9. Ranitidine 150 mg PO BID 10. Simvastatin 10 mg PO QPM 11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 12. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Seizure, acute encephalopathy Secondary: Adenocarcinoma of lung with brain metastases, ___ stomatitis, hypertension, hyperlipidemia, troponin elevation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with metastatic lung adenocarcinoma to brain, s/p XRT, now presenting after seizure. Evaluate for worsening metastases/edema/inflammation in setting of seizure TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 6 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: ___ brain MRI with and without contrast. ___ limited postcontrast brain MRI. ___ noncontrast head CT. FINDINGS: Postcontrast MP RAGE images are mildly limited by motion artifact. 17 x 18 mm enhancing right paramedian anterior frontal mass has decreased in size, previously 23 x 23 mm (series 10, image 19). Surrounding vasogenic edema has also improved. There is no significant mass effect at this time. A 3 mm cortical focus of enhancement posterior to this lesion noted on the prior examination is not clearly appreciated on the current exam. A 4 mm enhancing focus in the right cerebellar hemisphere is stable compared to the 2 prior MRIs when measured in the same fashion. There is no associated edema. There is no evidence for new enhancing intracranial lesions. Moderately numerous foci of high T2 signal in the periventricular, deep, and subcortical white matter of the cerebral hemispheres, without associated enhancement or slow diffusion, are grossly unchanged, nonspecific but likely sequelae of chronic microangiopathy in this age group. Stable prominence of the ventricles and sulci, in keeping with age related involutional changes is again noted. There is no acute infarction and no evidence for new blood products. Principal intracranial vascular flow voids are preserved. Dural venous sinuses enhance appropriately on postcontrast MP-RAGE sequences. Partial opacification of the left mastoid air cells is unchanged. A small T1 hyperintense lesion is again seen in the right parietal bone on images 4:22, 10:22, likely a hemangioma. IMPRESSION: 1. Decreased 17 x 18 mm right frontal lesion and improved surrounding vasogenic edema. 3 mm cortical focus of enhancement posterior to this lesion seen on the prior study is no longer present. 2. 4 mm enhancing lesion in the right cerebellar hemisphere is stable without associated edema. 3. No new enhancing intracranial lesions identified. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, Hypothermia Diagnosed with Altered mental status, unspecified temperature: 94.2 heartrate: 92.0 resprate: 16.0 o2sat: 95.0 sbp: 100.0 dbp: 66.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ after a fall and mental status changes which were thought to be due to a seizure. It is believed that lowering the dose of your anti seizure medicine combined with your recent immunologic therapy may have increased your risk of seizure. MRI showed improvement in your brain lesions, EEG showed no further seizures, but you remained somewhat confused so a lumbar puncture was performed which looks clear preliminarily, with evaluation for tumor cells pending. You had no evidence of any infections. Your mental status improved during your stay. You were switched to a new anti-seizure medication and should follow up with your oncologist as well as your new neuro-oncologist as below. Please do not drive until you see Dr. ___ in neuro-oncology on ___. He will help determine if driving is safe for you. It was a pleasure caring for you, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bee stings Attending: ___ ___ Complaint: Fevers, Night Sweats Major Surgical or Invasive Procedure: none History of Present Illness: ___ M->F transgender woman (goes by ___, DLBCL (dx ___, now on C3 of R-CHOP) s/p port placement ___, Cycle 3 R-CHOP ___ w/Neulasta ___, Latent TB (on INH), chronic hepatitis B (On lamivudine) who was recently admitted for presumed viral gastroenteritis 1 week ago, now returns with fever and night sweats and c/f possible port infection. Patient states that following her recent admission, on the day of her discharge her diarrheal and febrile symptoms had abated, however she still c/o nausea, which is chronic. States that three days PTA she noticed some difficulty swallowing and warm. Took temp and fever of 101. Over the next few days she reports increasing difficulty in swallowing solids and liquids w/o choking, and palpable lymph nodes of neck and bilateral axilla. Denies dynophagia or mouth sores. No recent sick contacts. Endorses daily cough, but unchanged from her baseline (smoker's cough). No increased production of mucus, no hemoptysis. Does endorse recurrence of diarrheal symptoms stating the she isn't rushing to the bathroom, but does have large volume watery diarrhea ___ times a day "when I do use the toilet." Continues to be febrile throughout the day and having drenching night sweats nightly. She also voices her concern over her port site (right chest wall) which remains mildly tender and appears erythematous to her. Endorses mild bone pain. Denies chest pain, shortness of breath, light headedness/dizziness and syncope. Denies weight gain/loss, numbness or tingling or extremities. With respect to her DLBCL, known to have germinal center derived diffuse large B-cell lymphoma arising from follicular lymphoma w/ multiple admissions for syncope attributed to extensive mediastinal lymphadenopathy causing mass effect on the bilateral main pulmonary arteries and central airways. Now s/p C3 of RCHOP with prior good response in peripheral lymphadenopathy. Received chemotherapy on recent admission ending ___. Past Medical History: PAST ONCOLOGIC HISTORY -___ The patient had been experiencing night sweats, fevers, chills, nausea, and decreased p.o. intake. She also had been experiencing substernal chest pain and tender progressive lymphadenopathy involving her right axilla, leftneck, and right inguinal canal. She first presented to ___ and Pathology at ___ wassigned out as follicular lymphoma; however, there were areas ofincreased proliferation (Ki-67 of 60%) and the patient's clinical course did not completely fit with this diagnosis. Thus, the patient underwent core needle biopsies of the left cervical node for pathology and cytogenetics. She then missed her initial outpatient Oncology visit that was scheduled for ___. She re-presented to the ___ Emergency Department that same day after another syncopal episode. She was admitted to the inpatient Hematologic Malignancy Service, where she got her first cycle of rituximab and CHOP chemotherapy (C1D1 = ___. She tolerated chemotherapy well and was discharged on ___. She then returned for Neulasta on ___. -cycle 2 D1 R-Chop ___ -Plan was for C3 of R-CHOP to be given on ___ but was interrupted given viral gastroenteritis -Port placed ___ -Cycle 3 D1 R-CHOP ___ -Neulasta ___ -Staging CT Torso w/con showing response to R-CHOP therapy ___ PAST MEDICAL HISTORY: -Tonsils out ___ -M to F on estradiol (goes by ___ -Breast implants ___ at ___ -Positive PPD (___) w/ negative CXR, positive Quant Gold ___, on isoniazid/pyridoxine -Chronic Hepatitis B -Tobacco Use Social History: ___ Family History: Mother: COPD, thyroid cancer Father: Recent health unknown to Mrs. ___ ___ Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 126/78 89 16 100%RA GENERAL: AOx3 NAD. HEENT: NC/AT, EOMI, PERRL, anicteric sclera w/o conjunctival injection. MMM without mucositis, with left sided dime sized gray clean based ulceration of buccal mucosa. Prominent bilateral anterior cervical lymphadenopathy R>L. No occipital, posterior or supraclavicular lymphadenopathy. CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes, rales or rhonchi (transmission of upper airway rhonchus breath sound diffusely). ABD: +BS, soft, Non distended. Mild tenderness to palpation of RUQ with liver percussed to 2 cm below costal margin and tip crossing midline. EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: A&O x 3, CN II-XII intact SKIN: Warm and dry, without rashes, well healing port on right chest wall without palpable cord. Mild tenderness to palpation. Without clear erythema thought pigmentation of skin makes difficult to appreciate. LYMPH: ENT lymph as above. Prominent bilateral axillary lymphadenopathy. Left posterior chain and tail of spence. >4 palpable. Right mid axillary prominent lymphadenopathy. Right deep inguinal LN vs post operative scarring. Not present on left inguinal region. DISCHARGE PHYSICAL EXAM: VS: 97.7 120/53 87 18 100%RA GENERAL: AOx3 NAD. HEENT: NC/AT, EOMI, PERRL, anicteric sclera w/o conjunctival injection. MMM without mucositis, with left sided dime sized gray clean based ulceration of buccal mucosa. No evidence of new ulcerations. Prominent bilateral anterior cervical lymphadenopathy R>L. Variable inter-nodal size variation. Hard. Non fixed. CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes, rales or rhonchi (transmission of upper airway rhonchus breath sound diffusely). ABD: +BS, soft, Non distended. Mild tenderness to palpation of RUQ EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: A&O x 3, CN II-XII intact SKIN: Warm and dry, without rashes, well healing port on right chest wall without palpable cord or erythema. LYMPH: ENT lymph as above. Prominent bilateral axillary lymphadenopathy, freely mobile. Left posterior chain and tail of spence. >4 palpable. Right mid axillary prominent lymphadenopathy. Bilateral inguinal lymphadenopathy is appreciated to much lesser extent. ___ <0.5cm nodes. Pertinent Results: ADMISSION LAB VALUES: ___ 06:30PM WBC-6.8 RBC-3.83* HGB-12.0* HCT-35.0* MCV-91 MCH-31.3 MCHC-34.3 RDW-15.2 RDWSD-49.3* ___ 06:30PM NEUTS-61 BANDS-1 ___ MONOS-9 EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-4.22 AbsLymp-1.97 AbsMono-0.61 AbsEos-0.00* AbsBaso-0.00* ___ 06:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 06:30PM PLT SMR-NORMAL PLT COUNT-379 ___ 06:30PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.3 MAGNESIUM-2.0 ___ 06:30PM LIPASE-25 ___ 06:30PM ALT(SGPT)-18 AST(SGOT)-17 ALK PHOS-81 TOT BILI-0.2 ___ 06:30PM GLUCOSE-96 UREA N-11 CREAT-0.6 SODIUM-140 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16 ___ 07:41PM LACTATE-1.7 ___ 11:30PM URINE RBC-9* WBC-7* BACTERIA-FEW YEAST-NONE EPI-7 ___ 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-TR ___ 11:30PM URINE HYALINE-1* PERTINENT IMAGING: ___ ABDOMINAL ULTRASOUND: IMPRESSION: 1. No sonographic evidence of cholelithiasis or acute cholecystitis. 2. Mildly 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. ___ CXR: FINDINGS: The lungs are well inflated and clear. There is persistent prominence of the right paratracheal station, compatible with known lymphadenopathy. The cardiac silhouette is normal. There is no pleural effusion or pneumothorax. A right chest Port-A-Cath is noted terminating at the mid SVC. Bilateral breast implants are identified. IMPRESSION: Persistent fullness at the right paratracheal station compatible with known lymphoma. No focal consolidation. ___ CT CHEST W/CON IMPRESSION: Substantial improvement in the mediastinal lymphadenopathy an resolution of the bilateral axillary lymphadenopathy. Minimal apical emphysema. Status post bilateral breast implants. Port-A-Cath catheter tip terminates at the proximal right atrium. Suspected respiratory bronchiolitis. ___BD & PELVIS W/CON: IMPRESSION: 1. No evidence of lymphadenopathy within the abdomen or pelvis. 2. Several lucent lesions with a thick sclerotic rim and associated cortical thickening are present, as described above. Given the patient's history of malignancy, these lesions are concerning for osseous involvement, although the level of activity of these lesions cannot be assessed. Several of these lesions would be amenable to biopsy. **OF NOTE; IN SUBSEQENT FOLLOW UP OF THESE LESIONS THEY WERE PRESENT ON PRIOR IMAGING, STABLE. NOT LYTIC. COULD STILL CONSIDER BX** 3. Please see separate chest CT report for details of intrathoracic findings. DISCHARGE LAB VALUES: ___ 06:33AM BLOOD WBC-9.0 RBC-3.59* Hgb-10.8* Hct-33.0* MCV-92 MCH-30.1 MCHC-32.7 RDW-15.5 RDWSD-50.2* Plt ___ ___ 06:33AM BLOOD Neuts-65 Bands-4 ___ Monos-5 Eos-0 Baso-1 ___ Metas-2* Myelos-3* AbsNeut-6.21* AbsLymp-1.80 AbsMono-0.45 AbsEos-0.00* AbsBaso-0.09* ___ 06:33AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Stipple-OCCASIONAL ___ 06:33AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06:33AM BLOOD Glucose-86 UreaN-15 Creat-0.7 Na-139 K-4.7 Cl-106 HCO3-27 AnGap-11 ___ 06:33AM BLOOD TotProt-6.0* Calcium-9.5 Phos-5.5* Mg-2.2 ___ 06:33AM BLOOD PEP-PND b2micro-PND Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acyclovir 400 mg PO Q12H 2. ClonazePAM 0.5 mg PO TID:PRN anxiety 3. Isoniazid ___ mg PO DAILY 4. LaMIVudine 100 mg PO DAILY 5. Mirtazapine 15 mg PO QHS 6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 7. Paroxetine 20 mg PO DAILY 8. Pyridoxine 50 mg PO DAILY 9. Ondansetron ___ mg PO Q8H:PRN nausea 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11. Spironolactone 300 mg PO DAILY 12. Estradiol 4 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. ClonazePAM 0.5 mg PO TID:PRN anxiety 3. Isoniazid ___ mg PO DAILY 4. LaMIVudine 100 mg PO DAILY 5. Mirtazapine 15 mg PO QHS 6. Ondansetron ___ mg PO Q8H:PRN nausea 7. Paroxetine 20 mg PO DAILY 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Pyridoxine 50 mg PO DAILY 10. Spironolactone 300 mg PO DAILY 11. Estradiol 4 mg PO DAILY 12. Acetaminophen 325 mg PO Q6H:PRN pain RX *acetaminophen 325 mg 1 tablet(s) by mouth every 6 hours Disp #*90 Tablet Refills:*0 13. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six hours Disp #*56 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: DLBCL SECONDARY: Nicotine dependence, Latent TB Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old M->F transgender named ___ with DLBCL with night sweats worsening axillary and clavicular lymphadenopathy with known mediastinal adenopathy compressing not invading pulm aa // worsening/progression of disease TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. IV Contrast: 130 mL Omnipaque. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 548 mGy-cm. COMPARISON: CT of the abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: Several lucent lesions with thick sclerotic rims and associated cortical thickening are present, including within the manubrium (9:38), L1 vertebral body extending into the left pedicle (5:28), bilateral iliac bones (5:68, 69), and within the left superior pubic ramus (5:86). SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of lymphadenopathy within the abdomen or pelvis. 2. Several lucent lesions with a thick sclerotic rim and associated cortical thickening are present, as described above. Given the patient's history of malignancy, these lesions are concerning for osseous involvement, although the level of activity of these lesions cannot be assessed. Several of these lesions would be amenable to biopsy. 3. Please see separate chest CT report for details of intrathoracic findings. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 12:27 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest CT INDICATION: Known mediastinal adenopathy TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen. Axial images were reviewed in conjunction with coronal and sagittal reformats COMPARISON: ___ FINDINGS: Bilateral breast implants are in place. Substantial axillary lymphadenopathy has resolved. Mediastinal lymphadenopathy has substantially improved in the interim, for example prevascular lymph nodes has decreased in size from 4.4 x 2.5 cm to 2.8 x 0.7 cm. Heart size is normal. There is no pericardial pleural effusion. Image portion of the upper abdomen will be reviewed separately in corresponding report will be issued. Airways are patent to the subsegmental level bilaterally. Apical bulla on the right, series 5, image 7 is unchanged. Centri lobular nodules in the upper lobes are most likely consistent with respiratory bronchiolitis. Bibasal areas of atelectasis are present. No discrete nodules seen. There are no lytic or sclerotic lesions worrisome for infection or neoplasm. IMPRESSION: Substantial improvement in the mediastinal lymphadenopathy an resolution of the bilateral axillary lymphadenopathy. Minimal apical emphysema. Status post bilateral breast implants. Port-A-Cath catheter tip terminates at the proximal right atrium. Suspected respiratory bronchiolitis. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: n/v/d, Chest pain Diagnosed with Fever, unspecified temperature: 100.1 heartrate: 107.0 resprate: 16.0 o2sat: 98.0 sbp: 135.0 dbp: 80.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a pleasure meeting you and taking care of you. You were admitted with subjective fevers and night sweats. We were concerned that this represented progression of your diffuse large B cell lymphoma so we obtained a staging CT scan. This showed decrease in the size of your lymph nodes which was very reassuring. You were monitored in the hospital and were stable without fevers or signs of infection. We felt that it was safe for you to go home and return for further outpatient chemotherapy.You should continue your R-CHOP as an outpatient. Your next appointment is on ___. It is VERY important that you keep this appointment. We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Keflex / Vioxx / Codeine / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Altered Mental Status, s/p fall Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with history of ___, asthma/COPD, HTN, HLD, DMII, obesity c/b OSA/obesity hypoventilation syndrome p/w dyspnea, right lower extremity DVT on coumadin, who presents after a fall at rehab and progressive altered mental status over the last several weeks. Per report, he has been progressively encephalopathic while at ___ for the past ___ weeks. He has had gained about 30lbs as diuresis has been limited by hypotension and he has not been able to routinely take his torsemide. Discharge weight 229kg, current weight 214 kg. He has also had frequent falls, including from a chair today. He was somnolent without loss on consciousness or immediate focal neurologic deficits. In the ED - initial vitals: 97.5 74 132/65 24 96% RA - labs notable for: VBG 7.36/53/66/31, lactate 0.7, proBNP 320 (close to baseline). INR 3.1. Na 129, Cl 86, HCO3 28, Cr 2.2, BUN 82, (prior labs on ___: Na 135, Cl 87, HCO3 40, Cr 1.3, BUN 54) - CXR showed increased pulm edema, cardiomegaly, small b/l pleural effusions - Given size, he was unable to have CT head As he was unable to fit in the CT scanner, he was admitted to the MICU for q1h neuro checks. Past Medical History: ?squamous cell penile lesion. ALCOHOLISM ANXIETY BACK PAIN DEPRESSION DIABETES MELLITUS on insulin GASTROPARESIS HYPERTENSION MORBID OBESITY PEPTIC ULCER DISEASE RECTAL FISSURE RESTRICTIVE LUNG DISEASE SHOULDER PAIN NARCOTICS AGREEMENT VITAMIN D DEFICIENCY HYPERLIPIDEMIA CONGESTIVE HEART FAILURE with preserved EF BENIGN PROSTATIC HYPERTROPHY VENOUS STASIS ULCERS DIABETIC RETINOPATHY DIABETIC NEPHROPATHY NECK PAIN H/O CARPAL TUNNEL SYNDROME H/O CELLULITIS H/O MOTOR VEHICLE ACCIDENT H/O PYELONEPHRITIS H/O COCAINE ABUSE H/O R Gastro DVT diagnosed ___, on anticoagulation SHOULDER SURGERY ___ HERNIA REPAIR x 6 Social History: ___ Family History: Father died at ___ years from MI. Mother is alive and well. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: T 97.6, HR 74, BP 87/67, RR 36, O2 96% RA GENERAL: Sleepy. Arousable to voice. Follows commands. Not oriented to person, place or time HEENT: Sclera anicteric, oropharynx clear. Pupils 3 mm, reactive NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, 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: Erythema of abdomen and bilateral lower extremity venous stasis NEURO: Limited ___ mental status DISCHARGE PHYSICAL EXAM ======================= GENERAL: obese, walking around unit frequently with walker. Sitting in chair in NAD. HEENT: Sclera anicteric, PERRL. MMM. NECK: supple, JVP not elevated though challenging exam due to body habitus LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses. significant ___ edema bilaterally, non-pitting on left and 1+ on right SKIN: bilateral lower extremity venous stasis Pertinent Results: ADMISSION LABS ============== ___ 02:00PM BLOOD WBC-6.0 RBC-3.45* Hgb-10.5* Hct-30.6* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6 Plt ___ ___ 02:00PM BLOOD Neuts-78.6* Lymphs-13.9* Monos-5.6 Eos-1.7 Baso-0.1 ___ 02:00PM BLOOD ___ PTT-54.0* ___ ___ 02:00PM BLOOD Glucose-76 UreaN-82* Creat-2.2* Na-129* K-4.4 Cl-86* HCO3-28 AnGap-19 ___ 02:00PM BLOOD proBNP-320* ___ 05:34AM BLOOD ___ ___ 01:41PM BLOOD ___ pO2-66* pCO2-53* pH-7.36 calTCO2-31* Base XS-2 ___ 02:14PM BLOOD Lactate-0.7 ___ 10:30PM URINE Color-Straw Appear-Clear Sp ___ ___ 10:30PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 10:30PM URINE RBC-2 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0 ___ 10:30PM URINE Hours-RANDOM UreaN-485 Creat-40 Na-10 K-12 Cl-LESS THAN ___ 10:30PM URINE Osmolal-236 MICROBIOLOGY ============ ___ MRSA screen negative ___ Urine culture negative IMAGING/STUDIES =============== ECG ___ Sinus rhythm. Non-specific intraventricular conduction delay. Early precordial R wave progression may be related to old posterior myocardial infarction. Compared to the previous tracing of ___ the QRS complex is slightly wider. CXR ___ Pulmonary edema, increased since the prior study. Cardiomegaly, and probable small bilateral pleural effusions. ECHO ___ The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. CT Head without Contrast ___ No evidence of infarction or large intracranial hemorrhage on this severely limited study. PATHOLOGY: -Penile Lesion biopsy: pending DISCHARGE LABS ============== ___ 06:34AM BLOOD WBC-8.9 RBC-3.74* Hgb-11.3* Hct-34.0* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.7 Plt ___ ___ 06:34AM BLOOD ___ ___:34AM BLOOD Glucose-288* UreaN-36* Creat-1.2 Na-132* K-4.0 Cl-92* HCO3-32 AnGap-12 ___ 06:34AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1 Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with hypoxia, CHF // Eval for volume status TECHNIQUE: Chest Frontal and Lateral COMPARISON: ___ FINDINGS: Cardiac and mediastinal silhouettes remain enlarged, grossly stable. Slight blunting of the costophrenic angles may be due to small pleural effusions. There is moderate pulmonary edema. Bibasilar atelectasis is noted. No evidence of pneumothorax is seen. IMPRESSION: Pulmonary edema, increased since the prior study. Cardiomegaly, and probable small bilateral pleural effusions. Radiology Report EXAMINATION: PORTABLE HEAD CT W/O CONTRAST INDICATION: ___ year old man with fall on comadin, evaluate for intracranial hemorrhage. TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. DOSE: DLP: 3839.3 mGy-cm CTDI: 212.19 mGy COMPARISON: Prior head CT dated ___. FINDINGS: Study is severely limited by motion artifact. Sensitivity for intracranial hemorrhage or signs of infarction is severely decreased. Axial sequences were repeated in an attempt to get better images without improvement due to underlying labored breathing. Allowing for these limitations, there is no evidence of large territory infarction, gross intracranial hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. Calcified choroid plexus within the temporal horn of the lateral ventricle is unchanged from the prior study. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No evidence of infarction or large intracranial hemorrhage on this severely limited study. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with ENCEPHALOPATHY, UNSPECIFIED, LONG TERM USE ANTIGOAGULANT temperature: 97.5 heartrate: 74.0 resprate: 24.0 o2sat: 96.0 sbp: 132.0 dbp: 65.0 level of pain: 9 level of acuity: 3.0

Dear Mr. ___, It was a pleasure caring for you during your admission to ___ ___. You were sent to the ___ from rehab for falls and worsening confusion. You were found to have an elevated level of carbon dioxide in your blood, which was caused by not using your BiPAP machine. Your confusion improved when you were treated with the BIPAP machine. It is very important that you use a BIPAP machine each night to prevent this problem from returning in the future. You can also sleep with your upper body elevated to help with this problem. I have spoken with the company that will deliver your machine. You should hear from them in a couple of days. If you have not heard from them please call: ___ at ___. You have worse swelling in your right leg compared to your left leg. This is probably related to the deep vein thrombosis (DVT) or blood clot that was diagnosed during your stay at rehab. You were started on coumadin to protect you from clots in the future. You have congestive heart failure, for which you received diuresis (water taken off). Please weigh yourself every morning, and call your PCP if weight goes up more than 3 lbs. Your insulin was reduced during your hospitalization because your blood sugars were low. We expect your insulin will need ongoing adjustment after you leave the hospital. Per the urology team the dermabond over the surgical site on your penis will come off naturally over the next few days. You should keep the area clean. Dr. ___ will call you with the results of your biopsy. If you have questions for Dr. ___ can reach him at ___. Best wishes, Your Medicine 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: dizziness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year-old right-handed man with hypertension and complete heart block s/p pacemaker who presents with "dizziness" since ___. He reports waking ___ morning, in the bathroom where he almost LOC and fell to the left. He proceded to feel dizzy with blurry vision in the distance while driving into work, felt nauseous and vomited so stayed home from work and rested. Symptoms improve/resolve with lying down. Continued to feel dizzy each day, again nausea and vomiting today. He is mail man with a foot route and has had trouble walking, feeling like he is falling to his left side, almost like he can't control it well, but doesn't report weakness. Does acknowledge it has been hot recently. Was seen by PCP today who referred in. Reports a somewhat similar sensation years ago that was brief and resolved, otherwise he is not a person who gets dizzy regularly, only time he lost consciousness was in the setting of heart block and very different (no dizziness symptoms, just sudden LOC). Denies headache, vertigo, diplopia, change in speech or comprehension, trouble swallowing, weakness, parasthesias or numbness anywhere. In the ED his BPs were 100s systolic and orthostatic VS normal. He was well appearing and symptomatic only when standing. The ED providers were concerned about gait falling to the left and ataxia so consulted Neurology. Cardiology was also consulted to interrogate the pacemaker which was normal. He had a NCHCT and CTA H/N which showed no clear infarct or significant stenosis/occlusion. Labs unremarkable and CXR negative for acute process. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: HTN HLD (patient denies?) CHB s/p PPM Macular degeneration Social History: ___ Family History: father with stroke in ___ Physical Exam: Vitals: General: Awake, cooperative, 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, NT/ND, no masses or organomegaly noted. Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. 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. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic exam performed with limited visualization but partial disc visualized and sharp III, IV, VI: EOMI with end gaze nystagmus that extinguishes. Saccadic intrusions. Dysconjugate gaze at rest with right exotropia. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibration throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 - 2 2 1 R 2 - 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Slightly wide based. Able to walk tandem for a few steps. Felt to the left with Romberg. When marching in place, left moving to the left. DISCHARGE PHYSICAL EXAM General: Awake, cooperative, 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, NT/ND, no masses or organomegaly noted. Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. 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. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI. Some nystagmus on R gaze that extinguishes. Dysconjugate gaze at rest with left exotropia. 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. positive HIT to left. ___ negative -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 - 2 2 1 R 2 - 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. past pointing on left -Gait: Good initiation. Slightly wide based. drifted to left when walking, occasionally stumbles. unterberger positive with movement to left. Pertinent Results: ___ 02:30PM BLOOD WBC-7.1 RBC-4.73 Hgb-13.7 Hct-42.9 MCV-91 MCH-29.0 MCHC-31.9* RDW-14.1 RDWSD-47.4* Plt ___ ___ 02:30PM BLOOD WBC-7.1 RBC-4.73 Hgb-13.7 Hct-42.9 MCV-91 MCH-29.0 MCHC-31.9* RDW-14.1 RDWSD-47.4* Plt ___ ___ 02:30PM BLOOD Neuts-64.8 ___ Monos-10.2 Eos-5.0 Baso-0.6 Im ___ AbsNeut-4.57 AbsLymp-1.35 AbsMono-0.72 AbsEos-0.35 AbsBaso-0.04 ___ 06:43AM BLOOD ___ PTT-28.8 ___ ___ 02:30PM BLOOD Glucose-132* UreaN-21* Creat-1.2 Na-141 K-4.2 Cl-104 HCO3-23 AnGap-14 ___ 02:30PM BLOOD cTropnT-<0.01 ___ 02:30PM BLOOD Calcium-10.5* Phos-2.9 Mg-2.2 ___ 07:08PM BLOOD %HbA1c-6.1* eAG-128* ___ 06:43AM BLOOD Triglyc-134 HDL-38* CHOL/HD-4.8 LDLcalc-118 ___ 02:30PM BLOOD TSH-2.3 ___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 06:15PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:15PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM* ___ 06:15PM URINE RBC-1 WBC-9* Bacteri-FEW* Yeast-NONE Epi-1 ___ 06:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG CTA H/n ___ IMPRESSION: 1. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. 2. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. NCHCT ___ IMPRESSION: No acute intracranial process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4.Outpatient Physical Therapy Vestibular ___ H81.92 Discharge Disposition: Home Discharge Diagnosis: Left sided peripheral vestibulopathy 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 3 days dizziness// pt w/ dizziness, ppm in place, edema? effusion? COMPARISON: Prior chest radiograph dated ___ FINDINGS: PA and lateral views of the chest provided. Left chest wall pacer is again seen with leads extending to the region of the right atrium and right ventricle. The lung volumes are somewhat low with mild atelectasis in the lower lungs. No convincing evidence for pneumonia or edema. No large effusion or pneumothorax. Cardiomediastinal silhouette is stable. Imaged bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with ataxia// assess for ICH TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformats were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 11.0 s, 19.3 cm; CTDIvol = 47.4 mGy (Head) DLP = 911.9 mGy-cm. Total DLP (Head) = 926 mGy-cm. COMPARISON: None. 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 unremarkable. Basilar cisterns are patent. Included paranasal sinuses and mastoids are essentially clear. Skull and extracranial soft tissues are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with dizziness// assess for dissection, stenosis TECHNIQUE: Helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Stationary Acquisition 8.0 s, 0.5 cm; CTDIvol = 39.9 mGy (Body) DLP = 19.9 mGy-cm. 2) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 15.2 mGy (Body) DLP = 600.0 mGy-cm. Total DLP (Body) = 620 mGy-cm. COMPARISON: CT head without contrast dated ___. FINDINGS: CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation greater than 3mm. The dural venous sinuses are patent. CTA NECK: Bilateral carotid and vertebral artery origins are patent. There is no evidence of internal carotid stenosis by NASCET criteria. The carotidandvertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. OTHER: The visualized portion of the lungs are clear. Left thyroid nodule measuring 1.3 cm posteriorly. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. 2. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. Gender: M Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: Dizziness Diagnosed with Dizziness and giddiness temperature: 96.7 heartrate: 65.0 resprate: 17.0 o2sat: 99.0 sbp: 129.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to feelings of dizziness and leaning to the left while walking. You had some tests done, like a CT scan of your head and the blood vessels in the head and neck, which were unremarkable. Based on your neurological examination and the symptoms you had told us, we believe that your balance issues are due to an inner ear problem. This is referred to as a peripheral vestibulopathy. Many things can cause this, we are not sure of the exact one at this time. We do not think this is Meniere's disease. This should improve with time. We had physical therapy see you. You will undergo vestibular physical therapy once you are out of the hospital, this will help your vestibular (inner ear) system which is responsible for your balance recover. Sincerely, Your ___ neurology team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Changes in sensation and slight weakness in the legs Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: He was at school today, in his usual state of health and sometime in the morning his legs began to feel odd in a hard to describe way, this then progressed to both legs feeling weak. He has still been able to walk. His R arm also felt odd, he comapred it to it feeling like it was asleep, this improved later in the day. When he was bending his neck today he sometimes felt an electric sensation in his neck. He was in his usual state of health prior to today. He denies any bowel bladder incontinence currently. He has not had any recent infectious symptoms or concern for infection. He states he cracks his neck often and wonders if it could be related to that. No shortness of breath. He denies any previous episodes of visual changes, eye pain, color vision changes, doubel vision, focal weakness, numbness. There is no family history of autoimmune disease. When he arrived home, his father, a card___, evaluated his symptoms and felt that the legs seemed weak perhaps ___ or so. He spoke with a neurologist he knows and decided to bring him in for evaluation in the ED. Past Medical History: None Social History: ___ Family History: No family history of neurological issues, autoimmune disease. Physical Exam: ADMISSION EXAM: =============== Vitals: T98.2 HR 68 BP 153/60 RR 18 Spo2 97% 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 ___ 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: Mild anisocoria. L pupil 4mm -> 2mm. R pupil 3 mm-> 1.5 mm. Unable to appreciate any clear APD, patient moving eyes a lot however. EOMI without nystagmus. Normal saccades. VFF to confrontation. No red desaturation V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 4- 5 5 4 5 4 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, throughout. -DTRs: Bi Tri ___ Pat Ach L 3 3 3 3 2 R 3 3 3 3 2 +pec jerk +suprapatellar, crossed adductor b/l Plantar response was extensor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. DISCHARGE EXAM: =============== VS: Temp: 98.0 (Tm 98.5), BP: 107/54 (107-143/54-69), HR: 74 (62-79), RR: 18 (___), O2 sat: 97% (96-100), O2 delivery: Ra EXAM General: Awake, cooperative, tearful, sitting on edge of bed with parents in the room HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Breathing comfortably on RA Cardiac: RRR, 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: -Mental Status: Alert, oriented, conversant. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: Mild anisocoria. L pupil 4mm -> 2mm. R pupil 3 mm-> 1.5 mm. Unable to appreciate any clear APD. EOMI without nystagmus. Normal saccades. VFF to confrontation. No red desaturation 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. Slight pronation of right hand; no drift. No adventitious movements, such as tremor, noted. No asterixis noted. Strength full throughout. -Sensory: Decreased pinprick/temperature sensation on left starting around T3. Decreased pinprick/temp to about 70-80% L5-S1 on left. No deficits to vibration or proprioception. -DTRs: ___ this AM -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Negative Romberg. -Gait: Good initiation. Narrow-based, normal stride and arm swing. No deficits on tandem, tip toes and heels, but overall ataxic. Pertinent Results: LABS: ===== ___ 12:11PM CEREBROSPINAL FLUID (CSF) PROTEIN-36 GLUCOSE-75 ___ 12:11PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-80* POLYS-15 ___ MACROPHAG-24 ___ 12:11PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-2 POLYS-0 ___ ___ 06:48AM GLUCOSE-94 UREA N-15 CREAT-0.9 SODIUM-143 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 ___ 06:48AM ALT(SGPT)-23 AST(SGOT)-20 LD(LDH)-185 ALK PHOS-49 TOT BILI-0.8 ___ 06:48AM CALCIUM-9.6 PHOSPHATE-4.3 MAGNESIUM-1.9 ___ 06:48AM VIT B12-515 ___ 06:48AM CRP-1.1 ___ 06:48AM WBC-6.1 RBC-5.28 HGB-15.8 HCT-46.2 MCV-88 MCH-29.9 MCHC-34.2 RDW-11.9 RDWSD-37.9 ___ 06:48AM PLT COUNT-181 ___ 06:48AM ___ PTT-27.0 ___ ___ 07:42PM URINE HOURS-RANDOM ___ 07:42PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 07:42PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 07:10PM GLUCOSE-100 UREA N-19 CREAT-1.0 SODIUM-143 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14 ___ 07:10PM estGFR-Using this ___ 07:10PM ALT(SGPT)-27 AST(SGOT)-26 CK(CPK)-149 ALK PHOS-57 TOT BILI-0.4 ___ 07:10PM LIPASE-18 ___ 07:10PM CK-MB-2 cTropnT-<0.01 ___ 07:10PM ALBUMIN-5.3* CALCIUM-9.8 PHOSPHATE-3.6 MAGNESIUM-2.0 ___ 07:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG ___ 07:10PM WBC-10.5* RBC-5.36 HGB-16.2 HCT-46.5 MCV-87 MCH-30.2 MCHC-34.8 RDW-11.9 RDWSD-37.5 ___ 07:10PM NEUTS-67.9 ___ MONOS-9.1 EOS-1.8 BASOS-0.3 IM ___ AbsNeut-7.14* AbsLymp-2.18 AbsMono-0.96* AbsEos-0.19 AbsBaso-0.03 ___ 07:10PM PLT COUNT-206 ___ 07:10PM ___ PTT-28.3 ___ IMAGING: ======== MRI C-SPINE WITH/WITHOUT CONTRAST ___: 1. Signal abnormality within the spinal cord likely active demyelinating plaque at the C3 level. Brain MRI can help for further assessment. 2. Multilevel cervical spondylosis with mild-to-moderate cervical spinal canal narrowing secondary to reversal of the normal cervical lordosis with flattening of the ventral cord but no associated cord signal abnormality. CXR ___: No acute cardiopulmonary process. MRI THORACIC AND LUMBAR SPINE ___: 1. The patient declined administration of IV contrast. 2. No evidence of thoracic or lumbar cord lesions. 3. Mild thoracic spondylosis with T6-T7 left paracentral disc protrusion and remodeling of the ventral cord but no cord signal abnormality. MRI HEAD WITH/WITHOUT CONTRAST ___: 1. Mildly enhancing white matter changes in both corona radiata. Given the known enhancing white matter plaque along the cervical spine, concerning for intracranial demyelinating changes. 2. No evidence of acute infarction, hemorrhage or intracranial mass. Medications on Admission: None Discharge Medications: 1. ALPRAZolam 0.25 mg PO TID:PRN Anxiety RX *alprazolam 0.25 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 2. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Multiple Sclerosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old man with no PMH with bilateral leg weakness, arm sensory changes today. C spine shows demyelinating lesion// ?other demyelinating lesions, evidence of MS. ___ obtain sagittal T2 sequences 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: MRI of the cervical spine from ___ FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. Note is made of T2/FLAIR hyperintensities in the bilateral corona radiata (series 12, image 18 and 19). The lesions in the parietal region demonstrate mild enhancement (14:19).. The ventricles and sulci are normal in caliber and configuration. Major vascular flow voids appear preserved. Major dural venous sinuses are patent. The paranasal sinuses and mastoid air cells appear clear. The orbits appear grossly unremarkable. IMPRESSION: 1. Mildly enhancing white matter changes in both corona radiata. Given the known enhancing white matter plaque along the cervical spine, concerning for intracranial demyelinating changes. 2. No evidence of acute infarction, hemorrhage or intracranial mass. Radiology Report EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE INDICATION: ___ year old man with no PMH with bilateral leg weakness, arm sensory changes today. C spine shows demyelinating lesion// ?demyelinating lesion TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. COMPARISON: MRI of the cervical spine from ___ FINDINGS: The patient declined administration of IV contrast. Thoracic spine: Vertebral body height and alignment is preserved. Intervertebral disc spaces appear maintained. Bone marrow signal intensity is within normal limits. At T6-T7, there is a left paracentral disc protrusion with flattening of the ventral cord but no definitive cord signal abnormality. Otherwise, there is no evidence of cord compression, severe spinal canal stenosis or significant neural foraminal narrowing along the remaining thoracic levels. The remainder of the cervical spine appears normal in caliber and configuration. Lumbar spine: Vertebral body height and alignment is preserved. There is mild straightening of a normal lumbar lordosis. There is mild decreased signal in the L5-S1 disc space, consistent with degenerative disc disease. Disc space heights are otherwise maintained. There is no evidence of cord compression, severe spinal canal stenosis or significant neural foraminal narrowing along the lumbar levels. Spinal cord appears normal in caliber and configuration. The cauda equina nerve roots are unremarkable. The conus terminates normally at the L1 level. IMPRESSION: 1. The patient declined administration of IV contrast. 2. No evidence of thoracic or lumbar cord lesions. 3. Mild thoracic spondylosis with T6-T7 left paracentral disc protrusion and remodeling of the ventral cord but no cord signal abnormality. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Leg weakness, R Arm numbness Diagnosed with Weakness, Anesthesia of skin temperature: 98.2 heartrate: 68.0 resprate: 18.0 o2sat: 97.0 sbp: 153.0 dbp: 60.0 level of pain: 4 level of acuity: 2.0

___ were admitted to the hospital because ___ had changes in sensation and slight weakness in your legs. WHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL? ___ were admitted to the General Neurology service after undergoing an MRI of your upper spine in the ED that revealed an abnormal lesion. ___ underwent a spinal tap for further evaluation with some labs pending. ___ underwent an MRI of your Head which showed other lesions which with your clinical symptoms is consistent with a diagnosis of MS. ___ were started on IV steroids which produced some improvement in symptoms. Due to this improvement, ___ were deemed stable for discharge home with further treatment as outpatient. WHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - ___ can take Alprazolam as needed for anxiety in the near future - Please continue steroid infusions at the BI ___ over the next two days; ___ will be contacted ___ AM to arrange for an infusion time that day - Keep your follow up appointments with your doctors - If ___ experience any of the danger signs listed below please call your primary care doctor or come to the emergency department immediately. It was a pleasure participating in your care. We wish ___ the best! - Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: chest pain and back pain with associated SOB Major Surgical or Invasive Procedure: pheresis line placement: ___ History of Present Illness: Patient is a ___ male with a history of multiple myeloma, diabetes presenting with back pain and chest pain. He said the pain started at 11 ___ the night of presentation, he reports the pain as being higher up in his back and radiates across his chest. He denies any recent trauma, the pain came on while he was laying in bed. He says the pain comes on in spasms, describes as ___ in severity. Has never felt pain like this before. HE is scheduled to get stem cell transfusion on ___. Reports SOB with the chest and back pain. Took oxycodone when the pain started with no relief. Past Medical History: PAST MEDICAL HISTORY HYPERLIPIDEMIA HYPERTENSION CORONARY ARTERY DISEASE ERECTILE DYSFUNCTION OBESITY SKIN CANCERS OBSTRUCTIVE SLEEP APNEA KNEE PAIN BENIGN PROSTATIC HYPERTROPHY RIGHT SHOULDER PAIN NASH Surgical History (Last Verified ___ by ___, MD): UMBILICAL HERNIA ___ s/p repair APPENDECTOMY ___ HEMORRHOIDECTOMY ___ PAST ONCOLOGIC HISTORY (per OMR): - ___: Cycle 1 Velcade/Dexamethasone - ___: Radiation therapy to right clavicle head, 5 treatments - ___ - ___: Admission for increasing neck pain. Felt more musculoskeletal. - ___ - ___: Admission for reduced appetite, dyspepsia & abdominal bloating. EGD showed nonspecific cobblestoning of the proximal duodenum, with biopsies showing enteritis; started on high-dose PPI and standing Reglan with meals (for possible Velcade-induced gastroparesis). Symptoms improved. - ___: Cycle 2 Velcade, Revlimid 25 mg D ___, Dexamethasone. Delayed for nausea and concern for delayed motility - ___ - ___: Admission for cough/URI. Treated with Z-pak and inhalers. - ___: Cycle 3 Velcade, Revlimid 25 mg D ___, Dexamethasone - ___: Fever; cough with Influenza B; treated with Tamiflu - ___: Cycle 4 Velcade, Revlimid 25 mg D ___, Dexamethasone - ___: Cycle 5 Velcade HELD d/t increasing neuropathies. Revlimid 25 mg x 14 days with weekly Dexamethasone. Social History: ___ Family History: -mother deceased at age ___ r/t bone cancer -sister dx with glomerulonephritis at age ___ Physical Exam: ADMISSION PHYSICAL EXAM ======================== 24 HR Data (last updated ___ @ 1723) Temp: 98.0 (Tm 98.0), BP: 148/75, HR: 70, O2 sat: 97%, O2 delivery: RA, Wt: 198.5 lb/90.04 kg GENERAL: pacing in room, appears comfortable, no acute distress, pleasant EYES: Pupils equally round reactive to light, anicteric sclera HEENT: Oropharynx clear, no lesions, moist mucous membranes NECK: Supple, normal range of motion LUNGS: Clear to auscultation bilaterally without any wheezes rales or rhonchi. Breathing even and non-labored. CV: Regular rate and rhythm no murmurs rubs or gallops normal distal perfusion no edema ABD: Soft nontender nondistended normoactive bowel sounds, no rebound or guarding EXT: No deformity, normal muscle bulk SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech LINES: PIV DISCHARGE PHYSICAL EXAM ======================== Temp: 97.8, BP: 142/79, HR: 62, O2 sat: 95%, O2 delivery: RA, Wt: 198.5 lb/90.04 kg GENERAL: lying down in phresis unit, appears comfortable, no acute distress, pleasant EYES: Pupils equally round reactive to light, anicteric sclera HEENT: Oropharynx clear, no lesions, moist mucous membranes NECK: Supple, normal range of motion LUNGS: Clear to auscultation bilaterally without any wheezes rales or rhonchi. Breathing even and non-labored. CV: Regular rate and rhythm no murmurs rubs or gallops normal distal perfusion no edema ABD: Soft nontender nondistended normoactive bowel sounds, no rebound or guarding EXT: No deformity, normal muscle bulk SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech LINES: tunneled pheresis line-CDI Pertinent Results: ADMISSION LABS ==================== ___ 03:27AM BLOOD WBC-0.6* RBC-4.19* Hgb-12.7* Hct-39.1* MCV-93 MCH-30.3 MCHC-32.5 RDW-14.7 RDWSD-50.3* Plt Ct-44* ___ 03:27AM BLOOD Neuts-0* Lymphs-75* Monos-10 Eos-8* Baso-1 Atyps-4* Myelos-2* AbsNeut-0.00* AbsLymp-0.47* AbsMono-0.06* AbsEos-0.05 AbsBaso-0.01 ___ 03:27AM BLOOD Poiklo-1+* Ovalocy-1+* Tear Dr-1+* RBC Mor-SLIDE REVI ___ 03:27AM BLOOD ___ PTT-30.9 ___ ___ 03:27AM BLOOD Plt Smr-VERY LOW* Plt Ct-44* ___ 03:27AM BLOOD Glucose-135* UreaN-19 Creat-1.2 Na-141 K-4.1 Cl-103 HCO3-25 AnGap-13 ___ 06:38AM BLOOD b2micro-2.0 DISCHARGE LABS ==================== ___ 12:00AM BLOOD WBC-17.7* RBC-3.39* Hgb-10.3* Hct-31.5* MCV-93 MCH-30.4 MCHC-32.7 RDW-15.4 RDWSD-52.2* Plt Ct-51* ___ 12:00AM BLOOD Neuts-62 Bands-30* Lymphs-3* Monos-0* Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-2* NRBC-0.6* AbsNeut-16.28* AbsLymp-0.71* AbsMono-0.00* AbsEos-0.18 AbsBaso-0.00* ___ 12:00AM BLOOD Anisocy-1+* Poiklo-1+* Polychr-1+* Ellipto-1+* RBC Mor-SLIDE REVI ___ 12:00AM BLOOD Plt Smr-VERY LOW* Plt Ct-51* ___ 12:00AM BLOOD Glucose-82 UreaN-10 Creat-0.9 Na-146 K-3.5 Cl-103 HCO3-26 AnGap-17 ___ 12:00AM BLOOD ALT-10 AST-21 LD(LDH)-443* AlkPhos-100 TotBili-0.3 ___ 12:00AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.0 Mg-1.8 ___ 12:00AM BLOOD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Cyanocobalamin 1000 mcg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. NIFEdipine (Extended Release) 30 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 7. Pyridoxine 50 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Hydrochlorothiazide 25 mg PO DAILY 10. LevoFLOXacin 500 mg PO Q24H 11. MetFORMIN (Glucophage) 500 mg PO BID 12. Filgrastim-sndz 480 mcg SC Q24H 13. Glargine 38 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Glargine 38 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. Acyclovir 400 mg PO Q12H 3. Cyanocobalamin 1000 mcg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. NIFEdipine (Extended Release) 30 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 10. Pyridoxine 50 mg PO DAILY 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== MULTIPLE MYELOMA ACUTE PAIN SECONDARY DIAGNOSIS ===================== STEROID INDUCED DIABETES Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with Multiple myeloma// Please place tunneled triple apheresis line for collection Thanks ___ TECHNIQUE: OPERATORS: Dr. ___ resident, Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service time of 40 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. CONTRAST: None FLUOROSCOPY TIME AND DOSE: 5 minutes min, 30 seconds, 28 mGy PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The neck was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced into the IVC. After sequential dilation of the soft tissue tract a triple lumen pheresis catheter was advanced over the wire into the superior vena cava with the tip in the cavoatrial junction. The access ports were aspirated, flushed and capped. The catheter was secured to the skin with 0 silk suture and sterile dressings were applied. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The patient tolerated the procedure well without immediate complications. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing the catheter tip terminating in the cavoatrial junction. IMPRESSION: Successful placement of a right internal jugular approach triple lumen temporary pheresis catheter. The line is ready to use. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with cough, neutropenia// eval for pna TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior chest radiographs, most recently ___. PET-CT ___. FINDINGS: Fragmented, lytic and blastic lesion medial right clavicle projects over and partially obscures the medial apex of the right hemithorax. Lungs and pleural surfaces elsewhere are clear. Hilar contours and cardiomediastinal silhouette are normal. IMPRESSION: 1. No acute cardiopulmonary process. 2. Similar appearance of a destructive right clavicular lesion as seen on recent PET-CT performed ___. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with MM, acute onset back pain CP and SOB// 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 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP = 9.1 mGy-cm. 2) Spiral Acquisition 4.5 s, 35.1 cm; CTDIvol = 16.7 mGy (Body) DLP = 584.4 mGy-cm. Total DLP (Body) = 593 mGy-cm. COMPARISON: PET-CT ___. 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: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Scarred mild centrilobular emphysema. Lungs are clear without masses or areas of parenchymal opacification. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Limited sections through the upper abdomen show subcentimeter left hepatic lobe hypodensities, too small to characterize. BONES: T2 vertebral body hemangioma is unchanged. Please refer to recent ___ PET-CT for evaluation of lytic lesions. No acute fractures. IMPRESSION: 1. No pulmonary embolism or aortic injury. 2. No acute fractures involving the osseous structures of the chest. Please refer to recent ___ F FDG PET-CT from ___ for evaluation of osseous lesions. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with hx multiple myeloma presenting with severe leg, chest and back pain.// evaluate symptoms including leg pain TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Back pain Diagnosed with Chest pain, unspecified temperature: 98.4 heartrate: 69.0 resprate: 16.0 o2sat: 98.0 sbp: 147.0 dbp: 86.0 level of pain: 10 level of acuity: 2.0

Dear Mr. ___. You were admitted for evaluation of acute chest and back pain likely due to neupogen bony pain. You improved with pain medication and underwent stem cell collection on ___ which you tolerated..... Please follow up with Dr. ___ as stated below. It was a pleasure taking care of you. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Unresponsiveness, hypoxia Major Surgical or Invasive Procedure: Endotracheal intubation, mechanical ventilation History of Present Illness: This is a ___ year-old gentleman with a PMHx of polysubstance abuse, hypertension, mood disorder, and hepatitis C infection presening with fever. He was admitted to ___ Inpatient Detox on ___ requesting benzodiazepine detox. He was initiated on phenobarbital and continued on methadone for which he is on maintenance for opioid abuse. Over the past day he was more fatigued, and on ___ he was febrile to 102.8F. He took ibuprophen with no effect. EMS was called and found his SpO2 to be 88% on RA, increasing to 95% on 4L NC. He was given Narcan without effect. He awoke slightly, and then had tonic-clonic acitivty en route to the ___. Given persistent somnolence, he was intubated for airway protection. CT head showed no acute process. LP showed 3 WBC. He was started empirically on ceftriaxone, vancomycin, and acyclovir. CXR was concerning for bilateral pneumonia, and meropenem was added. UTox screen was positive for methadone, cocaine, marijuana, benzos, barbituates, and TCAs. He was loaded with fosphenytoin given suspicion for seizure. On examination, a bag full of clonazepam was found in his rectum. He was transferred to ___ ED. - Initial VS were: HR 61 BP 99/59 RR 14 SpO2 100% - Labs were notable for H/H 10.7/30.6, INR 1.3, serum tox negative, urine tox positive for methadone, barbituates, benzos, and cocaine. BUN/CR ___, lactate 1.8. - UA showed moderate blood and few bacteria - Toxicology was consulted and recommended supportive care, avoidance of flumazenil given concern for seizures, and serial ECGs for QRS monitoring given TCA positivity with the recommendation to start a bicarbonate drip for QRS > 100. - He remained intubated and sedated on fentanyl 100 and midazolam 4 - Prior to transfer, VS were T 97.8, HR 62, RR 18, BP 106/65, SpO2 100% On arrival to the MICU, he was agitated and further sedated on fentanyl 125 and midazolam 2. Past Medical History: Polysubstance abuse Hypertension Hepatitis C History of alchohol withdrawal seizures History of head trauma Mood disorder PTSD Social History: Per ___ records: history of alcohol use ___ beers and 2 pints vodka dailly; crack 1gram daily (smoked), Klonopin and Xanax daily, Cannabis ___ joints daily. Is on methadone maintenance at ___ Line Ciinic (72mg). Reports a history of withdrawal seizures. Patient reports that prior to detox he was using EtOH ___ quarts beer in the AM or ___ of vodka or other hard liquor), benzos ___ times his prescribed Klonopin - 2g TID - along with friend's ___, and smoking cocaine on the day prior to going to detox. He wished to be detoxed off the EtOH only but was told he needed to come off benzos as well. When asked about hiding Klonopin he reports keeping some in a sock to hide it at home, but does not discuss the bag found on his body in ___. He denies any recent IVDU (last heroin use was years ago) or prescription opioids, or drug use at detox. When asked about TCAs he says he thinks his psychiatrist prescribes one. He reports history of withdrawal seizures, DTs from EtOH but no unprovoked seizures. He is homeless - his wife is in a woman's halfway house, mom is at a rehab, uncle is at his mom's home but he is concerned about going back there as he thinks he will go back to using. Was in school until ___ grade, works as a ___, last time 3 weeks prior to detox. Smokes 1ppd. He is transferring his care to ___ in ___, which also runs his ___ clinic. Current psychiatrist/prescriber is Dr. ___ who is a liberal benzodiazepine prescriber per ___ Globe. Family History: Unknown Physical Exam: On Admission: Vitals: T: 97.6 BP: 121/65 P: 73 R: 16 O2: 99% on 500x18 5 40% GENERAL: Intubated, sedated, opens eyes briefly to sternal rub HEENT: Sclera anicteric, ETT in place NECK: supple, JVP not elevated, no LAD LUNGS: Decrased breath sounds at bilateral bases 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: Dry, superficial abrasion of left shin NEURO: PERRL, + gag, withdraws to noxious stimuli, 2+ patellar reflexes, no clonus On Discharge: VS: 98.5 ___ 150s-180s/80s-100s ___ 97-99% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD RESP: good air movement, CTAB no wheezes CV: RRR, Nl S1, S2, No MRG ABD: Soft, mild diffuse ttp, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: motor function grossly normal SKIN: abrasion of left shin healing Pertinent Results: ADMISSION LABS: ___ 08:57PM BLOOD WBC-9.5 RBC-3.30* Hgb-10.7* Hct-30.6* MCV-93 MCH-32.4* MCHC-35.0 RDW-12.5 RDWSD-42.0 Plt Ct-78* ___ 08:57PM BLOOD ___ PTT-38.3* ___ ___ 08:57PM BLOOD Glucose-103* UreaN-27* Creat-1.5* Na-127* K-4.6 Cl-108 HCO3-16* AnGap-8 ___ 08:57PM BLOOD ALT-44* AST-52* LD(LDH)-325* CK(CPK)-310 AlkPhos-30* TotBili-0.4 ___ 08:57PM BLOOD Lipase-21 ___ 08:57PM BLOOD Albumin-2.4* Calcium-6.2* Phos-1.6* Mg-1.4* ___ 08:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:08PM BLOOD pO2-110* pCO2-44 pH-7.30* calTCO2-23 Base XS--4 Intubat-INTUBATED Comment-GREEN TOP ___ 09:43PM BLOOD Type-ART Rates-/15 Tidal V-480 PEEP-5 FiO2-100 pO2-337* pCO2-50* pH-7.27* calTCO2-24 Base XS--4 AADO2-316 REQ O2-59 -ASSIST/CON Intubat-INTUBATED ___ 09:08PM BLOOD Glucose-102 Lactate-1.8 Na-134 K-4.6 Cl-108 ___ 09:08PM BLOOD Hgb-11.1* calcHCT-33 O2 Sat-95 COHgb-2.9 MetHgb-0.3 ___ 09:08PM BLOOD freeCa-0.87* ___ 08:57PM URINE bnzodzp-POS barbitr-POS opiates-NEG cocaine-POS amphetm-NEG oxycodn-NEG mthdone-POS ___ 08:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CXR ___: 1. Satisfactory position of endotracheal and enteric tubes. 2. Heterogeneous bibasilar opacities concerning for multifocal pneumonia or aspiration. 3. Suspected left pleural effusion. Abdominal Xray ___ IMPRESSION: No radiopaque foreign bodies seen in the region of the rectum. No evidence of obstruction. Abdomen US ___: 1. Splenomegaly, with the spleen measuring 20.0 cm. 2. Trace free fluid in the ___'s pouch with mild gallbladder wall thickening likely related to surrounding fluid. 3. Hepatomegaly with a heterogeneous echotexture of the liver parenchyma, reflective of chronic liver disease in this patient with hepatitis C. CXR ___: Cardiac silhouette is within normal limits and there is no evidence of vascular congestion. There is extensive opacification at the right base. Although this could represent atelectasis, in the appropriate clinical setting right middle and lower lobe pneumonia would have to be seriously considered. Micro: GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Urine cx, blood cx, MRSA negative. DISCHARGE: ___ 07:27AM BLOOD Glucose-99 UreaN-16 Creat-1.1 Na-137 K-4.0 Cl-104 HCO3-20* AnGap-17 ___ 07:27AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.8 ___ 07:27AM BLOOD WBC-7.3 RBC-4.12* Hgb-12.9* Hct-36.0* MCV-87 MCH-31.3 MCHC-35.8 RDW-12.4 RDWSD-39.5 Plt ___ ___ 06:56PM BLOOD Hgb-12.8* Hct-36.0* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 200 mg PO QHS 2. QUEtiapine Fumarate 100 mg PO QAM 3. Albuterol Inhaler Dose is Unknown IH Frequency is Unknown 4. Qvar (beclomethasone dipropionate) 80 mcg/actuation inhalation BID 5. HydrOXYzine 25 mg PO BID 6. ALPRAZolam 2 mg PO QHS:PRN insomnia 7. ALPRAZolam 1 mg PO DAILY:PRN anxiety 8. Methadone 72 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Gabapentin 800 mg PO TID 11. Citalopram 20 mg PO DAILY 12. Vitamin D ___ UNIT PO DAILY 13. Hydrochlorothiazide 50 mg PO DAILY 14. Oxcarbazepine 300 mg PO TID 15. Labetalol 300 mg PO BID Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Gabapentin 800 mg PO TID 3. Oxcarbazepine 300 mg PO TID 4. Omeprazole 20 mg PO DAILY 5. QUEtiapine Fumarate 200 mg PO QHS 6. QUEtiapine Fumarate 100 mg PO QAM 7. Vitamin D ___ UNIT PO DAILY 8. Methadone 72 mg PO DAILY 9. Labetalol 300 mg PO BID 10. HydrOXYzine 25 mg PO BID 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath, wheeze 12. Hydrochlorothiazide 50 mg PO DAILY 13. Qvar (beclomethasone dipropionate) 80 mcg/actuation inhalation BID 14. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Last dose ___ RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #*5 Tablet Refills:*0 15. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Multisubstance abuse (opiates, barbituates, benzodiazepines, and cocaine) requiring intubation for somnolence and airway protection. Aspiration pneumonia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ intubated, transfer, TECHNIQUE: Portable upright chest radiograph COMPARISON: Outside hospital chest radiograph from the same day. FINDINGS: Endotracheal tube terminates 4.5 cm from the carina. Enteric tube terminates beyond the diaphragm, out of the field-of-view. Lung volumes are low with heterogeneous bilateral opacities concerning for infection or aspiration. Blunting of the lateral costophrenic angle seen on the left. No pneumothorax. IMPRESSION: 1. Satisfactory position of endotracheal and enteric tubes. 2. Heterogeneous bibasilar opacities concerning for multifocal pneumonia or aspiration. 3. Suspected left pleural effusion. Radiology Report EXAMINATION: ABDOMEN (SUPINE ONLY) INDICATION: ___ with pills in rectum, concern for ?body packing TECHNIQUE: Supine abdominal radiograph COMPARISON: None FINDINGS: Enteric tube is seen projecting over the upper aspect of the abdomen. Bowel gas pattern is nonobstructive. No radiopaque foreign bodies in the region of the rectum or elsewhere. Osseous structures are normal. IMPRESSION: No radiopaque foreign bodies seen in the region of the rectum. No evidence of obstruction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with previous infiltrates, intubated // f/u infiltrates f/u infiltrates IMPRESSION: In comparison with the study of ___, there is little overall change. Endotracheal tube tip is about 4 cm above the carina. Patchy heterogeneous opacification at the bases, especially on the right, is again consistent with aspiration or infectious pneumonia. Small pleural effusion is again seen on the left. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) PORT INDICATION: Evaluate for splenomegaly or evidence of cirrhosis in a patient with polysubstance abuse, HCV, and thrombocytopenia. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: There is hepatomegaly, the liver measures 18 cm in craniocaudal axis with mild heterogeneous echotexture of the liver parenchyma. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is minimal ascites in ___'s pouch. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm. GALLBLADDER: There is no evidence of stone. Gallbladder wall is mildly thickened, which can be seen in the setting of underlying liver disease or ascites. SPLEEN: Normal echogenicity, measuring 20.0 cm. KIDNEYS: Limited images of the bilateral kidneys demonstrate no stone, hydronephrosis, or focal mass. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Splenomegaly, with the spleen measuring 20.0 cm. 2. Trace free fluid in the Morison's pouch with mild gallbladder wall thickening likely related to surrounding fluid. 3. Hepatomegaly with a heterogeneous echotexture of the liver parenchyma, reflective of chronic liver disease in this patient with hepatitis C. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with multisubstance ingestion and hypoxia // Assess for cardiopulmonary process Assess for cardiopulmonary process IMPRESSION: No previous images. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion. There is extensive opacification at the right base. Although this could represent atelectasis, in the appropriate clinical setting right middle and lower lobe pneumonia would have to be seriously considered. If the condition of the patient permits, a lateral view could be helpful. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: POLYSBUBSTANCE ABUSE Diagnosed with POIS-BENZODIAZEPINE TRAN, ACC POISN-BENZDIAZ TRANQ temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Dear Mr. ___, It was a pleasure being part of your care at ___. You were admitted to the hospital due to somnolence and fevers. You were initially intubated to help you breathe, but extubated very soon afterward. You received antibiotics for a lung infection and medications to help control withdrawal. You were having diarrhea so we tested to see if you had an infection, which you did not. After discharge, please follow up with your PCP and the outpatient addictions program at ___. Please consider NA or AA groups as you felt like these might be helpful. You should complete the antibiotic (Augmentin) for your pneumonia which will be finished on ___. We wish you the best, Your ___ team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: dexamethasone Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: ___ MEDICINE ATTENDING ADMISSION NOTE . Date: ___ Time: ___ _ ________________________________________________________________ PCP: Name: ___ Location: ___ Address: ___ Phone: ___ Fax: ___ _ ________________________________________________________________ Oncologist at ___- Dr. ___ -------------- ___ obtained from friend and IMPORTANT CONTACT INFO: ___ ___ --------------- HPI: ___ with history of small cell lung cancer diagnosed in ___, and treated with chemotherapy and whole brain radiation for metastases. He then had radiosurgery (Gammaknife) for a solitary right temporal brain metastasis by Dr. ___ at ___ in ___. He is most recently s/p craniomtomy with resection of R temporal necrosis in ___ on no recent chemo whose disease is thought to be in remission and is transferred to ___ ED from ___ where he presented with altered MS. ___ and pt he was coming out of the BR after showering this morning when he became dizzy and he thinks he fell. He does not remember if he hit his head or lost consciousness. It may be that he then pulled a bell for assistance. ___ tells me that ___ his apartment complex manager went to check on him this am and he could not remember who she was even though he knows her very well. He was then referred to the ED. At ___, head ct showed no acute changes, BS 55, was given d50 with improvement to 107 and then 2 hours later it was 125 but there was no improvement in MS. ___ with increased pleural effusion (pt satting 96% on RA). UA pending, CK 853 trop neg. Labs significant for neutropenia with WBC = 3.8. Per our radiologist's read, pt's CT from ___ was unchanged from last MR in our system w/ no new acute process. In speaking with ___, pt's friend upon arrival to the floor he appears to be close to baseline c/w the last time ___ saw him which was approx 3 weeks ago. At that time as now, he was having word finding difficulty. Also, usually every two weeks the patient would usually call him to come to fill his pill boxes but ___ thinks that he has not filled his pill box for about 4 weeks and suspects that he has not had his medications for 4 weeks. He has not had a BM for 3 days. He has also had increased falls. No clear weight loss. The patient is a difficult historian but he tells me that he has orthopnea and has been waking up short of breath at night. No SOB on exertion. No ankle edema. While in the room he had an episode of chest pressure x 5 mins w/o SOB/diaphoresis. He has just eaten in the ED prior to going the floor. He is difficult historian but his friend ___ is very helpful. [ ] OSH UA: call ___ In ER: (Triage Vitals:0 97.3 70 144/95 16 ) Meds Given:none Fluids given: none Radiology Studies:CT from ___ read and compared to previous consults called: neurology who requested neuro-onc. . PAIN SCALE: ___ He could not quantify the chest pain when he was having it but does tell me several times that he does not have any chest pain right now. ________________________________________________________________ REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative" CONSTITUTIONAL: [X] All Normal [ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [ ] _____ lbs. weight loss/gain over _____ months Eyes Chronic blurred vision for one year but denies acute visual changes ENT [ X] Dry mouth -> [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ] Other: RESPIRATORY: [] All Normal [X ] Shortness of breath- per HPI [ ] Dyspnea on exertion [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [] All Normal [ ] Palpitations [ -] Edema [ ] PND [X ] Orthopnea [ ] Chest Pain [ ] Dyspnea on exertion [ ] Other: GI: [] All Normal [ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [ ] Diarrhea [ [+] Constipation [ ] Hematemesis [ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Incontinence or retention [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [X] All Normal [ ] Rash [ ] Pruritus MS: [X] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [] All Normal [- ] Headache [ -] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ -] Seizures [+ ] Weakness [+ ] Dizziness/Lightheaded [ ]Vertigo ENDOCRINE: [] All Normal [ +] Skin changes - cold skin [ ] Hair changes [ ] Heat or cold intolerance [ ] loss of energy HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy [X]all other systems negative except as noted above Past Medical History: 1. Small cell lung CA 2. Chronic neck pain 3. Arthritis 4. BPH 5. Whole brain irradiation in ___ 6. Gamma knife radiosurgery to a recurrent solitary right temporal brain metastasis by ___, MD at ___ in ___. 7. Lumbar puncture on ___ with negative cytology, protein elevated at 78. 8. Resection right temporal necrosis on ___ by Dr. ___. Social History: ___ Family History: His dtr died of complications from DM at age ___. Physical Exam: PHYSICAL EXAM: I3 - PE >8 PAIN SCORE ___ 1. VS: T 97.4, P 73 BP 113/82 RR 18 O2Sat on _100% on RA___ GENERAL: Pale obese male Nourishment: OK Grooming: good Mentation 2. Eyes: [X] WNL PERRL, EOMI without nystagmus, Conjunctiva: clear 3. ENT [] WNL [X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [] Poor dentition [-] Thrush [] Swelling [] Exudate 4. Cardiovascular [X] WNL [x] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6, Location: [] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6, Location: [X] Edema RLE None [] Bruit(s), Location: [X] Edema LLE None [] PMI [] Vascular access [X] Peripheral [] Central site: 5. Respiratory [ ] [X] CTA bilaterally [ ] Rales [ ] Diminshed [] Comfortable [ ] Rhonchi [ ] Dullness [ ] Percussion WNL [ ] Wheeze [] Egophony 6. Gastrointestinal [X ] WNL [X] Soft [-] Rebound [] No hepatomegaly [X] Non-tender [] Tender [] No splenomegaly [] Non distended [] distended [] bowel sounds Yes/No [] guiac: positive/negative 7. Musculoskeletal-Extremities [X] WNL [ ] Tone WNL [ X]Upper extremity strength ___ and symmetrical [ ]Other: [ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica [ ] Other: [] Normal gait []No cyanosis [ ] No clubbing [] No joint swelling 8. Neurological [] WNL He is very disinhibited [X ] Alert and Oriented x 2 ___, ___ [ ] Romberg: Positive/Negative [ ] CN II-XII intact [ X] Normal attention- able to DOWB [ ] FNF/HTS WNL [] Sensation WNL [ ] Delirious/confused [ ] Asterixis Present/Absent [ ] Position sense WNL [ ] Demented [ ] No pronator drift [] Fluent speech 9. Integument [X] WNL [] Warm [X] Dry [] Cyanotic [] Rash: none/diffuse/face/trunk/back/limbs [X] Cool [] Moist [] Mottled [] Ulcer: None/decubitus/sacral/heel: Right/Left 10. Psychiatric [] WNL Slightly inappropriate [] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic [] Combative DISCHARGE EXAM: AVSS Walking the halls Mental Status back at baseline Pertinent Results: ___ 06:42PM LACTATE-1.4 ___ 05:45PM GLUCOSE-81 UREA N-15 CREAT-1.0 SODIUM-135 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14 ___ 05:45PM estGFR-Using this ___ 05:45PM ALT(SGPT)-11 AST(SGOT)-39 ALK PHOS-35* TOT BILI-1.0 ___ 05:45PM ALBUMIN-4.5 ___ 05:45PM WBC-3.5* RBC-4.96 HGB-14.4 HCT-43.7 MCV-88 MCH-29.0 MCHC-32.9 RDW-14.5 ___ 05:45PM NEUTS-48.1* ___ MONOS-5.2 EOS-11.2* BASOS-1.3 ___ 05:45PM PLT COUNT-169 ___ 05:45PM ___ PTT-38.3* ___ OSH Head CT: No acute intracranial abnormality. Chronic atrophy and small vessel disease. R parietal encephalomalacia. CXR: Moderate-sized right pleural abnormality has basal or dependent component larger today than it was on ___, stable since ___, probably pleural effusion. Thickening of the lateral costal and apical pleural margins is unchanged and therefore could be thickening as well as loculated fluid. Might be a nodule in the left mid lung or might be a prominent nipple shadow. There is no pneumonia. Heart size is normal. Infusion port catheter can be traced as far as the region of the superior cavoatrial junction. No pneumothorax or new mediastinal widening. KUB: Upright and supine images of the abdomen demonstrate an unremarkable bowel gas pattern with no evidence of obstruction or ileus. There is no pneumatosis or free air. There is moderate fecal loading in the right colon and splenic flexure, but overall the fecal load is within normal limits. There are bilateral pleural effusions with the right greater than the left, better characterized on concurrent chest x-ray. IMPRESSION: Nonobstructive bowel gas pattern, with overall fecal load within normal limits. Discharge Labs: ___ 06:00AM BLOOD WBC-4.1 RBC-5.11 Hgb-14.5 Hct-44.3 MCV-87 MCH-28.4 MCHC-32.7 RDW-15.1 Plt ___ ___ 04:00AM BLOOD ___ PTT-42.5* ___ ___ 06:00AM BLOOD Glucose-122* UreaN-10 Creat-1.0 Na-137 K-4.3 Cl-105 HCO3-22 AnGap-14 ___ 06:00AM BLOOD CK(CPK)-686* ___ 04:00AM BLOOD CK-MB-10 MB Indx-1.3 cTropnT-<0.01 proBNP-91 ___ 06:00AM BLOOD Calcium-9.3 Phos-2.9 Mg-1.9 ___ 06:43PM BLOOD %HbA1c-5.4 eAG-108 ___ 05:45PM BLOOD T4-<1.0* T3-LESS THAN Free T4-<0.10* ___ 06:00AM BLOOD T4-2.2* Free T4-0.28* ___ 02:00PM BLOOD Cortsol-13.9 Test Result Reference Range/Units ACTH, PLASMA 18 ___ pg/mL CT Chest without Contrast INDICATION: History of metastatic small cell lung cancer with now right-sided pleural effusions identified on chest radiograph. Question of left-sided pulmonary nodule also raised. TECHNIQUE: MDCT images were obtained from the thoracic outlet to the upper abdomen without intravenous contrast. Lung reconstruction algorithm images and axial MIPs were acquired. COMPARISON: Chest radiograph ___. FINDINGS: A right Port-A-Cath terminates in the distal SVC. There is a moderate-sized loculated right pleural effusion with areas of pleural calcifications noted (2:19). There is geographic right paramediastinal soft tissue density likely reflecting post-radiation changes. Evaluation for underlying neoplasm is limited wihtout IV contrast. Coronary artery calcifications are noted as well as calcifications of the aortic valve. A small pericardial effusion is noted. The heart is otherwise unremarkable. The airways remain patent to the lobar bronchi. Evaluation distal to this is difficult. There is a 4-mm left upper lobe nodule (4:51). No pulmonary nodule corresponding to the density seen on prior chest radiograph. The left lung is otherwise clear. No mediastinal or axillary lymph nodes meeting pathologic criteria are seen. Evidencr of prior right thoracotomy are noted in the right third through fifth ribs. There is no lytic or blastic lesion suspicious for metastasis. Though not tailored for subdiaphragmatic evaluation, several additional abnormalities are noted. There is a 17 x 15 mm simple cyst arising from the upper pole of the right kidney (4:287). Additionally, there is a low-density linear lesion in segment IV of the liver that courses towards the falciform ligament (400B:116). Evaluation of the liver is limited in the absence of intravenous contrast. The stomach is distended with food, but is otherwise unremarkable. Small partially calcified 5-mm lymph node anterior to SMV. There is a small gallstone. IMPRESSION: 1. Moderate loculated right pleural effusion along with pleural calcifications. 2. Post-radiation changes. Limited evaluation for small cell lung cancer without IV contrast. 3. 4-mm left upper lobe nodule. In this patient with known diagnosis of small cell lung cancer, close interval followup is recommended. 4. Low-density area in segment IVB of the liver is likely fatty infiltration, attention on followup. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver typed list from friend ___. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit Oral daily 3. Diazepam 5 mg PO Q12H:PRN neck pain 4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN neck pain Hold for RR <10. 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN neck pain Hold for RR <10. 4. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit Oral daily 5. Diazepam 5 mg PO Q12H:PRN neck pain 6. Hydrocortisone 15 mg PO DAILY RX *hydrocortisone [Cortef] 5 mg 3 tablet(s) by mouth Each morning Disp #*90 Tablet Refills:*0 7. Hydrocortisone 5 mg PO QHS RX *hydrocortisone [Cortef] 5 mg 1 tablet(s) by mouth Each evening Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: myxedema coma / hypothyroidism adrenal insufficiency gait instability Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PA and lateral chest on ___ HISTORY: ___ man with small cell lung cancer metastatic to the brain after chemotherapy and surgery. New delirium and pleural effusions. IMPRESSION: PA and lateral chest compared to ___ and ___: Moderate-sized right pleural abnormality has basal or dependent component larger today than it was on ___, stable since ___, probably pleural effusion. Thickening of the lateral costal and apical pleural margins is unchanged and therefore could be thickening as well as loculated fluid. Might be a nodule in the left mid lung or might be a prominent nipple shadow. There is no pneumonia. Heart size is normal. Infusion port catheter can be traced as far as the region of the superior cavoatrial junction. No pneumothorax or new mediastinal widening. Radiology Report HISTORY: ___ male with metastatic lung cancer. No bowel movement for three days. Evaluation for fecal load. COMPARISON: Comparison is made to chest radiograph from ___ and ___. FINDINGS: Upright and supine images of the abdomen demonstrate an unremarkable bowel gas pattern with no evidence of obstruction or ileus. There is no pneumatosis or free air. There is moderate fecal loading in the right colon and splenic flexure, but overall the fecal load is within normal limits. There are bilateral pleural effusions with the right greater than the left, better characterized on concurrent chest x-ray. IMPRESSION: Nonobstructive bowel gas pattern, with overall fecal load within normal limits. Radiology Report INDICATION: History of metastatic small cell lung cancer with now right-sided pleural effusions identified on chest radiograph. Question of left-sided pulmonary nodule also raised. TECHNIQUE: MDCT images were obtained from the thoracic outlet to the upper abdomen without intravenous contrast. Lung reconstruction algorithm images and axial MIPs were acquired. COMPARISON: Chest radiograph ___. FINDINGS: A right Port-A-Cath terminates in the distal SVC. There is a moderate-sized loculated right pleural effusion with areas of pleural calcifications noted (2:19). There is geographic right paramediastinal soft tissue density likely reflecting post-radiation changes. Evaluation for underlying neoplasm is limited wihtout IV contrast. Coronary artery calcifications are noted as well as calcifications of the aortic valve. A small pericardial effusion is noted. The heart is otherwise unremarkable. The airways remain patent to the lobar bronchi. Evaluation distal to this is difficult. There is a 4-mm left upper lobe nodule (4:51). No pulmonary nodule corresponding to the density seen on prior chest radiograph. The left lung is otherwise clear. No mediastinal or axillary lymph nodes meeting pathologic criteria are seen. Evidencr of prior right thoracotomy are noted in the right third through fifth ribs. There is no lytic or blastic lesion suspicious for metastasis. Though not tailored for subdiaphragmatic evaluation, several additional abnormalities are noted. There is a 17 x 15 mm simple cyst arising from the upper pole of the right kidney (4:287). Additionally, there is a low-density linear lesion in segment IV of the liver that courses towards the falciform ligament (400B:116). Evaluation of the liver is limited in the absence of intravenous contrast. The stomach is distended with food, but is otherwise unremarkable. Small partially calcified 5-mm lymph node anterior to SMV. There is a small gallstone. IMPRESSION: 1. Moderate loculated right pleural effusion along with pleural calcifications. 2. Post-radiation changes. Limited evaluation for small cell lung cancer without IV contrast. 3. 4-mm left upper lobe nodule. In this patient with known diagnosis of small cell lung cancer, close interval followup is recommended. 4. Low-density area in segment IVB of the liver is likely fatty infiltration, attention on followup. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: MENTAL STATUS CHANGES Diagnosed with ALTERED MENTAL STATUS , MAL NEO BRONCH/LUNG NOS, SEC MAL NEO BRAIN/SPINE temperature: 97.3 heartrate: 70.0 resprate: 16.0 o2sat: nan sbp: 144.0 dbp: 95.0 level of pain: 0 level of acuity: 3.0

You were admitted with lethargy and instability while walking. The cause of this is because you stopped taking your medications. It is essential that you take your medications as prescribed otherwise this problem may return. You will need additional follow up to evaluate your lungs for any evidence of cancer return. This can be done at your primary care physician's office. You were started on a new medication: hydrocortisone. You should take 15mg every morning and 5mg every evening.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: TIA Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is an ___ yo man with significant vascular risk factors who presents with slurred speech. Today, around 10 am, he had trouble speaking. He was sitting up. He describes slurred speech. He knew what he wanted to say, and was able to say words. He was with his daughter, grandson, and ___. They noticed that the words were slurred. There was no weakness or facial droop. There was no clear aphasia. This lasted 15 minutes, resolving after lying down. No lightheadedness during this episode. His BP was not checked during this. This episode was similar to his prior episodes. ___ years ago, he 3 episodes of global aphasia. It was a hot and humid day. The first episode resolved after a sip of soda. The next day he had two more episodes. He went to the hospital and was diagnosed with TIAs and afib and started on warfarin. He is on lovenox, bridging to Coumadin. Recently admitted from ___ for Left femoral to peroneal bypass. He was seen several times by Neurology for episodes of slurred speech, which were thought due to possible embolus in the setting of held anticoagulation the first time, then poor cerebral perfusion, anemia and hypoxia the second time. Since he was already on therapeutic anticoagulation, aspirin, and statin, this was continued. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: atrial fibrillation on Coumadin (held for the past week) PVD s/p multiple peripheral stents and now femoral to peroneal bypass prior TIAs Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: 97.2 64 147/69 16 98% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Neck: Supple, no nuchal rigidity. Pulmonary: CTABL Cardiac: RRR Abdomen: soft, nontender, nondistended Extremities: left leg surgical scar with mild surrounding edema, no warmth, erythema or purulence Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history 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. Unable to name ___ backward despite multiple attempts. Pt. was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: Pupils post-surgical bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch in all distributions VII: No facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally 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: Increased tone. Bilateral thenar and EDB wasting. L pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 R ___ ___ ___ 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 1 1 1 0 0 R 1 1 1 0 0 - Plantar response was mute on right, extensor on left. - Pectoralis Jerk was absent, and Crossed Adductors are absent. -Sensory: No deficits to light touch except near surgical site, pinprick. Diminished proprioception in great toes bilaterally. -Coordination: No intention tremor noted. No dysmetria on FNF or toe to finger bilaterally. -Gait: Good initiation. Narrow-based, mildly antalgic (post-op). DISCHARGE PHYSICAL EXAM: 98.1 120-141/50-70 ___ 96%RA GEN: NAD Extrem: no peripheral edema. LLE with medial surgical incision. staples in place. erythematous outline surrounding the incision, worse near the groin. no drainage from the site. Mental Status: A&Ox3. normal speech and language, normal comprehension with good repetition and following commands appropriately. Cranial Nerves: EOMI, visual fields intact. no facial droop, normal bilateral activation. tongue protrudes midline. Motor: Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 R ___ ___ ___ 5 5 5 5 Slight LUE pronator drift. Pertinent Results: ___ 08:10AM BLOOD WBC-5.0 RBC-2.90* Hgb-9.5* Hct-30.4* MCV-105* MCH-32.8* MCHC-31.3* RDW-15.4 RDWSD-57.1* Plt ___ ___ 07:55AM BLOOD WBC-5.1 RBC-2.80* Hgb-9.4* Hct-29.3* MCV-105* MCH-33.6* MCHC-32.1 RDW-15.5 RDWSD-58.5* Plt ___ ___ 06:35AM BLOOD WBC-5.1 RBC-2.71* Hgb-8.8* Hct-28.5* MCV-105* MCH-32.5* MCHC-30.9* RDW-15.1 RDWSD-57.1* Plt ___ ___ 07:14AM BLOOD WBC-5.1 RBC-2.74* Hgb-9.0* Hct-28.7* MCV-105* MCH-32.8* MCHC-31.4* RDW-15.0 RDWSD-55.7* Plt ___ ___ 06:20PM BLOOD WBC-4.3 RBC-2.73* Hgb-9.0* Hct-28.8* MCV-106* MCH-33.0* MCHC-31.3* RDW-14.9 RDWSD-56.0* Plt ___ ___ 06:35AM BLOOD WBC-5.2 RBC-2.67* Hgb-8.8* Hct-27.8* MCV-104* MCH-33.0* MCHC-31.7* RDW-15.0 RDWSD-57.0* Plt ___ ___ 06:20PM BLOOD Neuts-70 Bands-0 ___ Monos-8 Eos-2 Baso-0 ___ Myelos-1* AbsNeut-3.01 AbsLymp-0.82* AbsMono-0.34 AbsEos-0.09 AbsBaso-0.00* ___ 06:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL ___ 08:10AM BLOOD Plt ___ ___ 08:10AM BLOOD ___ ___ 07:55AM BLOOD Plt ___ ___ 07:55AM BLOOD ___ ___ 03:17PM BLOOD PTT-49.0* ___ 01:20PM BLOOD PTT-58.2* ___ 06:35AM BLOOD Plt ___ ___ 06:35AM BLOOD ___ PTT-60.2* ___ ___ 01:51AM BLOOD PTT-48.4* ___ 07:05PM BLOOD PTT-49.9* ___ 06:35AM BLOOD ___ PTT-33.3 ___ ___ 08:10AM BLOOD Glucose-94 UreaN-16 Creat-0.7 Na-140 K-3.9 Cl-105 HCO3-27 AnGap-12 ___ 07:55AM BLOOD Glucose-99 UreaN-14 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-28 AnGap-12 ___ 06:35AM BLOOD Glucose-100 UreaN-14 Creat-0.8 Na-140 K-3.6 Cl-104 HCO3-27 AnGap-13 ___ 07:14AM BLOOD Glucose-83 UreaN-16 Creat-0.7 Na-143 K-3.6 Cl-106 HCO3-26 AnGap-15 ___ 06:20PM BLOOD Glucose-90 UreaN-18 Creat-0.7 Na-140 K-3.8 Cl-106 HCO3-26 AnGap-12 ___ 06:35AM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-140 K-3.7 Cl-106 HCO3-28 AnGap-10 ___ 06:20PM BLOOD ALT-23 AST-26 AlkPhos-43 TotBili-1.1 ___ 08:10AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1 ___ 07:55AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 ___ 06:35AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1 ___ 07:14AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1 ___ 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:41PM BLOOD Lactate-1.0 ___ CXR 1. Patchy opacities in the lung bases superimposed on a background of calcified pleural plaques may reflect atelectasis. 2. Small bilateral pleural effusions, unchanged. 3. Right apical nodule and bilateral hilar and mediastinal lymphadenopathy are better assessed on recent chest CT. ___ CTA HEAD W&W/O C & RECONS 1. Dental almalgam streak artifact limits study. 2. No new acute territorial infarct, hemorrhage, mass, or mass effect. 3. The hypodensity within the bilateral centrum semiovale, likely reflecting evolving known punctate infarcts. 4. Intracranial atherosclerosis with chronic occlusion of the left M2 artery origin, diffuse mild luminal irregularity throughout the intracranial vasculature, and segmental significant stenoses at the bilateral intracranial internal carotid arteries. 5. Patent neck vasculature without significant stenosis by NASCET criteria. 6. Chronic dissection at the right brachiocephalic artery. 7. Solid and semi-solid nodules within the lung apices which are unchanged comparison to prior study and some which are new in comparison to ___. In addition there are unchanged prominent mediastinal lymph nodes. Given the changing appearance this may represent an ongoing infectious or inflammatory process, however a neoplastic processes not excluded. As per the recommendations on prior CTA of the head neck, recommend follow-up noncontrast CT of the chest in 3 months. 8. Please note MRI of the brain is more sensitive for the detection of acute infarct. ___ ECG Sinus bradycardia. Right bundle-branch block. Rightward precordial R wave transition point. Compared to the previous tracing of ___ there is no diagnostic change. ___ MR HEAD W/O CONTRAST 1. Study is mildly degraded by motion. 2. Foci of slow diffusion within the right corona radiata which is mildly more confluent and extensive at its midportion as compared to prior study from ___ consistent with enlarging or new infarct. No evidence of hemorrhage. 3. Evolving punctate subacute left centrum semi ovale infarct. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Gabapentin 200 mg PO DAILY 3. Amlodipine 5 mg PO DAILY 4. Atenolol 100 mg PO DAILY 5. Doxazosin 8 mg PO HS 6. Finasteride 5 mg PO DAILY 7. Lisinopril 40 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Warfarin 5 mg PO 3X/WEEK (___) 10. Warfarin 2.5 mg PO 4X/WEEK (___) 11. Aspirin 81 mg PO DAILY Discharge Medications: 1. Enoxaparin Sodium 80 mg SC BID Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 80 mg/0.8 mL 1 syringe subcutaneously twice a day Disp #*10 Syringe Refills:*0 RX *enoxaparin 80 mg/0.8 mL 1 syringe subcutaneously twice a day Disp #*28 Syringe Refills:*0 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atenolol 100 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Doxazosin 8 mg PO HS 7. Finasteride 5 mg PO DAILY 8. Lisinopril 40 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Gabapentin 200 mg PO DAILY 11. Minocycline 100 mg PO BID RX *minocycline 100 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 12. Warfarin 5 mg PO DAILY16 RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: TIA 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 possible stroke/ transient ischemic attack TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___, CT chest ___ FINDINGS: Cardiac silhouette size is normal. The aortic knob is calcified. Mediastinal and hilar contours are unchanged, and known bilateral hilar and mediastinal lymphadenopathy is better appreciated on the recent CT of the chest. Bilateral calcified pleural plaques are noted with mild superimposed opacities in the lung bases possibly reflective of atelectasis. Small bilateral pleural effusions are not substantially changed from the recent chest CT. Approximately 1 cm right apical nodule is re- demonstrated, better assessed on the recent CT. No pneumothorax or pulmonary vascular congestion is demonstrated. No acute osseous abnormality is present. IMPRESSION: 1. Patchy opacities in the lung bases superimposed on a background of calcified pleural plaques may reflect atelectasis. 2. Small bilateral pleural effusions, unchanged. 3. Right apical nodule and bilateral hilar and mediastinal lymphadenopathy are better assessed on recent chest CT. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: ___ male with multiple transient ischemic attacks and strokes. Evaluate for dissection, aneurysm, or steno-occlusive disease. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 1,009.3 mGy-cm. 2) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP = 35.4 mGy-cm. 3) Spiral Acquisition 5.1 s, 40.2 cm; CTDIvol = 32.0 mGy (Head) DLP = 1,288.1 mGy-cm. Total DLP (Head) = 2,333 mGy-cm. COMPARISON: ___ contrast brain MRI. ___ head and neck CTA. FINDINGS: Dental almalgam streak artifact limits study. NONCONTRAST CT HEAD: There chronic lacune is within the bilateral basal ganglia. There is heterogeneous hypodensity within the bilateral centrum semiovale consistent with chronic microangiopathy and evolution of known punctate infarcts. Otherwise the gray-white matter differentiation is intact without new acute territorial infarct, hemorrhage, mass, or mass effect. There is background periventricular white matter hypodensity consistent with sequela of chronic microangiopathy. The extra-axial spaces are unremarkable. The bilateral lenses are absent. The soft tissues and calvarium are unremarkable. The paranasal sinuses and mastoid air cells are clear. CTA HEAD: There is atherosclerosis of the bilateral intracranial internal carotid arteries with irregular luminal narrowing and focal significant segmental stenosis at the posterior genu right cavernous segment internal carotid artery (5:243). There is focal significant stenosis at the left para clinoid segment internal carotid artery (5:247). There is a hypoplastic right A1 segment. The anterior communicating artery is visualized. There is a right fetal origin posterior cerebral artery. The left posterior communicating artery is not definitively seen. There is chronic occlusion at the proximal left anterior M2 segment middle cerebral artery with distal reconstitution. There are codominant vertebral arteries. There is a beaded stenotic appearance of the intracranial vasculature consistent with atherosclerosis. There is no occlusion. There is no evidence of dissection or aneurysm. The dural venous sinuses are patent. CTA NECK: There is a 4 vessel aortic arch which contains the origin of the left vertebral artery. There is atherosclerosis of the aortic arch and origin of the great vessels without significant stenosis. There is a chronic dissection at the right brachiocephalic artery. The subclavian arteries are patent. There is atherosclerosis at the right carotid bifurcation bulb without significant stenosis by NASCET criteria. There is atherosclerosis at the left carotid bifurcation bulb without significant stenosis by NASCET criteria. The vertebral arteries are patent and demonstrate codominant. There is no evidence of occlusion, significant stenosis, or aneurysm. The pharynx, larynx, nasal cavity, and oral cavities are unremarkable. There is streak artifact secondary to dental mg which obscures adjacent structures. There are multilevel degenerative changes of the cervical spine. The salivary glands are unremarkable. There is heterogeneous enhancement of the thyroid gland. The masticator parapharyngeal spaces are unremarkable. There is no lymphadenopathy by There are unchanged prominent mediastinal lymph nodes, the largest of which measures 1.1 cm in short access at the distal right pretracheal space (05:24). There is a 1.1 cm solid right apical lung nodule with spiculated borders (5:7). There is geographic semi-solid opacity at the anterior right lung apex measuring approximately 2.2 x 1.4 cm (5:78, which is relatively unchanged. There is a subpleural 1.2 cm semi-solid nodule at the anterior left upper lobe (05:52), which is relatively unchanged. There is dependent atelectasis at the posterior aspect the left upper lobe. There are calcified pleural plaques consistent with prior asbestos exposure. There is circumferential thickening of the esophagus. IMPRESSION: 1. Dental almalgam streak artifact limits study. 2. No new acute territorial infarct, hemorrhage, mass, or mass effect. 3. The hypodensity within the bilateral centrum semiovale, likely reflecting evolving known punctate infarcts. 4. Intracranial atherosclerosis with chronic occlusion of the left M2 artery origin, diffuse mild luminal irregularity throughout the intracranial vasculature, and segmental significant stenoses at the bilateral intracranial internal carotid arteries. 5. Patent neck vasculature without significant stenosis by NASCET criteria. 6. Chronic dissection at the right brachiocephalic artery. 7. Solid and semi-solid nodules within the lung apices which are unchanged comparison to prior study and some which are new in comparison to ___. In addition there are unchanged prominent mediastinal lymph nodes. Given the changing appearance this may represent an ongoing infectious or inflammatory process, however a neoplastic processes not excluded. As per the recommendations on prior CTA of the head neck, recommend follow-up noncontrast CT of the chest in 3 months. 8. Please note MRI of the brain is more sensitive for the detection of acute infarct. RECOMMENDATION(S): As per the recommendations on prior CTA of the head neck, recommend follow-up noncontrast CT of the chest in 3 months. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ male with recent acute punctate infarcts now with slurred speech. Evaluate for new acute infarct. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON ___ head and neck CTA. ___ contrast head MRI. ___ noncontrast head MRI. FINDINGS: Study is mildly degraded by motion. There is minimal slow diffusion at the left mid centrum semiovale which demonstrates pseudo normalization on ADC consistent with evolving subacute infarct. There are foci of mild slow diffusion within the right corona radiata which is mildly more confluent in demonstrates increased ADC hypointensity at its midportion as compared to prior study. There is correlate FLAIR hyperintensity without evidence of hemorrhagic conversion. There are bilateral chronic lacunar infarcts. There is periventricular white matter FLAIR hyperintensity likely reflecting sequela of chronic microangiopathy. There is bilateral prominent mineralization of view putaminal nuclei as seen on the gradient echo sequence. There is prominence of the ventricles and cortical sulci consistent with volume loss. Grossly stable punctate left cerebellar focus of micro hemorrhage versus mineralization is again noted (see 11:7 on current study, 4:8 on ___ prior exam, and 8:7 on ___ prior exam). IMPRESSION: 1. Study is mildly degraded by motion. 2. Foci of slow diffusion within the right corona radiata which is mildly more confluent and extensive at its midportion as compared to prior study from ___ consistent with enlarging or new infarct. No evidence of hemorrhage. 3. Evolving punctate subacute left centrum semi ovale infarct. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Wound eval Diagnosed with Transient cerebral ischemic attack, unspecified temperature: 97.2 heartrate: 64.0 resprate: 16.0 o2sat: 98.0 sbp: 147.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of slurred speech resulting from an Transient Ischemic Attack, a condition where a blood vessel providing oxygen and nutrients to the brain is temporarily blocked. 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. TIA's 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: -Episodes of low blood pressure causing poor blood circulation to your brain -Being off of Coumadin We are changing your medications as follows: Coumadin 5mg daily - this dose may be readjusted as needed depending on your INR levels. Please take your other medications as prescribed. Please followup with Neurology, vascular surgery, 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

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: cefepime / imipramine / piperacillin / vancomycin Attending: ___. Chief Complaint: Left distal tibia fracture Major Surgical or Invasive Procedure: ORIF left distal tibia History of Present Illness: NAME: ___ MRN: ___ DATE: ___ ATTENDING: ___ CONSULTING SERVICE: ED CC: left ankle pain HPI: ___ who was helping to change a tire on a car when the car fell off the ___ and landed on top of his left ankle. With the help of his friend he was able to maneuver out from under. Had immediate pain and deformity. No new numbness or tingling. Injury occurred at about 11:30 AM. No other injuries sustained. PMH/PSH: Mantle cell lymphoma (in recession since ___, bicuspid aortic valve, chemo induced peripheral neuropathy MEDS: ASA 325 daily, Lexapro 15 daily, Prilosec ALL: cefepime, imipramine, piperacillin, vancomycin SHx: Married, non-smoker, no alcohol ROS: 13-point ROS negative. PHYSICAL EXAMINATION: In general, the patient is a healthy appearing male in NAD Vitals: 97.7 66 119/60 16 96% RA 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 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 Right lower extremity: Superficial abrasion across anterior shin 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 Non-tender thigh and leg. Compartments soft and compressible Full, painless AROM/PROM of hip, knee Wiggles toes Sensation diminished to SPN/DPN/TN/saphenous/sural distributions (at patient's baseline due to chemo-induced neuropathy) ___ pulses, foot warm and well-perfused LABS: CBC BMP Coags T&S Pending IMAGING: XR left ankle demonstrates spiral, minimally displaced comminuted distal tibia fracture with what appears to be extension into the plafond. CT ankle demonstrates almost no articular involvement at the plafond in addition to non-displaced fibula fracture. ASSESSMENT/RECOMMENDATIONS: ___ with left spiral comminuted tibia/fibula fracture with only minimal extension into the plafond after car fell off ___ onto his leg. PMH of Mantle Cell Lymphoma in recession and chemo induced neuropathy. Patient was placed into a splint in the ED, where his pain was well controlled. Plan to admit to Orthopaedics overnight for consideration of left ankle ORIF in the morning. - Pre-op labs pending - Restart home meds, hold ASA - NPO midnight - Periop antibiotics Please see attending addendum for final recommendations. ___, MD ___ Combined Orthopaedic ___ Program Addendum by ___, MD on ___ at 10:59 pm: patient to be staffed by Dr. ___ ___ Medical History: PMH/PSH: Mantle cell lymphoma (in recession since ___, bicuspid aortic valve, chemo induced peripheral Social History: ___ Family History: NC Physical Exam: On discharge: NAD, A+Ox3 Pain well-controlled Afebrile, VSS Neurovascularly intact distally Pertinent Results: None Radiology Report EXAMINATION: CT of the left lower extremity without contrast. INDICATION: ___ year old man with left distal tibia and fibular fracture. Assess angulation and articular involvement. TECHNIQUE: Axial helical in the CT images were obtained from the lower leg through the midfoot without administration of IV contrast. Para coronal and parasagittal reformats were obtained along the axis of the tibia as per fracture protocol. DOSE: DLP: 420 mGy-cm COMPARISON: ___. FINDINGS: There is a comminuted fracture of the distal tibia. There is an oblique component involving the distal shaft, with mild, 5 mm posterior displacement of the dominant distal component. There is a further minimally displaced oblique component extending to the distal tibia-fibular syndesmosis, and along the ___ lateral aspect of the tibial plafond articular surface (series 2, image 97). There is also a 6 mm tibial fracture fragment positioned transversely, extending into the interosseous space (401b:65). There is an nondisplaced obliquely orientated fracture involving the lateral malleolus extending to the inferior aspect of the tibia fibular syndesmosis. The mortise joint space is not widened. There is significant subcutaneous stranding with high density material compatible with blood and edema. Tiny amount of gas is demonstrated anterior to the talus (series 2, image 115). A small Achilles tendon insertional enthesophyte is present. The Achilles tendon appears minimally thickened, 7 mm. IMPRESSION: 1. Comminuted tibial fracture with extension to the tibial plafond. 2. Nondisplaced lateral malleolar fracture. 3. Small bubble of gas anterior to the talus suggests an open injury. 4. Incidental distal Achilles tendinosis and enthesophyte formation. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT IN O.R. INDICATION: ORIF of left ankle fracture TECHNIQUE: Flouroscopic assistance provided in the OR without the radiologist present. 6 Spot views obtained. 73.1 seconds of flouro time recorded on the requisition. FINDINGS: Views demonstrate steps related to ORIF of distal tibia and fibular fractures. Please refer to procedure note for further details. IMPRESSION: Correlate with real-time findings and, when appropriate, correlative radiographs for full assessment. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, L Ankle fx Diagnosed with FX ANKLE NOS-CLOSED, STRUCK BY FALLING OBJECT temperature: 97.7 heartrate: 66.0 resprate: 16.0 o2sat: 96.0 sbp: 119.0 dbp: 60.0 level of pain: 5 level of acuity: 3.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - NWB LLE; Elevation MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325mg daily for 14 days WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your surgeon's team (Dr. ___, with ___, NP in the Orthopaedic Trauma Clinic ___ days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: NWB LLE, in splint until follow-up. Rest, elevation Treatments Frequency: cont splint until follow-up

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Cipro / Flagyl / Iodinated Contrast Media - IV Dye / Novocain / ibuprofen / MRI contrast Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with a history of hyperlipidemia, chronic anemia, RCC status post left partial nephrectomy not on chemo presents with abdominal pain. Patient was recently admitted to this hospital for abdominal pain consistent with pancreatitis secondary to cholelithiasis. She is status post cholecystitis cystectomy on ___ and was discharged on ___ at which point she was feeling well up until yesterday. At this time she was started having increasing abdominal pain nonbloody nonbilious vomiting multiple episodes of loose stools decreased p.o. intake fevers and lethargy. When attempting to go to the bathroom today with her daughter's help she collapsed in her arms no LOC no head strike. They called an ambulance and brought her in for an eval. Past Medical History: ___ s/p partial nephrectomy s/p bilateral oophorectomy Hypertension Hypercholesterolemia anemia osteoarthritis osteopenia glaucoma Social History: ___ Family History: h/o heart disease, cirrhosis, cancer Physical Exam: Physical Examination: ___ General: Alert and Well Developed; mod distress HEENT: Normal ENT inspection. Eyes: Lids Normal; . Oropharynx / Throat: Normal Pharynx. Neck: No Lymphadenopathy, No Meningismus and Supple Respiratory: No Resp Distress and Normal Breath Sounds Cardio-Vascular: No murmur, No rub and RRR Abdomen: No Organomegaly; distended, incision c,d,i, +rebound/no peritonitis, +tymapnitic Back: No CVA tenderness, No Midline Tenderness and Non-tender Extremity: No edema Neurological: Alert, Oriented X3 and No Gross Weakness Skin: No rash, No Petechiae, Warm and Dry Psychological: Mood/Affect Normal and Normal Memory/Judgment Physical examination upon discharge: ___: vital signs: t=98 bp 137/72, HR=71, O2 SAT=96 % room air GENERAL: NAD CV: ns1, s2, no murmurs LUNGS: diminished BS bases bil, no wheezes ABDOMEN: hypoactive BS, mild distention, soft, non-tender, port sites healed EXT: no calf tenderness bil, no pedal edema bil NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 05:17AM BLOOD WBC-9.9 RBC-2.76* Hgb-7.5* Hct-24.4* MCV-88 MCH-27.2 MCHC-30.7* RDW-15.8* RDWSD-49.3* Plt ___ ___ 04:48AM BLOOD WBC-10.9* RBC-2.94* Hgb-8.0* Hct-26.3* MCV-90 MCH-27.2 MCHC-30.4* RDW-15.6* RDWSD-49.9* Plt ___ ___ 05:05AM BLOOD WBC-35.3* RBC-2.99* Hgb-8.4* Hct-26.5* MCV-89 MCH-28.1 MCHC-31.7* RDW-15.2 RDWSD-48.4* Plt ___ ___ 12:50AM BLOOD WBC-24.5* RBC-3.48* Hgb-9.7* Hct-30.0* MCV-86 MCH-27.9 MCHC-32.3 RDW-14.7 RDWSD-45.5 Plt ___ ___ 04:34AM BLOOD Plt ___ ___ 04:34AM BLOOD Glucose-91 UreaN-7 Creat-1.1 Na-140 K-4.3 Cl-103 HCO3-23 AnGap-14 ___ 05:17AM BLOOD Glucose-97 UreaN-8 Creat-1.1 Na-143 K-4.3 Cl-103 HCO3-22 AnGap-18 ___ 12:50AM BLOOD Glucose-159* UreaN-11 Creat-1.1 Na-133* K-6.5* Cl-92* HCO3-22 AnGap-19* ___ 04:34AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9 ___ 01:00AM BLOOD Lactate-1.3 K-5.4* ___: CXR: 1. Low lung volumes with bibasilar atelectasis. 2. Small left pleural effusion. 3. No evidence of free intra-peritoneal air. ___: CT abd/pelvis: 1. Acute pancreatitis with interval slight improvement of ___ stranding since ___. No ___ fluid collection. 2. Dilated and fluid-filled small bowel loops with transition point visualized in the right lower quadrant suggests small bowel obstruction. No ascites or bowel wall thickening to suggest ischemia at this time. 3. Extensive sigmoid colonic diverticulosis with new focal thickening of the sigmoid colon and faint ___ fat stranding suggests early acute uncomplicated diverticulitis. 4. Additionally there is slight mural thickening and thumb-printing of the transverse colon which is nonspecific and can be seen in C diff colitis. 5. No free air or free fluid in the abdomen. 6. Trace bilateral pleural effusions with minimal compressive atelectasis of the dependent lung bases. ___: CT abd/pelvis: 1. Interval resolution of bowel obstruction. 2. No significant change in acute pancreatitis. No fluid collection. 3. Bilateral lower lobe peripheral airspace disease is slightly worse compared to yesterday and may represent atelectasis or pneumonia in the appropriate clinical scenario. 4. Additional stable findings, including a stable right renal mass, as above. ___: KUB: Following removal of the nasogastric tube, there has been interval increase in small and large bowel dilatation suggestive of recurrence postoperative ileus, similar to ___ ___ 6:57 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: CLOSTRIDIUM DIFFICILE. Positive for toxigenic C difficile by the Cepheid nucleic amplification assay. (Reference Range-Negative). Reported to and read back by ___ ON ___ AT 23:27. Medications on Admission: Medications - Prescription BRIMONIDINE - brimonidine 0.15 % eye drops. 1 drop ___ twice a day - (Prescribed by Other Provider) DORZOLAMIDE - dorzolamide 2 % eye drops. 1 drop ___ twice a day - (Prescribed by Other Provider) ENALAPRIL MALEATE - enalapril maleate 20 mg tablet. Take one Tablet(s) by mouth once a day EPINEPHRINE [EPIPEN] - EpiPen 0.3 mg/0.3 mL injection, auto-injector. - (Prescribed by Other Provider: ___ HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. TAKE 1 TABLET BY MOUTH EVERY DAY HYDROCORTISONE - hydrocortisone 2.5 % topical cream with perineal applicator. Apply twice a day as needed for hemorrhoids HYDROCORTISONE [ANUSOL-HC] - Anusol-HC 2.5 % rectal cream with applicator. Apply rectally twice a day as needed for hemorrhoids VERAPAMIL - verapamil ER (SR) 240 mg tablet,extended release. 1 tablet(s) by mouth once a day Medications - OTC CALCIUM CARBONATE-VITAMIN D3 - calcium carbonate 500 mg (1,250 mg)-vitamin D3 400 unit tablet. Take one Tablet(s) by mouth twice a day - (OTC) DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider: ___ during ___ hospitalization) MULTIVITAMIN - multivitamin capsule. Take one capsule(s) by mouth daily - (OTC) OMEPRAZOLE - omeprazole 20 mg tablet,delayed release. 2 tablet(s) by mouth once a day - (Not Taking as Prescribed) --------------- --------------- --------------- --------------- Discharge Medications: 1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 7 Days 7 days left, last dose ___ RX *vancomycin [Firvanq] 50 mg/mL 125 mg by mouth every six (6) hours Disp ___ Milliliter Refills:*0 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 4. Enalapril Maleate 20 mg PO DAILY 5. Labetalol 200 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. Verapamil SR 240 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction clostridium. difficile colitis 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 surgery p/w abdominal pain// Eval for free air TECHNIQUE: Frontal radiograph of the chest. COMPARISON: ___ chest radiograph. FINDINGS: The lung volumes are low-normal. There is atelectasis of the bilateral lung bases. There is no focal consolidation. Blunting of the left costophrenic angle suggests a small left pleural effusion. There is no free intraperitoneal air under the diaphragm. There is no acute osseous abnormality. IMPRESSION: 1. Low lung volumes with bibasilar atelectasis. 2. Small left pleural effusion. 3. No evidence of free intraperitoneal air. Radiology Report INDICATION: NO_PO contrast; History: ___ with recent cholecystectomy p/w n/v/d, abdominal pain and distentionNO_PO contrast// eval for evidence of infection in RUQ due to recent cholecystectomy vs bowel perforation allergic to contrast TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.2 s, 48.6 cm; CTDIvol = 20.7 mGy (Body) DLP = 1,005.7 mGy-cm. Total DLP (Body) = 1,006 mGy-cm. COMPARISON: ___ MRCP, ___ CT abdomen and pelvis without IV contrast FINDINGS: LOWER CHEST: Trace bilateral pleural effusion with minimal compressive atelectasis of the dependent lung no pericardial effusion bases. 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. Patient is status post cholecystectomy with surgical clips visualized at the gallbladder fossa. PANCREAS: There is moderate stranding of the peripancreatic fat without an organized fluid collection, compatible with acute pancreatitis, also seen in the most recent ___ MRCP. There is no pancreatic ductal dilatation. 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. Again seen at the upper pole of the right kidney is an exophytic high density 1.9 cm lesion, better characterized on the most recent MRCP, which likely represents a cyst with proteinaceous contents (02:19). Patient is status post partial left nephrectomy. The 1.9 cm interpolar simple renal cysts is also unchanged. There are no other 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. The small bowel loops are dilated to 3.4 cm and fluid-filled, some of which demonstrate air-fluid level. There is a transition point within the right mid abdomen (2:58, 601:23) with disc compression of the distal small bowel loops within the right lower quadrant which is concerning for small bowel obstruction. There is no wall thickening or ascites fluid to suggest ischemia. Additionally there is extensive sigmoid diverticulosis with wall thickening and mild pericolonic stranding around the sigmoid colon concerning for acute uncomplicated sigmoid diverticulitis (2:65). Additionally there is slight mural thickening and thumbprinting of the transverse colon which is nonspecific in can be seen in C diff colitis. The appendix is normal. There is no free air. 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: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Midline abdominal wall incisional changes from prior laparotomy IMPRESSION: 1. Acute pancreatitis with interval slight improvement of peripancreatic stranding since ___. No peripancreatic fluid collection. 2. Dilated and fluid-filled small bowel loops with transition point visualized in the right lower quadrant suggests small bowel obstruction. No ascites or bowel wall thickening to suggest ischemia at this time. 3. Extensive sigmoid colonic diverticulosis with new focal thickening of the sigmoid colon and faint pericolonic fat stranding suggests early acute uncomplicated diverticulitis. 4. Additionally there is slight mural thickening and thumbprinting of the transverse colon which is nonspecific and can be seen in C diff colitis. 5. No free air or free fluid in the abdomen. 6. Trace bilateral pleural effusions with minimal compressive atelectasis of the dependent lung bases. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:7am, 1 minutes after discovery of the findings. Radiology Report INDICATION: ___ s/p lap chole ___ presenting with SBO-- non resolving.// eval for obstruction-- please with PO (via NGT) contrast. has IV contrast allergy-- hives and angioedema (swollen lips and eyelids). TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.8 s, 49.7 cm; CTDIvol = 19.1 mGy (Body) DLP = 946.9 mGy-cm. Total DLP (Body) = 947 mGy-cm. COMPARISON: CT abdomen pelvis ___, MRI abdomen ___. FINDINGS: LOWER CHEST: Bilateral lower lobe peripheral consolidation is slightly worse compared to yesterday. ABDOMEN: The liver, spleen, and adrenal glands are unremarkable. Mild peripancreatic stranding is similar to yesterday. 2.1 cm right upper pole hyperdense renal mass is unchanged in size since ___. 2.1 cm left upper pole renal cyst is again seen. Patient is status post partial left nephrectomy. No hydronephrosis. GASTROINTESTINAL: There is an esophagogastric tube tip in stomach. Enteric contrast reaches small-bowel in the lower mid abdomen. The previous dilated small bowel loops are no longer visualized. There is no ascites. Previously reported pericolonic fat stranding is less conspicuous on this exam. No engorgement of the mesenteric vessels. No pneumoperitoneum or fluid collection. The appendix is not dilated or inflamed. PELVIS: The uterus and adnexa are unremarkable on CT for age. LYMPH NODES: No enlarged abdominal or pelvic lymph nodes are visualized. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. OSSEOUS STRUCTURES AND SOFT TISSUES: No aggressive osseous lesions are demonstrated. There is postsurgical change in the subcutaneous tissues of the right anterior abdominal wall. There are post injection changes in the subcutaneous tissues of the anterior abdominal wall. IMPRESSION: 1. Interval resolution of bowel obstruction. 2. No significant change in acute pancreatitis. No fluid collection. 3. Bilateral lower lobe peripheral airspace disease is slightly worse compared to yesterday and may represent atelectasis or pneumonia in the appropriate clinical scenario. 4. Additional stable findings, including a stable right renal mass, as above. Radiology Report INDICATION: ___ year old woman with SBO after Lap chole. Cdiff positive. Now with worsening bloating.// Eval for sbo/ ileus TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis dated ___ and abdominal radiograph dated ___ FINDINGS: There has been interval removal of a nasogastric tube. There are multiple dilated loops of small bowel measuring up to 4.7 cm in the right upper quadrant. There also multiple loops of dilated colon measuring up to 7.1 cm near the hepatic flexure. Bilateral lower lobe opacities are better appreciated on prior chest CT. There is no free intraperitoneal air. Osseous structures are notable for mild degenerative change in the bilateral hips and pubic symphysis. Cholecystectomy clips are again seen in the right upper quadrant. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Following removal of the nasogastric tube, there has been interval increase in small and large bowel dilatation suggestive of recurrence postoperative ileus, similar to ___. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: n/v/d Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst temperature: 97.8 heartrate: 73.0 resprate: 14.0 o2sat: 96.0 sbp: 159.0 dbp: 58.0 level of pain: 0 level of acuity: 3.0

You underwent removal of your gallbladder and you were discharged home. You returned to the hospital with abdominal pain, nausea, and vomiting. You underwent imaging and there was concern for a small bowel obstruction. You were placed on bowel rest and a ___ tube was placed for bowel decompression. During this time, you also had an elevated white blood cell count. A stool specimen was sent which returned as an infection, clostridium difficile. You were started on a course of vancomycin for C. Diff colitis and your white blood cell count decreased. The ___ tube was removed and you resumed a regular diet. Your vital signs have been stable and you are preparing for discharge with the following instructions: You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Complete course of vancomycin as directed

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Remicade / Lipitor / simvastatin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___: flexible sigmoidoscopy History of Present Illness: Mr ___ is a ___ year-old gentleman with a PMH of fistulizing Crohn's Disease c/b entero-splenic fistula s/p total abdominal colectomy (___) and on certolizumab/hydrocortisone/mesalamine, cholecytectomy and splenectomy, who now presents with one day of right lower quadrant abdomen pain and nausea. Of note, he was recently discharged from the hospital in early ___ with similar symptoms that improved with a 14-day course of PR mesalamine and PR hydrocortisone. This is his ___ occurrence over the past one year. Per patient reports acute onset of right lower quadrant pain with associated nausea without vomiting. Endorses ___ bouts of non-bloody diarrhea per day, which is unchanged from a baseline of ___ episodes per day. Denies assoicated fever, chills, sweats. Denies recent sick contacts. Progressive pain (to max ___ prompted presentation to the ED, where initial vitals were pain: 98.7 92 147/81 18 96% RA. Labs were remarkable for WBC 14.3 without neutrophilic prodominance or left shift; labs were otherwise normal, including lactate 1.8. GI consult in the ED preliminarily recommended: -Obtain KUB to r/o perforation or obstruction -Strict bowel rest/NPO/IVF until clinical improvement -Start hydrocortisone enemas and mesalamine enemas -Check C. diff and stool cultures -Check inflammatory markers -Smoking cessation In the ED, the patient was given ondansetron, morphine, hydromorphone, hydrocortisone enema and mesalamine suppository. Vitals prior to transfer were: T 98.7, HR 92, BP 147/81, RR 18, O2 96 on RA. Currently, patient reports pain that is improved to ___. He is otherwise comfortable. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies vomiting, constipation. No recent change in bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative Past Medical History: # Crohn's disease: c/b fistulae (colon-splenic in the past), diagnosed in 1990s, followed by Dr. ___, s/p total colectomy and splenectomy with ileo-rectal anastamosis in ___ # COPD # Hypertension # Hyperlipidemia # h/o DVT # Reactive arthritis # Sleep Apnea, improved w/wt loss # Obesity # Substance Abuse # Depression # Chronic Back Pain # Allergic rhinitis # s/p open cholecystectomy # Intraabdominal abscess s/p surgical drainage and antibiotics ___ # Scrotal abscess Social History: ___ Family History: Sister with colitis, mother with CHF, grandmother with CAD s/p MI Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.0 113/53 78 20 97%RA General: Obese. Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse expiratory wheezes throughout, no rales or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Midline incision with well-healed veritcal scar. Obese, soft, NABS. Tender to deep palpation in RLQ. No rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused. 1+ ankle edema. 2+ pulses, no clubbing or cyanosis Skin: No rashes. Neuro: Alert, awake and oriented x3. Strength in UE and ___ was intact and symmetric. Sensation was intact and symmetric distally. DISCHARGE PHYSICAL EXAM: Vitals: 98.3, 97.9, 63-85, 108-143/48-83, ___, 95%RA I/O: 4100/1675+ General: Obese. Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: CTAB, no wheezes, rales or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Midline incision with well-healed veritcal scar. Obese, soft, NABS. Tender to deep palpation in RLQ. No rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused. 1+ ankle edema. 2+ pulses, no clubbing or cyanosis Skin: No rashes. Neuro: Alert, awake and oriented x3. No focal deficits. Pertinent Results: ADMISSION LABS: ___ 11:44AM URINE MUCOUS-FEW ___ 11:44AM URINE HYALINE-11* ___ 11:44AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11:44AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-NEG ___ 11:44AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:40PM SED RATE-10 ___ 12:40PM PLT COUNT-406 ___ 12:40PM NEUTS-57.5 ___ MONOS-4.4 EOS-2.4 BASOS-0.9 ___ 12:40PM WBC-14.3* RBC-4.42* HGB-15.8 HCT-46.7 MCV-106* MCH-35.7* MCHC-33.8 RDW-13.2 ___ 12:40PM CRP-7.7* ___ 12:40PM estGFR-Using this ___ 12:40PM GLUCOSE-116* UREA N-10 CREAT-1.1 SODIUM-135 POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-18 ___ 12:45PM LACTATE-1.8 DISCHARGE LABS: ___ 05:55AM BLOOD WBC-10.7 RBC-4.37* Hgb-15.2 Hct-47.3 MCV-108* MCH-34.9* MCHC-32.3 RDW-12.7 Plt ___ ___ 05:55AM BLOOD Glucose-100 UreaN-7 Creat-1.0 Na-136 K-4.3 Cl-101 HCO3-26 AnGap-13 ___ 05:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.8 IMAGING: STUDY: Abdomen supine and erect films, ___. CLINICAL HISTORY: ___ man with Crohn's flare. Evaluate for perforation or obstruction. FINDINGS: Comparison is made to the prior radiographs from ___. There is a nonspecific bowel gas pattern without signs for obstruction. Thereis some air seen throughout the colon and stomach. No dilated loops of smallbowel are seen. Air is seen in the rectum and sigmoid colon. There is no freeintra-abdominal air on the upright view. There are several small roundedmetallic densities throughout the abdomen related to prior abdominal surgery. The lumbar spine demonstrates severe degenerative changes of lower aspect as well as right greater than left hip osteoarthritis. IMPRESSION: Nonspecific bowel gas pattern with some air seen throughout non-dilated loops of small bowel and colon. No definite sign for obstruction. MICROBIOLOGY: **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 2:06 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. BLOOD CULTURES: no growth CMV VIRAL LOAD: no growth Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Duloxetine 60 mg PO DAILY Start: In am 2. Furosemide 20 mg PO EVERY OTHER DAY Start: In am hold for SBP < 100 3. Lisinopril 10 mg PO HS hold for SBP < 100 4. Risperidone 1 mg PO HS 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 6. Cimzia *NF* (certolizumab pegol) 400 mg/2 mL (200 mg/mL x 2) Subcutaneous qMonth Last dose ___ 7. Loperamide 2 mg PO TID:PRN diarrhea 8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QID:PRN pain 9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION BID 10. Hydrocortisone Enema 100 mg PR HS 11. Mesalamine (Rectal) ___AILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 2. Duloxetine 60 mg PO DAILY 3. Furosemide 20 mg PO EVERY OTHER DAY hold for SBP < 100 4. Hydrocortisone Enema 100 mg PR HS 5. Lisinopril 10 mg PO HS hold for SBP < 100 6. Loperamide 2 mg PO TID:PRN diarrhea 7. Mesalamine (Rectal) ___AILY 8. Risperidone 1 mg PO HS 9. Nicotine Patch 21 mg TD DAILY RX *nicotine 21 mg/24 hour apply one patch every 24 hours daily Disp #*7 Each Refills:*0 10. Cimzia *NF* (certolizumab pegol) 400 mg/2 mL (200 mg/mL x 2) Subcutaneous qMonth Last dose ___ 11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO QID:PRN pain RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg 1 tablet(s) by mouth q6 hours Disp #*30 Tablet Refills:*0 12. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION BID 13. Ciprofloxacin HCl 750 mg PO Q12H Duration: 6 Days RX *ciprofloxacin 750 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*18 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Crohn's flare Secondary diagnoses: COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report STUDY: Abdomen supine and erect films, ___. CLINICAL HISTORY: ___ man with Crohn's flare. Evaluate for perforation or obstruction. FINDINGS: Comparison is made to the prior radiographs from ___. There is a nonspecific bowel gas pattern without signs for obstruction. There is some air seen throughout the colon and stomach. No dilated loops of small bowel are seen. Air is seen in the rectum and sigmoid colon. There is no free intra-abdominal air on the upright view. There are several small rounded metallic densities throughout the abdomen related to prior abdominal surgery. The lumbar spine demonstrates severe degenerative changes of lower aspect as well as right greater than left hip osteoarthritis. IMPRESSION: Nonspecific bowel gas pattern with some air seen throughout non-dilated loops of small bowel and colon. No definite sign for obstruction. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABDO PAIN Diagnosed with REGIONAL ENTERITIS NOS temperature: 98.7 heartrate: 92.0 resprate: 18.0 o2sat: 96.0 sbp: 147.0 dbp: 81.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted with abdominal pain from a Crohn's flare and were given steroid enemeas, antibiotics, IV fluids, bowel rest and IV pain medication with improvement. You had a sigmoidoscopy which showed active Crohn's disease and you should follow up with Dr. ___ as indicated below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ toe plantar ulcer Major Surgical or Invasive Procedure: ___ RLE angio History of Present Illness: Mr. ___ is a ___ year old man ___ CAD s/p 5x CABG ___ CFA endarterectomy w/ SFA stenting x2 in ___, CLI s/p thrombolysis @ ___ ___, presenting on transfer from ___. He states that he developed a small cut on his right foot by his great toe roughly 1 month ago that never healed. He was seen in wound clinic, and had some improvement until last week, when his wound became significantly worse. He was admitted to ___, and an arterial duplex showed his SFA stent was occluded with poor ABIs. He was transferred to ___ due to a lack of access to specialist vascular surgery care at ___. On initial assessment in the ___ ED, Mr. ___ denies fever, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, dysuria, or changes in bowel movements. Past Medical History: PMH: T2DM neuropathy PAD prostate Ca ___ HLD Endocarditis CAD s/p MI (5x CABG ___ anxiety/depression Sciatica L Charcot foot TIA ___ (carotid US ___ b/l carotid a. stenosis) PSH: Radical prostatectomy ___ ruptured tendon repair L foot ___ 5x CABG ___ R ___ toe amp ___ R CF endarterectomy w/ patch angioplasty, SFA angioplasty/stent ___ R ___ toe amp ___ RLE thrombolysis ___ @ ___ Social History: ___ Family History: noncontributory Physical Exam: On discharge: Pertinent Results: admission labs: ___ 03:50PM BLOOD WBC-6.8 RBC-2.98* Hgb-9.3* Hct-28.8* MCV-97 MCH-31.2 MCHC-32.3 RDW-14.1 RDWSD-49.5* Plt ___ ___ 03:50PM BLOOD ___ PTT-35.9 ___ ___ 03:50PM BLOOD Plt ___ ___ 03:50PM BLOOD Glucose-333* UreaN-52* Creat-1.6* Na-135 K-5.6* Cl-106 HCO3-19* AnGap-10 ___ 02:59AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.7 Imaging: ANGIOGRAM FINDINGS: ___ 1. Normal caliber abdominal aorta without stenosis. Bilateral renal arteries are patent. 2. Bilateral common, internal and external iliac arteries are patent. 3. The right common femoral and profunda femoris are patent. There is a large calcification at the origin of the profunda. 4. The entirety of the right superficial femoral artery stented and the artery is occluded. 5. There is reconstitution of the below-knee popliteal artery. The popliteal artery is patent throughout its course. 6. There is a high takeoff of the anterior tibial artery. The anterior tibial artery is the primary blood supply down the lower leg. The TP trunk is patent, but then the posterior tibial and peroneal arteries are occluded. 7. There is continuation of the anterior tibial artery into the dorsalis pedis on the foot. The posterior tibial artery at the ankle filled via collateral and supplies minimal applied to the foot. Pre op Xray ___ FINDINGS: Fine bony detail is obscured by an overlying dressing along the plantar aspect of the forefoot. As seen on the prior study there has been prior resection of the second and third rays at the level of the base of the proximal phalanges. No fracture or dislocation seen. Incidental note is made of a bipartite sesamoid first metatarsal. No definite bony destruction seen to suggest osteomyelitis. Extensive vascular calcification. IMPRESSION: Unchanged appearances when compared to the prior study. Post op Xray ___ IMPRESSION: Post right partial first ray amputation, without complication. Medications on Admission: Plavix 75mg daily Atorvastatin 80mg qhs atenolol 25mg daily Paroxetine 20mg daily famotidine 20mg BID warfarin 3.5mg daily ASA 81mg daily 15u levemir insulin qhs Novolog sliding scale TID Tramadol 50mg q12 FeSo4 aily Vitamin B12 daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever Do not take more than 4000mg acetaminophen in 24 hours 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Hours 3. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS 4. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES QID Duration: 1 Week 5. Atenolol 25 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Clopidogrel 75 mg PO DAILY 8. Famotidine 20 mg PO Q24H 9. Levemir U-100 Insulin (insulin detemir U-100) 100 unit/mL subcutaneous ONCE 10. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100 unit/mL subcutaneous sliding scale 11. PARoxetine 20 mg PO DAILY 12. Warfarin 3.5 mg PO ONCE Duration: 1 Dose Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Peripheral arterial disease, Right foot chronic wound Secondary diagnosis: T2DM neuropathy PAD prostate Ca ___ HLD Endocarditis CAD s/p MI (5x CABG ___ anxiety/depression Sciatica L Charcot foot TIA ___ (carotid US ___ b/l carotid a. stenosis) Discharge Condition: Stable, alert and oriented x3, including with assistance Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph, portable AP upright. INDICATION: Preoperative for angiography. COMPARISON: None available. FINDINGS: Patient is status post coronary artery bypass graft surgery. Heart is normal in size. Mediastinal and hilar contours appear within normal limits. There is no pleural effusion or pneumothorax. Lungs appear clear. Completely imaged in characterized cervical fusion. IMPRESSION: No evidence of acute cardiopulmonary process. Radiology Report EXAMINATION: ___ DUP UPPER EXT BILAT (MAP) INDICATION: Mr. ___ is a ___ w/ CAD s/p 5x CABG ___ CFA endarterectomy w/ SFA stenting x2 in ___, CLI s/p thrombolysis @ ___ ___, presents with occlusion of R SFA stent R as well as plantar ___ toe ulcer w/ exposed tendon. // upper extremity vein mapping TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging was obtained. COMPARISON: None FINDINGS: RIGHT UPPER EXTREMITY: Right Cephalic Vein Location: Diameter / Patency Proximal upper arm 0.29 cm/Patent Mid upper arm 0.3 cm/Patent Distal upper arm 0.33 cm/Patent Antecubital fossa 0.29 cm/Thickened walls Proximal forearm 0.2 cm/Patent Mid forearm 0.17 cm/Patent Distal forearm 0.15 cm/Patent Right Basilic Vein Location: Diameter Patency Proximal upper arm .16 cm/Patent Mid upper arm 0.16 cm/Patent Distal upper arm 0.15 cm/Patent Antecubital fossa 0.15 cm/Patent Proximal forearm .16 cm/Patent Mid forearm .16 cm/Patent ---------------------------------------------------------------- LEFT UPPER EXTREMITY: Left Cephalic Vein Location: Diameter Patency Proximal upper arm 0.17 cm /Patent Mid upper arm 0.21 cm/Patent Distal upper arm 0.19 cm/Patent Antecubital fossa 0.07 cm/Thickened walls Proximal forearm 0.18 cm/Patent Mid forearm 0.18 cm/Patent Distal forearm 0.12 cm/Patent Left Basilic Vein Location: Diameter Patency Proximal upper arm 0.19 cm/Patent Mid upper arm 0.25 cm/Patent Distal upper arm 0.17 cm/Patent Antecubital fossa 0.26 cm/Patent Proximal forearm 0.16 cm/Thickened walls Mid forearm 0.1 cm/Patent IMPRESSION: Patent veins with diameters as noted above. Radiology Report EXAMINATION: ___ INDICATION: ___ year old man with CAD s/p CAVG, R CFA endarterectomy w/ SFA stenting, CLI s/p thrombolysis, presents w/ reported R SFA stent occlusion // bilateral vein mapping TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging was obtained. COMPARISON: None FINDINGS: RIGHT LOWER EXTREMITY: Right Greater Saphenous Vein Location: Diameter / Patency ___ upper thigh 0.38 cm/Patent Mid thigh .23 cm/Patent Distal thigh 0.25 cm/Patent Mid knee .17 cm/Patent Proximal calf /Could not be visualized Mid calf /Could not be visualized Distal calf /Could not be visualized Right Small Saphenous Vein Location: Diameter / Patency Proximal calf .19 cm/Patent Mid calf .19 cm/Thickened walls Distal calf Occlusive thrombus LEFT LOWER EXTREMITY: Left Greater Saphenous Vein Location: Diameter / Patency ___ upper thigh 0.45 cm/Patent Mid thigh .22 cm/Patent Distal thigh 0.27 cm/Patent Mid knee .30 cm/Patent Proximal calf 0.16 cm/Patent Mid calf 0.17 cm/Patent Distal calf 0.15 cm/Patent Left Small Saphenous Vein: Diameter / Patency Proximal calf .14 cm/Thickened walls Mid calf .14 cm/Thickened walls Distal calf .14 cm/Patent IMPRESSION: Occlusive clot in right distal clot does not qualify as a DVT. Remaining visualized vessels are patent with diameters as noted above. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ year old man with R foot wound, s/p bypass // pre op planning TECHNIQUE: Three views right foot COMPARISON: Right foot radiographs ___ FINDINGS: Fine bony detail is obscured by an overlying dressing along the plantar aspect of the forefoot. As seen on the prior study there has been prior resection of the second and third rays at the level of the base of the proximal phalanges. No fracture or dislocation seen. Incidental note is made of a bipartite sesamoid first metatarsal. No definite bony destruction seen to suggest osteomyelitis. Extensive vascular calcification. IMPRESSION: Unchanged appearances when compared to the prior study. Radiology Report EXAMINATION: FOOT SESAMOID SERIES AX,LO,MO RIGHT INDICATION: ___ year old man with R foot wound // SESAMOID AXIAL, surgical pre op TECHNIQUE: Radiographs of the right foot sesamoid bones were obtained COMPARISON: Radiographs of the right foot dated ___ from earlier in the day FINDINGS: No acute fractures or dislocation are seen. The first metatarsal sesamoids are present and demonstrate a slightly heterogeneous appearance however there is no evidence of fracture or erosions. There appears to be a skin defect overlying the sesamoid bones with possible exposed bone. Mineralization is normal. Radiology Report EXAMINATION: FOOT 1 VIEW RIGHT INDICATION: ___ year old man s/p R partial ___ ray amputation // post op eval TECHNIQUE: Lateral right foot radiograph. COMPARISON: Radiographs from ___. FINDINGS: The patient is post right partial first ray amputation. Extensive vascular calcifications are again seen. There is moderate overlying soft tissue swelling at the surgical site. No acute fracture is detected. IMPRESSION: Post right partial first ray amputation, without complication. Radiology Report INDICATION: ___ with PMHx of significant PVD, has non-healing ulcer of R foot // ?osteo TECHNIQUE: AP, lateral, and oblique views of the right foot. COMPARISON: None. FINDINGS: Patient is status post amputation of the second and third toes at the level of the mid proximal phalanx. Cortical margins at the postop site are preserved. There is however a relatively rounded lucency projecting over the remaining portion base of the proximal phalanx of the third toe. This is only seen on the frontal view. On the additional views there is overlapping of the soft tissues obscuring additional evaluation.. Elsewhere, mineralization is preserved. Vascular calcifications are noted. Surgical clips project over the lower catheterization. IMPRESSION: Patient is status post amputation of the second and third digits. Well-circumscribed lucency projecting over the remaining base of the proximal phalanx of the right third toe, however it is uncertain if this is due to demineralization versus lucency in the overlying soft tissues. Consider dedicated toe films to better assess in different projections. Elsewhere, preserved mineralization. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: R Foot pain Diagnosed with Type 2 diabetes mellitus with foot ulcer, Long term (current) use of insulin temperature: 97.4 heartrate: 62.0 resprate: 18.0 o2sat: 97.0 sbp: 155.0 dbp: 46.0 level of pain: 0 level of acuity: 3.0

It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after surgery on your leg. This surgery was done to improve blood flow to your leg. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. Vascular bypass Surgery Discharge Instructions What to except: •It is normal feel tired for ___ weeks after your surgery •It is normal to have leg swelling. Keep your leg elevated as much as possible. This will decrease the swelling. •Your leg will feel tired and sore. This usually passes within a few weeks. •Your incision will be sore, slightly raised, and pink. Any drainage should decrease or stop with in the first 2 weeks. •If you are home, you will likely receive a visit from a Visiting Nurse ___. Members of your health care team will discuss this with you before you go home. Medications: •Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! •It is very important that you take Aspirin every day! You should never stop this medication before checking with your surgeon Pain Management: •It is normal to feel some discomfort/pain following surgery. This pain is often described as “soreness”. •You may take Tylenol (acetaminophen ) as needed for pain. You will also receive a prescription for stronger pain medicine, if the Tylenol doesn’t work, take prescription medicine. •Narcotic pain medication can be very constipating, please also take a stool softner such as Colace. If constipation becomes a problem, your pharmacist can suggest additional over the counter medications. •Your pain medicine will work better if you take it before your pain gets to severe. •Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. Activity: •Do not drive until your surgeon says it is okay. In general, driving is not allowed until -the staples in your leg have been taken out -your leg feels strong -you have stopped taking pain medication and feel you could respond in an emergency •Walking is good because it helps your muscles get stronger and improves blood flow. Start with short walks. If you can, go a little further each time, letting comfort be your guide. •Try not to go up and downstairs too much in the first weeks. Use stairs only once or twice a day until your incision is fully healed and you are back to your usual strength. •Avoid things that may constrict blood flow or put pressure on your incision, such as tight shoes, socks or knee highs. •Do not take a tub bath or swim until your staples are removed and your wound is healed. •When you sit, keep your leg elevated to reduce swelling. •If swelling in your leg is getting worse, lie down with your leg up on a pillows. If your swelling continues, please call your surgeon. You may be instructed to use special elastic bandages or stockings. •Try not to sit in the same position for a long while. For example, ___ go on a long car ride. •You may go outside. But avoid traveling long distances until you see your surgeon at your next visit. •You may resume sexual activity after your incisions are well healed. Your incision •Your incision may be slightly red around the stitches or staples. This is normal. •It is normal to have a small amount of clear or light red fluid coming from your incision. This will decrease and stop in a few days. If it does not stop, or if you have a lot of fluid coming out., please call your surgeon. •You may shower 48 hours after your surgery. Do not let the shower spray right on the incision, Let the soapy water run over the incision, then rinse. Gently pat the area dry. Do not scrub the incision, Do not apply ointment or lotions to the incision. •You do not need to cover the incision if there is no drainage, If there is a small amount of drainage, put a small sterile gauze or Bandaid over the incison. •It is normal to feel a firm ridge along the incision, This will go away as your wound heals. •Avoid direct sun exposure to the incision area for 6 months. This will help keep the scar from becoming discolored. •Over ___ months, your incision will fade and become less prominent. Diet and Bowels •It is normal to have a decreased appetite. Your appetite will return over time. Follow a well-balanced, health healthy diet, without too much salt and fat. •Prescription pain medicine might make you constipated. If needed, you may take a stool softener (such as Colace) or gentle laxative (ask your pharmacist for recommendations). Drinking more fluid may also help. •If you go 48 hours without a bowel movement, or having pain moving your bowels, call your primary care physician.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim Attending: ___ Chief Complaint: fall, weakness, bradycardia Major Surgical or Invasive Procedure: Dual chamber pacemaker placement ___ History of Present Illness: Mr. ___ is a ___ year old man with a history of hairy cell leukemia s/p cladribine on ___ who presented to the ER with generalized weakness and a fall the day prior to admission. He reports feeling unwell for the past few days with fatigue and according to his wife has been eating and drinking much less. He cannot recall if he experienced any lightheaded symptoms prior to the fall and does not know the circumstances surrounding the fall. He was recently in a rehab facility after receiving Cladribine and was treated for PNA with levaquin, now home and off abx. In the emergency department, initial vitals: 97.8 71 121/71 18 100%. CXR and head CT were clear. ECG showed a junctional rhythm with a rate of 69 bpm. No ST/T changes. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Atrial fibrillation (not on anticoagulation) systolic/diastolic heart failure (EF 30%) hypertension/LVH hairy cell leukemia memory loss Shatzki's ring hiatal hernia Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS: BP 98.3 BP 99/66 HR 65 RR18 96%RA GENERAL: alert and oriented, NAD HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RR. Normal S1, S2. No m/r/g. LUNGS: CTA B, good air movement bilaterally. ABDOMEN: NABS. Soft, mildly distended abdomen without tenderness. EXTREMITIES: trace peripheral edema, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. Gait assessment deferred DISCHARGE PHYSICAL EXAM: VS: T: 97.4 BP: 120/79 (90-126/56-93) HR:90 RR:16 O2 sat: 96%RA GENERAL: WDWN male in NAD. Oriented x3. NECK: Supple without elevated JVP. CARDIAC: regular rate, rhythm, normal S1/S2, II/VI systolic murmur at base. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, minimal TTP in lower abdomen. No HSM or tenderness. EXTREMITIES: WWP, 1+ ankle edema. PULSES: equal and 2+ bilaterally Pertinent Results: ___ 05:45PM BLOOD WBC-2.4*# RBC-3.43* Hgb-11.3* Hct-35.5* MCV-104*# MCH-33.1* MCHC-31.9 RDW-18.6* Plt ___ ___ 05:45PM BLOOD Neuts-92.5* Lymphs-4.7* Monos-0.8* Eos-2.0 Baso-0.1 ___ 05:45PM BLOOD Glucose-118* UreaN-37* Creat-1.8* Na-138 K-4.7 Cl-101 HCO3-27 AnGap-15 ___ 05:45PM BLOOD ALT-21 AST-35 CK(CPK)-52 AlkPhos-183* TotBili-1.7* DirBili-0.7* IndBili-1.0 ___ 05:45PM BLOOD cTropnT-0.18* ___ 05:45PM BLOOD CK-MB-4 ___ ___ 05:45PM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.7 Mg-2.1 ___ CXR: Slight interval increase in size of moderate left pleural effusion. Left basilar opacity likely reflects atelectasis. Trace right pleural effusion also noted. Mild pulmonary vascular congestion, similar compared to the prior study. ___ Head CT: No intracranial hemorrhage or acute territorial infarction. ___ ECG: junctional rhythm at ___hanges. 2D-ECHOCARDIOGRAM (___): The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= ___ %) secondary to severe hypokinesis of the inferior and infero-lateral walls and mild hypokinesis of the remaining segments. The LV apex contracts best. Right ventricular chamber size is normal. with moderate global free wall hypokinesis. 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. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a trivial/physiologic pericardial effusion. DISCHARGE LABS: ___ 08:51AM BLOOD WBC-1.6* RBC-2.93* Hgb-9.8* Hct-30.2* MCV-103* MCH-33.5* MCHC-32.4 RDW-18.3* Plt ___ ___ 08:51AM BLOOD Glucose-128* UreaN-33* Creat-1.4* Na-137 K-4.4 Cl-102 HCO3-28 AnGap-11 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Furosemide 20 mg PO 3X/WEEK (___) 3. Aspirin 325 mg PO DAILY 4. Donepezil 10 mg PO HS 5. Memantine 5 mg PO DAILY 6. Vitamin D 400 UNIT PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO BID 8. Calcium Carbonate 500 mg PO Frequency is Unknown Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Memantine 5 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 5. Vitamin D 400 UNIT PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO BID 7. Calcium Carbonate 500 mg PO DAILY 8. Furosemide 20 mg PO 3X/WEEK (___) 9. Cephalexin 250 mg PO Q8H Duration: 2 Days Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Symptomatic Bradycardia Secondary: Hairy Cell Leukemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report HISTORY: Generalized weakness. TECHNIQUE: AP upright and lateral views of the chest. COMPARISON: ___. FINDINGS: Moderate to severe cardiomegaly is unchanged. The aortic knob remains calcified. Mediastinal and hilar contours are similar. Moderate size left pleural effusion appears minimally increased compared to the prior study. Opacification of the left lung base likely is due to compressive atelectasis. Mild pulmonary vascular congestion appears similar. Trace right pleural effusion is relatively unchanged. No pneumothorax is identified. IMPRESSION: Slight interval increase in size of moderate left pleural effusion. Left basilar opacity likely reflects atelectasis. Trace right pleural effusion also noted. Mild pulmonary vascular congestion, similar compared to the prior study. Radiology Report HISTORY: Status post fall with altered mental status. COMPARISON: None. TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain without administration of IV contrast. Coronal, sagittal, and thin slice bone algorithm reformats were reviewed. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large territorial infarction. Prominent ventricles and sulci are compatible with age-related volume loss. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: No intracranial hemorrhage or acute territorial infarction. Radiology Report HISTORY: Patient with hairy cell leukemia and elevated bilirubin assess for gallstones and cholecystitis. COMPARISON: None. FINDINGS: The liver appears normal in echotexture with no focal lesions identified. The main portal vein is patent. The spleen measures 12.5 cm and is at the upper limits of normal. There are bilateral pleural effusions as well as free fluid in the abdomen. The gallbladder shows presence of shadowing gallstones. The common bile duct measures 0.3 cm and is within normal limits. The right kidney appears unremarkable. The left kidney demonstrates a 3.1 x 2.7 x 3.2 cm upper pole cyst. A 0.5 cm nonobstructing renal stone is noted within the upper pole of the left kidney. IMPRESSION: 1. Cholelithiasis without cholecystitis. 2. Bilateral pleural effusions and abdominal free fluid. 3. Left upper pole nonobstructive 5 mm renal calculus. 4. Left lower pole renal cyst. Radiology Report INDICATION: ___ male patient with shortness of breath, crackles, hypotension. Study requested for evaluation of an acute process. COMPARISON: Prior chest radiograph from ___. TECHNIQUE: Portable chest radiograph. FINDINGS: Moderate-to-severe cardiomegaly is stable. The mediastinal and hilar contours are unchanged. As compared to prior chest radiograph from ___, pulmonary congestion appears slightly more prominent. Left pleural effusion and compressive atelectasis are unchanged. There is no pneumothorax. Right costodiaphragmatic angle is not included in this examination. Radiology Report CLINICAL HISTORY: Dual-chamber pacemaker placed. Evaluate lead positions. CHEST, PA AND LATERAL: The pacemaker leads are in the appropriate position. The heart is enlarged. A left effusion is present. No other evidence of failure is seen. IMPRESSION: Pacemaker leads in good position, no pneumothorax. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: WEAKNESS,UNABLE TO AMBULATE Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, OTHER MALAISE AND FATIGUE temperature: 99.1 heartrate: 66.0 resprate: 18.0 o2sat: 94.0 sbp: 124.0 dbp: 87.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure caring for you at ___. You came to the hospital because you were feeling very weak. We found that your heart was beating very slow and you were having symptoms from it. We stopped your metoprolol but your heart rate was still slow. You then had a pacemaker implanted in order to increase your heart rate and prevent the slow rate. Please follow up with the appointments scheduled below. 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: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abscess Major Surgical or Invasive Procedure: I & D of two abscesses History of Present Illness: ___ male hx of Hidrenitis (recurrent skin infections axilla/groin/face since ___ was ___ years old. Countless sets of antibiotics and many many I&D), OSA on CPAP, uncontrolled NIDDM2, HTN, gout, NAFLD, obesity who was referred to ___ ED from PCP office on ___ for cellulitis. THe patient saw ___ NP at his PCP office on ___. ___ has had a painful rash in the left arm and right breast area for 3 days prior to ED arrival. ___ had a ___ recorded at home. The rash was progressively larger and more red in the past 1 day prior to presenting to his PCP ___ denies any bug bite or trauma or cuts that preceded them. ___ says ___ takes frequent hot showers and ___ pop the erythematous area with pimples and drain the pus himself. Last month ___ had an area on the abdomen ___ addressed himself. ___ rarely goes to the office for them. It was only this week it was quite severe with pain and redness and induration that ___ went to the PCP office yesterday. Currently ___ has ___ pain but no other chest pain, dyspnea, ongoing fever, abdominal pain, dysuria, diarrhea, or nausea. Past Medical History: NAFLD OSA on CPAP NIDDM2 - newly diagnosed and poorly controlled. Not tolerating metformin. Cervical radiculopathy HTN Gout Obesity ___ treatment of H pylori without confirmation of eradication Hidrenitis Supportivia Social History: ___ Family History: History of diabetes in family Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. 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: 10 cm circular erythema on the inside of the upper left arm s/p I+D there by the ED, 10 cm erythema just inferior to the right nipple, no fluctuance, dressing intact PSYCH: pleasant, appropriate affect NEUROLOGIC: MENTATION: alert and cooperative. Oriented to person and place and time. Exam on discharge: ___ 1454 Temp: 99.6 PO BP: 134/94 R Standing HR: 90 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: Alert and in no apparent distress, obese EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation SKIN: 10 cm circular erythema on the inside of the upper left arm with induration and minimial fluctuance, no drainage. 10 cm erythema just inferior to the right nipple, +induration, no fluctuance, dressing intact, ertythema extends beyond marked lines PSYCH: pleasant, appropriate affect NEUROLOGIC: MENTATION: alert and cooperative. Oriented to person and place and time. Pertinent Results: ___ 04:15PM WBC-9.8 RBC-4.57* HGB-14.5 HCT-42.4 MCV-93 MCH-31.7 MCHC-34.2 RDW-11.7 RDWSD-39.7 ___ 07:15AM BLOOD WBC-7.0 RBC-4.41* Hgb-13.8 Hct-41.1 MCV-93 MCH-31.3 MCHC-33.6 RDW-11.5 RDWSD-39.4 Plt ___ ___ 07:15AM BLOOD UreaN-15 Creat-0.9 Na-139 K-4.1 Cl-100 HCO3-23 AnGap-16 ___ 07:45AM BLOOD %HbA1c-11.2* eAG-275* ___ 07:45AM BLOOD CRP-74.9* Ultrasound: Transverse and sagittal images were obtained of the superficial tissues of the left upper arm and right chest wall/upper arm. In the right chest wall in the area of superficial redness near the previous drain site is a very superficial, small complex collection lacking vascularity measuring 1.0 x 1.0 x 1.0 cm. In the left medial upper arm, in the location of the old drain site, is a small area of heterogeneity and superficial edema without a frank fluid collection identified. More proximally in the upper arm in area redness, is a very superficial small complex collection with only peripheral vascularity measuring 0.8 x 0.4 x 0.7 cm. IMPRESSION: Small very superficial complex collections in the areas of redness measuring 1.0 cm in the right chest wall and 0.8 cm in the left upper arm, as described above. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colchicine 0.6 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 5. Allopurinol ___ mg PO DAILY Discharge Medications: 1. BD Ultra-Fine Nano Pen Needle (pen needle, diabetic) 32 gauge x ___ miscellaneous QID RX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needle] 32 gauge X ___ use with insulin pen 5 times daily Disp #*400 Each Refills:*1 2. chlorhexidine gluconate 4 % topical Other qWeek RX *chlorhexidine gluconate 4 % apply to body once a week in shower qWeek Refills:*2 3. Clindamycin 1% Solution 1 Appl TP BID Duration: 30 Days RX *clindamycin phosphate 1 % apply to affected areas twice a day Refills:*3 4. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a day Disp #*40 Capsule Refills:*0 5. Glargine 40 Units Bedtime Humalog 12 Units Breakfast Humalog 12 Units Lunch Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *blood sugar diagnostic [FreeStyle Test] use to test sugar up to 4 times daily up to 5 times daily Disp #*150 Strip Refills:*0 RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR SQ 40 Units before BED; Disp #*5 Syringe Refills:*3 RX *blood-glucose meter [FreeStyle Freedom] dispense one meter Daily Disp #*1 Kit Refills:*0 RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR SQ As per sliding scale and before meals Disp #*10 Syringe Refills:*3 RX *lancets [ForaCare Lancets] 30 gauge use to check sugar up to 5 times daily Disp #*200 Each Refills:*0 6. Allopurinol ___ mg PO DAILY 7. amLODIPine 10 mg PO DAILY 8. Colchicine 0.6 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Abscess, Cellulitis Type 2 diabetes poorly controlled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: US CHEST WALL SOFT TISSUE RIGHT; US MSK SOFT TISSUE INDICATION: ___ year old man with uncontrolled DM and concern for abscess, right chest wall upper arm, please asses// ? Abscess ; ___ year old man with uncontrolled DM and concern for abscess, left upper arm, please asses// ?abscess- left upper arm TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the left upper arm and right chest wall/upper arm in areas of redness. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the left upper arm and right chest wall/upper arm. In the right chest wall in the area of superficial redness near the previous drain site is a very superficial, small complex collection lacking vascularity measuring 1.0 x 1.0 x 1.0 cm. In the left medial upper arm, in the location of the old drain site, is a small area of heterogeneity and superficial edema without a frank fluid collection identified. More proximally in the upper arm in area redness, is a very superficial small complex collection with only peripheral vascularity measuring 0.8 x 0.4 x 0.7 cm. IMPRESSION: Small very superficial complex collections in the areas of redness measuring 1.0 cm in the right chest wall and 0.8 cm in the left upper arm, as described above. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: L Arm Redness Diagnosed with Type 2 diabetes mellitus with hyperglycemia, Cellulitis of left upper limb temperature: 98.5 heartrate: 88.0 resprate: 20.0 o2sat: 98.0 sbp: 137.0 dbp: 83.0 level of pain: 5 level of acuity: 2.0

Mr. ___, It was a pleasuring caring for you. You were admitted to help treat the abscess in your arm/chest and to start insulin to have your diabetes better controlled. It is important that you check your sugar and give your insulin as instructed by the diabetes team. Please make sure you see your primary care doctor in follow-up and finish the course of antibiotics. You are leaving against the advice of your doctors. If you notice very high (>400) or very low (<70) sugars, if you notice spreading of the redness or fever or other symptoms that concern you it is important that you seek medical care immediately. We wish you the best, Your ___ 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: Left sided clumsiness, gait instability Major Surgical or Invasive Procedure: n/a History of Present Illness: ___ is a ___ F with h/o HLD who presents as a transfer from ___ after finding of a right parietal IPH on head CT. The patient was in her usual state of health when she awoke early this morning with a severe posterior headache. She took some ibuprofen for the pain and went back to sleep. She awoke later and the headache continued. She went about her day and noticed that she seemed to be clumsy on the left side. She tripped slightly while walking up a flight of stairs, but did not fall. She later was out with a friend who noticed that her gait was off and recommeded presenting to the ___. The patient contacted her son, who is an EMT. Her son noticed again she she appeared to be clumsy on the left side and that she seemed to have some proprioceptive deficit, not lifting her left leg high enough to clear obtacles and missing the target when trying to place a bottle cap on a bottle. She presented to the ___ where a ___ demonstrated a right parietal IPH. The patient notes a history of headaches, which are generally mild and bifrontal. She does report one instance of the worst headache of her life about ___ years ago, which was located in the right posterior region. She did present to an ___ at that time where she had a CT scan without contrast, which showed some sinusitis, but was otherwsie unremarkable. She was discharged with symptoms attributed to sinus headache. Upon evaluation the patient complains of a mild bifrontal headache of her normal type and some continued clusiness on the left side, but otherwise has no complaints. Past Medical History: Hyperlipidemia Social History: ___ Family History: No family history of intracranial hemorrhage or bleeding diathesis. Physical Exam: GEN: Awake, cooperative, Having Headache. HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx NECK: Supple RESP: CTAB CV: RRR ABD: soft, NT/ND EXT: No edema, no cyanosis SKIN: Full body skin exam on ___. No evidence of lesions. NEURO EXAM: MS: 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. Speech was not dysarthric. Pt was able to name both high and low frequency objects. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes. Good knowledge of current events. No evidence of apraxia or neglect. CN: II: PERRLA 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI, no nystagmus. Normal saccades. V: Sensation intact to LT. VII: Facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate rise symmetric. XI: Trapezius and SCM ___ bilaterally. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. Left Parietal Drift. No adventitious movements. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ ___ 5 5 R ___ ___ ___ ___ 5 5 Sensory: Mild defecit to pinprick on Left (feels pin, but feels less than right). No extinction to DSS. There is mild agraphesthesia in the left hand, with delay in identifying a quarter placed in the left hand compared to rapid identification of a dime in the right. There is slowed finding of the nose with the eye closed with the left hand. Slowed left finger tapping and foot tapping Reflexes: Bi Tri ___ Pat Ach L ___ 2 1 R ___ 2 1 Toes mute bilaterally Coordination: No intention tremor, no dysdiadochokinesia noted. Slowed left finger tapping, rapid alternating movements and foot tapping Pertinent Results: ========== LABS ========== ___ 10:04AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 10:04AM BLOOD Triglyc-114 HDL-63 CHOL/HD-3.7 LDLcalc-144* ___ 10:04AM BLOOD %HbA1c-5.6 eAG-114 =========== IMAGING =========== CTA HEAD AND NECK WITH AND WITHOUT CONTRAST (___): 1. A 3.2x3.1cm right posterior parietal lobe acute intraparenchymal hematoma with some surrounding edema and mass effect. No abnormal vessels in the vicinity. 2. Patent major intra and extracranial arteries as discussed above. 3. Mild fullness in the left pyriform sinus and multiple small nodes not enlarged by size criteria however correlate clinically. NCHCT (___): Stable right parietal intraparenchymal hemorrhage. No new hemorrhagic lesions. MRI/V HEAD WITH AND WITHOUT CONTRAST (___): 1. Right parietal intraparenchymal hematoma, 2.8x2.5x2.7cm, unchanged compared to prior CT. Thick rind of slightly irregular and heterogeneous peripheral enhancement seen in/surrounding the hematoma on post-contrast images. This could be a finding seen with a subacute hematoma, however an underlying mass lesion cannot be completely excluded, given the thickness and irregularity. Close Followup is recommended to assess for interval change. 2. T2/FLAIR signal hyperintense focii in the periventricular, deep, and subcortical white matter which are nonspecific but most likely secondary to chronic small vessel ischemic disease. 3. Patent major dural venous sinuses NCHCT (___): 3.0 cm right parietal intraparenchymal hemorrhage with associated edema. No new intracranial hemorrhage. The hematoma appears slightly increased in size which could be due to differences in slight selection or slight actual increase which can be assessed on follow up. Increased surrounding edema is noted without significant change in mass effect. Medications on Admission: Aspirin 325 daily Fioital prn headache Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN pain Limit use to 15 days/month 2. Docusate Sodium 100 mg PO DAILY constipation 3. Gabapentin 300 mg PO TID 4. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN Headache 5. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 6. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Left parietal intraparenchymal hemorrhage Secondary diagnosis: Hyperlipidemia Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MRI AND MRA BRAIN INDICATION: ___ year old woman with spontaneous right parietal IPH // assess for underlying cause of IPH TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T-weighted, axial fast spin echo T2-weighted,axial flair, axial diffusion weighted and axial gradient echo images. The T1 weighted images were repeated after the administration of intravenous gadolinium contrast. An MRV of the head was also performed. COMPARISON: No prior MRI of the head. Prior CT of the head dated ___. FINDINGS: MRI brain: There is a right parietal intraparenchymal hematoma measuring approximately 25 mm AP x 27 mm TV x 28 mm SI. There is no significant change in size compared to prior study. Signal abnormality is noted on diffusion-weighted images; assessment for ischemic changes is confounded by the presence of blood products. On post-contrast images, there is a thick, slightly irregular rind of heterogeneous peripheral enhancement, approx. 1.1cm in thickness. There is surrounding vasogenic edema. There is local mass effect with sulcal effacement and narrowing of the atrium and occipital horn of the right lateral ventricle. There is no shift of midline structures. The sulci and vetricles are normal elsewhere. There is a small right subdural fluid collection or hemorrhage. There are scattered foci of T2/FLAIR signal hyperintensity in the periventricular, deep, and subcortical white matter which is nonspecific but likely secondary to chronic small vessel ischemic disease. The major vascular flow voids are maintained. The orbits are unremarkable. There is minimal mucosal thickening within the paranasal sinuses. The mastoid air cells are clear. MRV brain: The superior sagittal sinus, straight sinus, transverse sinuses, sigmoid sinuses, and the visualized internal jugular veins are patent without filling defect to suggest thrombosis. The visualized deep cerebral veins are also patent. The vein ___ is unremarkable. IMPRESSION: 1. Right parietal intraparenchymal hematoma, 2.8x2.5x2.7cm, unchanged compared to prior CT. Thick rind of slightly irregular and heterogeneous peripheral enhancement seen in/surrounding the hematoma on post-contrast images. This could be a finding seen with a subacute hematoma, however an underlying mass lesion cannot be completely excluded, given the thickness and irregularity. Close Followup is recommended to assess for interval change. 2. T2/FLAIR signal hyperintense focii in the periventricular, deep, and subcortical white matter which are nonspecific but most likely secondary to chronic small vessel ischemic disease. 3. Patent major dural venous sinuses Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with right parietal IPH // assess for progression of hemorrhage, please obtain at 8am if MRI has not been done in close proximity TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: CTDIvol: 70.73 mGy DLP: ___ MGy-cm COMPARISON: Non-enhanced head CT study from ___. FINDINGS: Right parietal intraparenchymal hemorrhage, measuring approximately 27 x 22 mm, not significantly changed compared to prior study. No new hemorrhage lesions identified. Mild mass effect is re-demonstrated with slight narrowing of the right occipital ventricular horn. No midline shift is seen. The basal cisterns appear patent. The visualized bony structures are grossly unremarkable. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Atherosclerotic mural calcification of the bilateral internal carotid arteries is noted. The globes are unremarkable. IMPRESSION: Stable right parietal intraparenchymal hemorrhage. No new hemorrhagic lesions. Radiology Report INDICATION: ___ year old woman with R parietal IPH 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. DOSE: DLP: 54 mGy-cm. CTDIvol: 1003 MGy. COMPARISON: CT from ___ and MRI from ___. FINDINGS: There is no evidence of new intracranial hemorrhage, edema, mass effect, or vascular territorial infarction. There is a 2.7 x 3.0 cm right parietal intraparenchymal hemorrhage with associated edema, relatively stable from prior CT (2:25). The ventricles and sulci are normal in size and configuration for age. Periventricular white matter hypodensities are likely sequela of chronic small vessel ischemic disease. The basal cisterns appear patent, and there is preservation of normal gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells,and middle ear cavities are clear. The globes are intact. IMPRESSION: 3.0 cm right parietal intraparenchymal hemorrhage with associated edema. No new intracranial hemorrhage. The hematoma appears slightly increased in size which could be due to differences in slight selection or slight actual increase which can be assessed on follow up. Increased surrounding edema is noted without significant change in mass effect. . Radiology Report EXAMINATION: CTA HEAD AND CTA NECK INDICATION: History: ___ with R parietal/occipital ICH // please eval for vasc abnormality TECHNIQUE: CT HEAD WITHOUT IV CONTRAST; CT ANGIOGRAM OF THE HEAD AND NECK WITH IV CONTRAST; 2D AND 3D REFORMATIONS OF THE INTRA AND EXTRACRANIAL ARTERIES DOSE: DLP: 2534 mGy-cm; CTDI: 128 mGy COMPARISON: CT HEAD ___ FINDINGS: NECT HEAD There is a 3.2 x 3.1 cm acute intraparenchymal hematoma in the right posterior parietal lobe, with mild to moderate surrounding edema. There is also slightly increased attenuation of the overlying cortex, which may relate to congestion or contusion along with small foci of subarachnoid hemorrhage adjacent, latter better seen on the subsequent MRI. There is mass effect on the atrium of the right lateral ventricle along with adjacent sulcal effacement. There are multiple small hypodense foci in the subcortical and periventricular white matter, nonspecific in appearance. The ventricles, extra-axial CSF spaces and sulci elsewhere are unremarkable. No suspicious osseous lesions are noted. The mastoid air cells are clear. The petrous apices are pneumatized left more than right. Mild ethmoidal mucosal thickening on both sides. Sphenoid sinus has one major septation and 1 minor septation, the latter inserts on the left carotid groove. Mild mucosal thickening in the right side of the frontal sinus. CT ANGIO HEAD The major intracranial arteries of the anterior and the posterior circulation are patent, without focal flow-limiting stenosis, occlusion or aneurysm more than 3 mm within the resolution of the study. The right posterior inferior cerebellar artery origin is faintly seen. No obvious abnormal blood vessels are noted in the region of the right posterior parietal hematoma. The enhancement in the venous sinuses in the venous tributaries is grossly unremarkable though not targeted. Minimal calcifications are noted in the right cavernous carotid segment. CT ANGIO NECK Slightly suboptimal due to the slightly decreased intensity of the bolus. The origins of the arch vessels are patent. Minimal calcifications are noted in the aortic arch. 2 vessel aortic arch pattern, with common origin of the brachiocephalic trunk and the left common carotid artery. Right vertebral artery is dominant. The vertebral arteries is slightly tortuous in course with scattered calcifications in the left vertebral artery. No focal flow-limiting stenosis or occlusion noted. The common carotid arteries are patent. Mild calcifications are noted at the common carotid bifurcations, without focal flow-limiting stenosis or occlusion. The cervical internal carotid arteries or patent, without focal flow-limiting stenosis or occlusion. There is mild focal dilation of the left proximal cervical internal carotid artery proximally, with some narrowing question related to tortuosity. CT NECK Mild fullness in the left pyriform sinus. Multiple small nodes are noted in both sides of the neck, not abnormally enlarged by size criteria. No obvious mass like lesions noted. Mild degenerative changes in the cervical spine without significant canal or foraminal narrowing. IMPRESSION: 1. A 3.2x3.1cm right posterior parietal lobe acute intraparenchymal hematoma with some surrounding edema and mass effect. No abnormal vessels in the vicinity. Please see subsequent MRI for additional findings and discussion. 2. Patent major intra and extracranial arteries as discussed above. 3. Mild fullness in the left pyriform sinus and multiple small nodes not enlarged by size criteria however correlate clinically. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ICH, Transfer Diagnosed with INTRACRANIAL HEMORR NOS, HEADACHE temperature: 98.9 heartrate: 100.0 resprate: 18.0 o2sat: 97.0 sbp: 140.0 dbp: 70.0 level of pain: 3 level of acuity: 2.0

Dear ___, ___ were hospitalized due to symptoms of headache resulting from an brain bleed (intraparenchymal hemorrhage), a condition in which a blood vessel providing oxygen and nutrients to the brain bleeds. 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. The cause of this brain bleed remained unclear at time of discharge. High blood pressure can sometimes cause a brain bleed; however, your blood pressure was normal while ___ were in the hospital. ___ should have an MRI at the time and date scheduled below to assess for resolution of the bleed and to re-assess for any abnormalities that may have led to the bleed. ___ also had a severe headache throughout hospitalization. We have discharged ___ with an aggressive pain control regimen. Please follow-up with your primary care doctor regarding further pain control. Please followup with Neurology and your primary care physician as listed below. If ___ experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to ___ - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around ___ - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing ___ with care during this hospitalization. We wish ___ all the best!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / ciprofloxacin / amlodipine Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMHx morbid obesity, HTN, HLD, and T2DM presented with chest pain. On day of presentation noted onset of substernal chest pain which awoke her from sleep. Notably, the patient has a long standing history of intermittent chest pain. Evaluated in ___ ED 10 days prior to presentation with negative serial enzymes, D-dimer 876 and L>R leg edema, but CTA chest was negative. At that time an outpatient stress planned but not completed. The patient describes her chest pain as sharp, but subsequent have been a pressure sensation. She reports each episode lasts approximately ___ minutes. Has been associated with dyspnea. No associated cough or fever, no radiating pain, no nausea/vomiting. Of note, she had a negative stress MIBI at ___ ___. She is transferred to the floor for nuclear stress since she is not sufficiently independent of ADLs for ED observation stress test. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes A1C 6.7, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: None 3. OTHER PAST MEDICAL HISTORY: - Nephrolithiasis, status post ureteroscopy/laser lithotripsy and stent placement in the right ureteropelvic junction s/p stent removal ___. - Morbid obesity. - Proteinuria. - Depression. - CVA (___), per report, experienced transient aphasia which resolved without subsequent deficit - Cardiomegaly. - Bilateral knee OA - Positive QuantiFERON Gold, negative PPD, likely false positive. Social History: ___ Family History: (As per OMR): Mother - dementia, age ___. She had two strokes in the past. Father - diabetes ___ type 2 and died of a suicide. He may have had depression. Sister - diabetes ___, stroke. Physical Exam: ADMISSION PHYSICAL EXAM: General: Morbidly obese. HEENT: PERRL, EOMI. Neck: Unable to evaluate JVP due to body habitus. CV: Normal S1, S2. No m/r/g. Lungs: Decreased breath movement bilaterally. Exam limited by body habitus. Abdomen: Soft. NTND. No r/g. BS+ Ext: Limited left knee flexion and extension due to pain. Negative anterior drawer. Pain with palpation left medial joint line. DISCHARGE PHYSICAL EXAM: General: Morbidly obese. HEENT: PERRL, EOMI. Neck: Unable to evaluate JVP due to body habitus. CV: Normal S1, S2. No m/r/g. Lungs: Decreased breath movement bilaterally. Exam limited by body habitus. Abdomen: Soft. NTND. No r/g. BS+ Ext: Able to move both knees without pain. Strength ___ bilateral ___. Pertinent Results: ADMISSION RESULTS: ----------------- ___ 09:30AM CK-MB-3 cTropnT-<0.01 ___ 07:05PM CK-MB-3 cTropnT-<0.01 ___ 12:45AM proBNP-83 ___ 12:45AM WBC-7.2 RBC-4.66 HGB-12.8 HCT-39.6 MCV-85 MCH-27.4 MCHC-32.2 ___ 12:45AM NEUTS-52.6 ___ MONOS-5.3 EOS-1.9 BASOS-0.6 ___ 12:45AM GLUCOSE-155* UREA N-11 CREAT-0.9 SODIUM-141 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-31 ANION GAP-13 ------- IMAGING: PHARMACOLOGIC STRESS TEST ___: IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. NUCLEAR STRESS TEST ___: IMPRESSION: 1. Limited study due to body habitus and inability to use gated SPECT imaging. Mild, apical, fixed perfusion defect which may be due to soft tissue attenuation. No evidence of exercise-induced ischemia. INTERPRETATION: Resting and stress perfusion images reveal no reversible defect with a possible moderate-mild apical perfusion defect, which in the setting of soft tissue attenuation, may be an artifact. Gated images and LVEF were unable to be calculated. BILATERAL STANDING KNEE FILMS ___: On the right, the medial compartment is severely narrowed with subchondral sclerosis. Moderate-sized tricompartmental osteophytes are present. Findings are very similar on the left. The medial compartment is moderate to severely narrowed, although to a somewhat lesser degree than on the contralateral side. Small-to-moderate medial and lateral osteophytes are present as well as moderate patellofemoral osteophytes. Moderate varus angulation is noted bilaterally. There is a symmetric pattern of irregular ossification along each medial femoral condyle which may relate to prior medial collateral ligament pathology. Projecting partly over the lateral side of the right distal femoral shaft is a calcification of uncertain location that may reside in overlying soft tissues. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Sertraline 50 mg PO DAILY 5. Simvastatin 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Sertraline 50 mg PO DAILY 5. Simvastatin 10 mg PO DAILY 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Lidocaine 5% Patch 1 PTCH TD DAILY 8. GlipiZIDE 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Atypical chest pain Morbid obesity (BMI=60) Osteoarthritis of bilateral knees Left knee pain due to pes aneserine bursitis 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: Chest pain. COMPARISON: ___ chest radiograph. FINDINGS: AP and lateral views of the chest. Moderate-to-severe cardiomegaly is unchanged. The aorta is tortuous. Slight increase in interstitial markings compared to prior study which likely indicates mild interstitial pulmonary edema. No pleural effusions. No pneumothorax. No focal consolidation. IMPRESSION: Slight increase in interstitial markings compared to prior study likely indicates mild interstitial pulmonary edema. Moderate-to-severe cardiomegaly is unchanged. Radiology Report INDICATION: Left lower extremity swelling, evaluate for DVT. COMPARISON: ___. FINDINGS: There is normal phasicity in the common femoral veins bilaterally. There is normal compression of the common femoral and proximal superficial femoral veins. In the mid and distal superficial femoral veins and popliteal vein, only flow could be visualized which diminished with compression. Calf veins were not well visualized. IMPRESSION: Limited study due to patient's body habitus. Calf veins not visualized. Limited evaluation of the distal superficial femoral and popliteal veins; however within these limitations, no DVT was identified. Radiology Report BILATERAL KNEE RADIOGRAPHS HISTORY: Acute on chronic left medial knee pain. Suspicion for pes anserine bursitis. COMPARISONS: None. TECHNIQUE: Standing AP radiographs of each knee. FINDINGS: On the right, the medial compartment is severely narrowed with subchondral sclerosis. Moderate-sized tricompartmental osteophytes are present. Findings are very similar on the left. The medial compartment is moderate to severely narrowed, although to a somewhat lesser degree than on the contralateral side. Small-to-moderate medial and lateral osteophytes are present as well as moderate patellofemoral osteophytes. Moderate varus angulation is noted bilaterally. There is a symmetric pattern of irregular ossification along each medial femoral condyle which may relate to prior medial collateral ligament pathology. Projecting partly over the lateral side of the right distal femoral shaft is a calcification of uncertain location that may reside in overlying soft tissues. IMPRESSION: Substantial bilateral osteoarthritis. Radiology Report INDICATION: Morbid obesity with new lateral knee pain on transfer from one hospital bed to another. Question displaced patella. COMPARISON: ___. LEFT KNEE: There are severe tricompartmental degenerative changes of the left knee. Evaluation for fracture is limited by overlying soft tissues. However, no definite fracture is appreciated. No dedicated sunrise view was obtained. The patella, on the frontal views, appears normally aligned. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with CHEST PAIN NOS temperature: 97.3 heartrate: 87.0 resprate: 14.0 o2sat: 100.0 sbp: 129.0 dbp: 64.0 level of pain: 9 level of acuity: 3.0

Dear Ms. ___, It was pleasure taking care of your at ___. You were admitted with chest pain. You underwent nuclear heart studies which did not show any evidence of heart attack. You also had left knee pain, which was due to osteoarthritis and pes anserine bursitis.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Levaquin Attending: ___. Chief Complaint: Cough and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman w/ PMHx of ___ disease, bilateral blindness, HTN, bronchitis who was admitted from ___ ED for unresolved cough and shortness of breath after 3 days of outpatient antibiotic treatment. Of note, patient is currently living with her son, her primary care giver. At baseline, patient was not very active physically due to her poor vision and only ambulates minimally with walker. In the past few days, patient has developed increased cough, productive of scant white sputum and SOB. She was seen at OSH, where she was diagnosed with "pneumonia" and was started with doxycycline PO treatment. She took doxycycline for 3 days but her symptoms did not resolve. She has felt weaker since the start of her current episode. In the ED, patient was noted to be afebrile and stable. She had an CXR which was unremarkable. Labs did not show any leukocytosis. Patient was given one dose of IV ceftriaxone and clindamycin before she was admitted to medicine service for observation. Review of Systems: ROS negative except as above. Past Medical History: ___ Disease HTN Bronchitis Bilateral blindness Social History: ___ Family History: not significant Physical Exam: Admission: GEN: NAD, AAOx3. HEENT: NC, AT, bilateral blindness at baseline, MMM. Neck: No JVD, no carotid bruit, no thyromegaly. CV: RRR, nl S1/S2, no m/r/g. Lungs: coarse breath sounds bilaterally, scattered wheezes. Abdomen: NT, ND, BS active. Ext: No ___, pulses 2+. Discharge: VS: AVSS Gen: NAD, resting comfortably in bed HEENT: bilateral blindness, MMM CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e Neuro: CN II-XII intact, ___ strength throughout Psych: normal affect Skin: warm, dry. Upper chest and neck rash resolved. Pertinent Results: ___ 07:40PM WBC-9.8 RBC-4.12 HGB-12.3 HCT-37.2 MCV-90 MCH-29.9 MCHC-33.1 RDW-13.2 RDWSD-43.2 ___ 07:40PM GLUCOSE-124* UREA N-15 CREAT-0.7 SODIUM-136 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17 ___ 06:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG CXR ___: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Carbidopa-Levodopa (___) 1.5 TAB PO TID 3. Metoprolol Succinate XL 12.5 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Lodosyn (carbidopa) 25 mg oral DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Rasagiline 0.5 mg PO DAILY 9. melatonin 3 mg oral QHS Discharge Medications: 1. Atorvastatin 20 mg PO QPM 2. Carbidopa-Levodopa (___) 1.5 TAB PO TID 3. Lodosyn (carbidopa) 25 mg oral DAILY 4. melatonin 3 mg oral QHS 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Rasagiline 0.5 mg PO DAILY 10. Ipratropium Bromide Neb 1 NEB IH Q6H RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb INH every 6 hours for 2 weeks and then as needed Disp #*90 Vial Refills:*0 11. Fluticasone Propionate 110mcg 2 PUFF IH BID RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puff INH twice daily Disp #*3 Inhaler Refills:*0 12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing, dyspnea, cough RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inh every 4 hours as needed Disp #*90 Vial Refills:*0 13. Spacer Diagnosis: Bronchitis, reactive airways disease Please use with fluticasone inhaler Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Bronchitis vs airway reactivity after infection ___ disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with reported PNA recently at OSH, ongoing sx, N/V // Eval for PNA TECHNIQUE: AP and lateral views of the chest. COMPARISON: ___. FINDINGS: The lungs are clear without focal consolidation, effusion, or edema. Cardiomediastinal silhouette is within normal limits. Markedly tortuous thoracic aorta is noted with some calcifications at the arch. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL LEFT INDICATION: ___ year old woman with left foot pain after mild trauma. // evaluate for fracture TECHNIQUE: Foot three views COMPARISON: None IMPRESSION: There is marked osteopenia probably from disuse. A fracture could be missed in bones of this lucency. There are some hammertoe deformities of the second third and fourth toes. There is some soft tissue ossification that seen lateral to the first metatarsal head and at the second metatarsal phalangeal joint These could be due to old trauma. There is also deformity of the ankle mortise that is likely due to old trauma or degenerative changes. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with bilateral knee pain, hip pain, headstrike and frontal ecchymosis status post fall on heparin TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 13.9 s, 21.2 cm; CTDIvol = 29.0 mGy (Body) DLP = 577.3 mGy-cm. Total DLP (Body) = 587 mGy-cm. COMPARISON: CT chest dated ___ FINDINGS: The bones are osteopenic. No acute fracture is present. There is unchanged anterior compression deformity of the T3 vertebral body since ___. There is no prevertebral soft tissue abnormality. Severe cervical spondylosis is present with vertebral body height loss at C4, C5, and C6 and multilevel anterior and posterior osteophyte formation with intervertebral disc space height loss, worse between C3-C4, C4-C5, C5-C6, and C6-C7. There is mild anterolisthesis of C2 on C3 and minimal anterolisthesis of C7 on T1, likely degenerative in nature. Mild to moderate central canal narrowing is noted, most pronounced at C3-4, C4-5, and C5-6 due to posterior osteophytes. Mild bilateral neural foraminal narrowing is also noted at multiple levels without critical stenosis. Evaluation of the lung apices is limited due to motion degradation but appears grossly unremarkable. Multiple nodules are seen in the thyroid, the largest being a hypodense nodule in the right lobe of the thyroid measures which measures 12 mm. IMPRESSION: 1. No acute fracture identified. 2. Severe cervical spondylosis with mild anterolisthesis of C2 on C3 and C7 on T1. Mild to moderate central canal narrowing without high-grade stenosis. 3. Anterior compression deformity of the T3 vertebral body is unchanged. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: History: ___ with bilateral knee pain, hip pain, headstrike and frontal ecchymosis s/p fall on heparin // eval for fracture/injury TECHNIQUE: Single AP view of the chest. COMPARISON: ___. FINDINGS: The lungs are clear without focal consolidation, effusion, or edema. The cardiomediastinal silhouette is unremarkable. The thoracic aorta is tortuous. Bones are diffusely demineralized, and note is made of scoliosis, as well as decreased height of a lower thoracic vertebral bodies, not fully evaluated on this portable chest exam. IMPRESSION: No acute intrathoracic abnormality. Consider dedicated spine imaging if there is clinical concern for thoracic spinal fracture. Radiology Report EXAMINATION: PELVIS (AP ONLY) INDICATION: ___ with bilateral knee pain, hip pain post headstrike and frontal ecchymosis s/p fall on heparin TECHNIQUE: Single AP view of the pelvis COMPARISON: ___, CT pelvis dated ___ FINDINGS: The bones are markedly osteopenic. A poorly assessed apparent fracture of the greater trochanter of the proximal left femur and overlying soft tissue calcified apparent granuloma are little changed from images ___. There is bilateral chondrocalcinosis and joint space narrowing in the hips with minimal osteophytic changes. Similar degenerative changes is seen in the pubic symphysis. No acute fracture or bone destruction. Bowel gas is within normal limits with considerable colonic stool IMPRESSION: No fracture identified. Marked generalized demineralization Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILATERAL INDICATION: History: ___ with bilateral knee pain, hip pain, headstrike and frontal ecchymosis s/p fall on heparin // eval for fracture/injury eval for fracture/injury TECHNIQUE: Three views right knee COMPARISON: None. FINDINGS: The bones are severely demineralized. No fracture or joint effusion is present. Prominent chondrocalcinosis. No osteophytic changes or joint effusion. IMPRESSION: No fracture. Prominent osteoporosis Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT INDICATION: History: ___ with bilateral knee pain, hip pain, headstrike and frontal ecchymosis s/p fall on heparin TECHNIQUE: Three views left ankle COMPARISON: None. FINDINGS: The bones are severely osteopenic. No fracture is identified with slight soft tissue swelling overlying medial malleolus. There is prominent chondrocalcinosis. The ankle mortise is congruent with the talus. Incidental plantar calcaneal spur. IMPRESSION: No fracture. Marked generalized demineralization. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with bilateral knee pain, hip pain, headstrike and frontal ecchymosis status post fall on heparin TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Total DLP (Head) = 927 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of large territorial infarction, hemorrhage, edema, or mass effect. There is significant age-related cortical volume loss with resultant dilatation of the ventricles and sulci. Periventricular and subcortical hypodensities are noted which in a patient of this age are most suggestive of chronic small vessel ischemic disease. Mild atherosclerotic calcifications are seen involving the cavernous carotid arteries bilaterally. No acute osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: N/V Diagnosed with Pneumonia, unspecified organism temperature: 97.4 heartrate: 72.0 resprate: 16.0 o2sat: 98.0 sbp: 129.0 dbp: 63.0 level of pain: 4 level of acuity: 3.0

You were admitted for occasional wheezing and cough. There was concern for pneumonia but your chest X-ray did not show pneumonia and your symptoms quickly improved with nebulizers. Antibiotics were stopped and you tolerated this just fine. Overall, your presentation is most consistent with a post infectious bronchitis or asthma like syndrome. You were evaluated by speech and language pathology who felt you would benefit from a ground diet with thin liquids to minimize your risks of accidentally inhaling some of your food when you eat (which can predispose to pneumonia and coughing fits). You were deconditioned and had difficulty moving around and physical therapy recommended going to a rehab facility. You did not qualify for acute level rehab and so you and your family elected to go home with maximal services in order to work on getting stronger at home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: hydralazine / metal / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with history of end stage renal disease status post deceased after cardiac death renal transplant in ___, coronary artery disease, hypertension, and insulin-dependent diabetes ___ who presents with sudden-onset left flank pain radiating to the left upper quadrant. She reports pain radiates to the left lower quadrant and back and is associated with nausea, ___ episodes of nonbloody emesis, and nonbloody diarrhea; no history of kidney stones, has atrophic kidneys; denies burning with urination, positive urinary frequency; denies vaginal bleeding/discharge; denies fevers; nothing similar in the past; no sick contacts. In the ED, initial vital signs were: 98.4 88 166/111 18 95% RA. Admission labs were unremarkable. Past Medical History: Insulin-dependent diabetes ___ Peptic ulcer disease End-stage renal disease status post donation after cardiac death renal transplant in ___ Chronic anemia Left internal carotid artery stenosis status post stenting Coronary artery disease status post BMS to distal RCA in ___ Hypertension Dyslipidemia Peripheral vascular disease First-degree AV block COPD Status post cholecystectomy Status post cesarean section Status post surgery for retinopathy and cataracts History of MSSA bacteremia from an infected AV graft status post revision History of angioplasty thrombectomy and subseqent stenting of of AV graft Social History: ___ Family History: Her father died at ___ years old of lung cancer. Her mother died at ___ years old of possible complications of diabetes ___. She has 3 brothers and 3 sisters. 1 sister has hypertension. All 3 sisters have diabetes ___. She has 1 daughter who is healthy. Physical Exam: On admission: VS: 98.6 190/63 87 18 95RA General: screaming in pain CV: RRR,S1S2, no m/r/g Lungs: CTAb, no w/r/r Abdomen: tender LUQ and LLQ w/o rebound or guarding BACK: no CVA tenderness GU: no foley Ext: WWP, no c/e/e Neuro: AAO3, awake, alert, moving all extremities At discharge: VS: 97.7, 130/51, 66, 18, 93% RA General- Alert, oriented, comfortable HEENT- Sclerae anicteric, MM slightly dry Neck- supple, JVP not elevated Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- multiple well healed scars in midline and RLQ. Has + BS, abdomen appears slightly distended, mildly tender diffusely in left upper and lower quadrant without rebound or guarding. BACK: + mild left sided parapsinal tenderness thoracic and lumbar spine. No CVA tenderness elicited. GU- no foley Ext- warm, 1+ pulses lower extremities with hyperpigmented changes, no active ulceration Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: On admission: ___ 04:45PM WBC-8.2# RBC-4.93 HGB-13.3 HCT-37.9 MCV-77* MCH-26.9* MCHC-35.1* RDW-15.3 ___ 04:45PM NEUTS-82.1* LYMPHS-11.5* MONOS-5.4 EOS-0.8 BASOS-0.2 ___ 04:45PM PLT COUNT-183 ___ 04:45PM ALBUMIN-4.6 ___ 04:45PM LIPASE-29 ___ 04:45PM ALT(SGPT)-21 AST(SGOT)-19 ALK PHOS-108* AMYLASE-46 TOT BILI-0.4 ___ 04:45PM GLUCOSE-372* UREA N-16 CREAT-1.3* SODIUM-140 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-18 ___ 05:17PM LACTATE-1.7 ___ 07:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 07:10PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 07:10PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:19PM tacroFK-4.1* At discharge: ___ 10:37AM BLOOD WBC-4.4 RBC-4.48 Hgb-11.8* Hct-35.4* MCV-79* MCH-26.4* MCHC-33.5 RDW-14.9 Plt ___ ___ 10:37AM BLOOD Glucose-264* UreaN-32* Creat-1.6* Na-133 K-4.3 Cl-97 HCO3-23 AnGap-17 ___ 10:37AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.3 ___ 10:37AM BLOOD tacroFK-12.1 In the interim: ___ 06:50AM BLOOD tacroFK-2.8* ___ 05:32AM BLOOD tacroFK-7.8 ___ 08:10AM BLOOD tacroFK-9.7 Microbiology: Blood culture (___): No growth. Imaging: Renal transplant ultrasound (___): 1. Unchanged complex cystic lesion in the upper pole of the transplant kidney, as previously characterized on MRI. 2. Minimal fullness of the upper pole of the transplant kidney without frank hydronephrosis. 3. Unchanged mildly elevated resistive indices. Patent vasculature. CT abdomen/pelvis without contrast (___): 1. No retroperitoneal hematoma. 2. Transplanted kidney in right lower quadrant with 2.6 cm hypodensity in the upper pole, better characterized on MR dated ___. Interval decrease in fat stranding surrounding transplanted kidney. 3. Distended bladder. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheeze 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO HS 5. Carvedilol 50 mg PO BID 6. CloniDINE 0.2 mg PO BID 7. Clopidogrel 75 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Famotidine 20 mg PO DAILY 10. Furosemide 40 mg PO DAILY 11. Myfortic (mycophenolate sodium) 360 mg Oral BID 12. Polyethylene Glycol 17 g PO DAILY 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 14. Tacrolimus 0.5 mg PO Q12H 15. Bisacodyl 5 mg PO DAILY:PRN constipation 16. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) 17. Acetaminophen 325-650 mg PO Q6H:PRN pain 18. Humalog ___ 30 Units Breakfast Humalog ___ 30 Units Dinner 19. Tacrolimus 2 mg PO Q12H Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheeze 3. Amlodipine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO HS 6. Bisacodyl 5 mg PO DAILY:PRN constipation 7. Carvedilol 50 mg PO BID 8. Clopidogrel 75 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Famotidine 20 mg PO DAILY 11. Humalog ___ 30 Units Breakfast Humalog ___ 30 Units Dinner 12. Myfortic (mycophenolate sodium) 360 mg Oral BID 13. Polyethylene Glycol 17 g PO DAILY 14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 15. Tacrolimus 0.5 mg PO Q12H 16. Tacrolimus 2 mg PO Q12H 17. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) 18. TraMADOL (Ultram) 50 mg PO BID:PRN breakthrough pain RX *tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 19. CloniDINE 0.2 mg PO BID 20. Furosemide 40 mg PO DAILY 21. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN pain Please do not take within 2 hours of mycophenolate. RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20 mg/5 mL ___ mL by mouth four times a day Disp #*1 Bottle Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Abdominal/back pain of uncertain etiology Secondary: End stage renal disease status post renal transplant Diabetes ___ Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: History: ___ with renal transplant presenting with 1 day history of left flank pain with radiation to left lower quadrant with nausea, vomiting, diarrhea TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: ___ renal transplant ultrasound and MR pelvis ___ FINDINGS: The right lower quadrant 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. Minimal fullness of the upper pole of the right kidney is seen on postvoid images, but there is no frank hydronephrosis and no perinephric fluid collection. Re- demonstrated within the upper pole of the right kidney is a complex cystic mass with internal echoes and internal vascularity measuring 2.9 x 2.5 x 2.6 cm, not substantially changed compared with the previous studies. No renal calculi or new renal mass is present. The resistive index of intrarenal arteries ranges from 0.82 to to 0.88, similar compared to the previous exam. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 108 cm/s. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Unchanged complex cystic lesion in the upper pole of the transplant kidney, as previously characterized on MRI. 2. Minimal fullness of the upper pole of the transplant kidney without frank hydronephrosis. 3. Unchanged mildly elevated resistive indices. Patent vasculature. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ with 1 day of left flank pain, nausea, vomiting, diarrhea. Assess for retroperitoneal bleed. TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis without the administration of intravenous contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. DLP: 854.19 mGy-cm COMPARISON: MRI abdomen ___. CT abdomen/ pelvis ___. FINDINGS: The examination is limited secondary to the lack of intravenous contrast. CHEST: Limited assessment of the lung bases are clear. No pleural effusion or large pneumothorax. The visualized heart is normal in size without pericardial effusion. Coronary artery calcifications are noted. ABDOMEN: The liver is homogeneous and grossly unremarkable. The gallbladder is surgically absent. The spleen is normal. The pancreas is homogeneous without peripancreatic fat stranding or focal fluid collection. The adrenal glands are again noted to be thickened with calcification in the right adrenal gland, similar to previous examination. The native kidneys are slightly atrophic with small hypodensity in the upper pole of the right kidney which is too small to characterize. No additional focal renal lesions. No hydronephrosis or hydroureter identified. No renal or proximal ureter calculi. A small hiatal hernia is present. The stomach is grossly unremarkable in appearance. The small bowel is normal in caliber without wall thickening. The large bowel is normal in caliber without wall thickening, fat stranding, or focal mass lesion. The appendix is normal without evidence of acute appendicitis. The abdominal aorta is normal in caliber without aneurysmal dilatation. Large amount of atherosclerotic calcification noted. The iliac arteries are normal in course and caliber. No retroperitoneal hematoma. No retroperitoneal or mesenteric lymph node enlargement by CT size criteria. No free abdominal fluid, abdominal wall hernia, or pneumoperitoneum. PELVIS: The bladder is largely distended. No pelvic side-wall or inguinal lymph node enlargement by CT size criteria. No free pelvic fluid seen. The transplanted kidney is again seen within the right lower quadrant. A 2.6 x 2.0 cm (02:49) hypodensity is seen within the upper pole of the right transplanted kidney is better characterized on ___ MR. ___ fat stranding seen around the transplanted kidney is decreased since previous examination. Uterus is notable for several calcified fibroids. OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. No retroperitoneal hematoma. 2. Transplanted kidney in right lower quadrant with 2.6 cm hypodensity in the upper pole, better characterized on MR dated ___. Interval decrease in fat stranding surrounding transplanted kidney. 3. Distended bladder. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: L Flank pain Diagnosed with ABDOMINAL PAIN LLQ temperature: 98.4 heartrate: 88.0 resprate: 18.0 o2sat: 95.0 sbp: 166.0 dbp: 111.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a pleasure participating in your care at ___ ___. You were admitted after you developed left-sided back and abdominal pain. Imaging of your belly did not show signs of infection or other clear explanation. You were given medications to help with the pain and the nausea. Ultimately, your pain improved and you were able to tolerate meals. You may continue to take the pain medications you received in the hospital as needed at home as your pain continues to improve. Please continue your home medications, including furosemide (Lasix), when you return home. If you find that you are eating and drinking poorly again, please contact the kidney clinic (___) to discuss whether your furosemide dose should be adjusted. Please have your blood drawn on ___. You can come to the lab and have your routine transplant labs drawn. It is important that you have your blood drawn on that day, especially since your tacrolimus dose may need to be adjusted based on the level seen.

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: Mr. ___ is a ___ male with history of CAD s/p CABG, Type II diabetes, hypertension, and chronic knee pain, who presents from rehab with chest pain. Patient states at rehab he had to use the bathroom and called for assistance, but nobody would come to help him. He then called ___. EMS helped him to the restroom. During this interaction he developed sudden-onset moderate chest pain, which he describes as a left-sided heaviness, that then radiated to the right side. This is in the setting of coronary artery disease and is typical for his episodes of angina. He was therefore brought to the ED. Denies any associated shortness of breath, cough, fever, diaphoresis, nausea, vomiting. Denies abdominal pain. Denies dizziness or lightheadedness. Patient states that his typical chest pain will start on the left side. He will often try SL nitro at this point, which most often relieves the pain. However, at times it does not and radiates to the right side and will become squeezing. He states that this happened a lot in ___ and ___, but has been doing better. He feels that it is triggered by stress. Regarding his UTI, he notes that had he has had two urinary tract infections this past month. The one he is being treated for now he did not have any symptoms, but it was found on testing. Regarding his knee pain, he notes that he both knees hurt, especially the left, which will buckle sometimes, causing him to fall. This was worse after knee replacements ___ years ago. Uses a wheelchair. He has discussed an operation to help repair his knees, but states that his cardiologist doesn't feel that a surgery would be safe until can go a year without a cardiac event. He states that being in rehab has been very difficult. He notes that he is there with many people who are much older than him, and this has taken a mental toll. He has seen many things that have made him uncomfortable and feel that the care he gets is often very poor. He also struggles with the idea of being stuck in a wheelchair at a rehab at such a young age. He also reports that he used to see Dr ___, who is now at ___. Would like to see her again, previously limited by insurance. On review of records, patient has had around five admissions since ___ with chest pain, and several additional ED visits. He underwent a PCI to OM1 with DES in ___. He underwent angiography again on ___ which showed stable nonobstructive CAD with evidence of diffuse microvascular disease. He most recently underwent a nuclear stress on ___ which was normal. In the ED: Initial vital signs were notable for: T 97, HR 95, BP 133/86, RR 20, 97% RA Exam notable for: well-appearing on exam. He has tenderness to palpation of the anterior chest wall. He is breathing comfortably on room air and lungs are clear to auscultation. Radial pulses intact. Abdomen soft and nontender. Labs were notable for: - CBC: WBC 4.8, hgb 12.9, plt 354 - Lytes: 139 / 103 / 11 AGap=12 -------------- 242 4.4 \ 24 \ 0.8 - trop <0.01 x2 Studies performed include: CXR with no acute intrathoracic process. Patient was given: ___ 06:40 IV Ketorolac 15 mg ___ 08:02 PO/NG amLODIPine 5 mg ___ 08:02 PO/NG Clopidogrel 75 mg ___ 08:02 PO/NG Gabapentin 300 mg ___ 08:02 PO Isosorbide Mononitrate (Extended Release) 30 mg ___ 08:02 PO Metoprolol Succinate XL 25 mg ___ 08:02 PO Pantoprazole 40 mg ___ 08:03 SC Insulin 2 Units ___ 08:04 PO/NG Aspirin 81 mg ___ 08:04 PO TraMADol 75 mg ___ 15:19 PO/NG Gabapentin 300 mg ___ 17:08 SC Insulin 6 Units ___ 18:10 PO TraMADol 75 mg Plan was initially for patient to return to rehab. However, he declined to go with plan to go to Motel. After multiple discussions with ___, CM, SW, plan to admit patient to medicine for further physical therapy and discuss returning to rehab. Patient amenable with this plan. Vitals on transfer: T 98.3, HR 81, BP 134/70, RR 18, 95% RA Upon arrival to the floor, patient recounts history as above. He has no chest pain now. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes (+) - Hypertension (+) - Dyslipidemia (+) 2. CARDIAC HISTORY - CABG: ___ - PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal anomalous RCA), ___ - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY - Osteoarthritis - Constipation Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION EXAM: ==================== VITALS: T 98.2, HR 79, BP 120/70, RR 18, 99% 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, 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. Lower extremities with knee pain to flexion and extension SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM: ==================== GENERAL: Alert and in no apparent distress, sitting up in CHAIR EYES: Anicteric, pupils equally round CV: RRR no m/r/g LUNGS: CTAB ABD: obese, normal bowel sounds. NEURO: Alert, oriented, face symmetric, speech fluent PSYCH: Calm Pertinent Results: ADMISSION LABS: ___ 12:14AM BLOOD WBC-4.8 RBC-4.50* Hgb-12.9* Hct-40.8 MCV-91 MCH-28.7 MCHC-31.6* RDW-12.4 RDWSD-41.1 Plt ___ ___ 12:14AM BLOOD Neuts-53.8 ___ Monos-7.6 Eos-3.1 Baso-1.0 Im ___ AbsNeut-2.60 AbsLymp-1.66 AbsMono-0.37 AbsEos-0.15 AbsBaso-0.05 ___ 12:14AM BLOOD Glucose-242* UreaN-11 Creat-0.8 Na-139 K-4.4 Cl-103 HCO3-24 AnGap-12 ___ 12:14AM BLOOD cTropnT-<0.01 ___ 03:24AM BLOOD cTropnT-<0.01 ___ 03:24AM BLOOD cTropnT-<0.01 ====================================== EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with chest pain// eval pna COMPARISON: Chest radiograph ___ FINDINGS: AP and lateral views of the chest. Mid sternotomy wires are again seen and appear similarly positioned. Low lung volumes bilaterally, particularly on the right where there is unstable right hemidiaphragm elevation. No areas of focal consolidation, pulmonary edema, pneumothorax or pericardial effusion. Cardiac size is normal. IMPRESSION: No acute intrathoracic process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lidocaine 5% Patch 1 PTCH TD QAM 2. LORazepam 0.5 mg PO BID:PRN anxiety 3. Clopidogrel 75 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. amLODIPine 5 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. melatonin 3 mg oral QHS 10. Tamsulosin 0.4 mg PO QHS 11. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third Line 14. Gabapentin 300 mg PO TID 15. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 16. GlipiZIDE 10 mg PO BID 17. TraMADol 75 mg PO Q6H:PRN Pain - Moderate 18. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second Line 19. Cefpodoxime Proxetil 100 mg PO Q12H 20. MetFORMIN (Glucophage) 1000 mg PO BID 21. Acetaminophen 975 mg PO Q6H:PRN Pain - Mild/Fever 22. Aspirin 81 mg PO DAILY 23. Multivitamins 1 TAB PO DAILY 24. Senna 17.2 mg PO QHS 25. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 26. Mylanta 30 ml oral Q4H:PRN dyspepsia Discharge Medications: 1. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever RX *acetaminophen [8HR Muscle Aches-Pain] 650 mg 1 tablet(s) by mouth q8 Disp #*30 Tablet Refills:*0 3. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *blood sugar diagnostic [Blood Glucose Test] use for blood sugar monioring 4x dialy Disp #*200 Strip Refills:*0 RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) ___ Units before BED; Disp #*3 Syringe Refills:*0 RX *blood-glucose meter [Blood Glucose Monitoring] blood sugar monitoring 4X day Disp #*1 Kit Refills:*0 RX *lancets [BD Microtainer Lancet] 30 gauge use for glucose monitoring Disp #*200 Each Refills:*0 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 81 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*0 6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 7. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID RX *exenatide [Byetta] 10 mcg/0.04 mL per dose (250 mcg/mL) 2.4 mL 10 mcg twice a day Disp #*1 Syringe Refills:*0 8. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 10. GlipiZIDE 10 mg PO BID diabetes RX *glipizide 10 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. LORazepam 0.5 mg PO BID:PRN anxiety RX *lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 14. melatonin 3 mg oral QHS 15. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin [Fortamet] 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 16. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate [Kapspargo Sprinkle] 50 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 17. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second Line 18. Multivitamins 1 TAB PO DAILY 19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp #*15 Tablet Refills:*0 20. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*30 Tablet Refills:*0 21. Tamsulosin 0.4 mg PO QHS RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 22. TraMADol 75 mg PO Q6H:PRN Pain - Moderate RX *tramadol [Ultram] 50 mg 1.5 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 23.bedside Commode Drop arm, no diagnosis: ambulatory dysfunction physical function: good length of need: 13 months 24.Standard Manual Wheelchair Standard Manual Wheelchair, Seat and back cushion, Elevating leg rests, Anti tip and brake extensions Dx: Ambulatory dysfunction Px: good ___ 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Diabetes, type II Coronary artery disease Anxiety Knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with chest pain// eval pna COMPARISON: Chest radiograph ___ FINDINGS: AP and lateral views of the chest. Mid sternotomy wires are again seen and appear similarly positioned. Low lung volumes bilaterally, particularly on the right where there is unstable right hemidiaphragm elevation. No areas of focal consolidation, pulmonary edema, pneumothorax or pericardial effusion. Cardiac size is normal. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: CTA CHEST INDICATION: ___ year old man with pain with deep breath, immobility and chest pain// Pe? TECHNIQUE: Multidetector helical scanning of the chest was performed with intravenous contrast and reconstructed as axial, coronal, parasagittal, and,MIPs axial images. DOSAGE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.9 mGy (Body) DLP = 3.0 mGy-cm. 2) Stationary Acquisition 5.5 s, 0.2 cm; CTDIvol = 150.2 mGy (Body) DLP = 30.0 mGy-cm. 3) Spiral Acquisition 5.6 s, 36.3 cm; CTDIvol = 14.8 mGy (Body) DLP = 525.8 mGy-cm. Total DLP (Body) = 559 mGy-cm. COMPARISON: CT ___ and multiple priors dating back to ___. FINDINGS: FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: Thyroid is grossly unremarkable. No supraclavicular or axillary lymphadenopathy. UPPER ABDOMEN: Small hiatal hernia noted. 3.5 cm hypodensity arising from the upper pole of the right kidney, compatible with a simple cyst. Limited assessment the abdomen is otherwise grossly unremarkable. MEDIASTINUM: No mediastinal lymphadenopathy. HILA: No hilar lymphadenopathy. HEART and PERICARDIUM: Pericardial effusion. Coronary calcification. PLEURA: Pleural effusion. LUNG: 1. PARENCHYMA: No suspicious pulmonary nodules. There is mild atelectasis at the right lung base. 2. AIRWAYS: There is a small amount of debris in the dependent portion of the mid trachea (series 6, image 65). Airways are otherwise patent the subsegmental level. 3. VESSELS: Aorta and main pulmonary artery are normal in size. No pulmonary embolus. CHEST CAGE: Patient is status post median sternotomy. Bridging anterior vertebral body osteophytes are noted throughout midthoracic spine. An 11 mm lucent lesion within posterolateral aspect of right seventh rib (series 6, image 165), is unchanged from ___ and of doubtful clinical significance. IMPRESSION: No evidence of pulmonary embolus. No acute intrathoracic abnormality. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Other chest pain temperature: 97.0 heartrate: 95.0 resprate: 20.0 o2sat: 97.0 sbp: 133.0 dbp: 86.0 level of pain: 6 level of acuity: 3.0

Mr. ___, You were admitted to the hospital for chest discomfort and anxiety while at rehab. We made adjustments in your blood pressure regimen to help in case the chest pain was due to heart disease. We also adjusted your insulin regimen since you had elevated blood sugars. You should continue your home regimen at discharge. Your urine studies revealed elevation in WBC concerning for a urinary tract infection. You are prescribed 10 days of Ciprofloxacin antibiotics.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: LLE ___ and lumbar back ___ Major Surgical or Invasive Procedure: Ultrasound guided aspiration of ___ fluid collection ___ History of Present Illness: Mr. ___ is a ___ year old male with a past medical history of failed back surgery syndrome s/p nevro SCS implantation, who was recently discharged on ___ s/p removal of spinal cord stimulator and T8-T12 laminectomy. Patient initially presented in the clinic with Dr. ___ his desire to have his SCS explanted and underwent removal of spinal cord stimulator and pulse generator/leads on ___. At that time it was noted that the patient had a large amount of scar tissue and hematoma, therefore it was decided to have the patient return to the OR on ___ for T8-T10 laminectomy with removal of scar/hematoma from previous ___ lead site. Prior to that patient had been having increasing difficulty with ___, which prompted his decision to have his SCS removed. Patient was last seen in ___ on ___, at that time a refill of his prescription of Dilaudid was provided. Patient continued to have ongoing ___ rated ___ to his lower lumbar spine as well as bilateral lower extremities. He also was endorsing decreased sensation to BLE as well as lumbar spine that had worsened over the past month before initial presentation. Patient noted that he could hardly feel his legs, which led to his presentation for SCS removal. On most recent presentation ___, patient stated that he had been doing well since his discharge on ___, but starting the previous night his ___ started to become increasingly worse, specifically in the lower back and left leg. He said that prior to this, he had no sensation in either lower extremity. He notes that since last night, he feels like all the sensation is coming back extra strong, "like the nerve is waking up in his left leg". He states it is very severe and can barely touch it without ___ all over his left lower extremity. The right lower extremity is still numb at baseline levels. Patient states his lower back is also in ___ which seems to radiate slightly up to the mid back as well. He also notes that since this onset of ___, he has had increasing difficulty in breathing and feels SOB. Patient denies numbness/tingling in his groin or buttocks, and denies loss of bowel of bladder function. He denies fevers, or chills. Past Medical History: - Chronic ___ of back and legs - Obesity - GERD - Lumbosacral radiculopathy - Post-laminectomy syndrome s/p Nevro SCS implantation - PLACEMENT OF IPG ___ - PLACEMENT OF THORAIC SPINAL CORD STIMULATOR LEAD ___ - REMOVAL OF SPINAL CORD STIMULATOR ___ - T8-T12 laminectomy with removal of scar tissue at site of previous SCS lead position ___ Social History: ___ Family History: non-contributory Physical Exam: At discharge: General: ___ 0723 Temp: 97.7 PO BP: 150/89 HR: 57 RR: 19 O2 sat: 100% O2 delivery: Ra Fluid Balance (last updated ___ @ 625) Last 8 hours Total cumulative -650ml IN: Total 0ml OUT: Total 650ml, Urine Amt 650ml Last 24 hours Total cumulative 190ml IN: Total 840ml, PO Amt 840ml OUT: Total 650ml, Urine Amt 650ml Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast Sensation intact to light touch on LLE from the mid thigh distally (improving since yesterday per patient). Patient reports of proximal thigh numbness for more than ___ since remote lumbar surgery. sensation to light touch remains absent in RLE. Pt. reports of painful paresthesias of the LLE from the mid thigh distally, "as though his leg is waking up" have improved since day prior. Wound: Right low back for removal IPG, healing well with some scabbing: [x]Clean, dry, intact [x]Suture removed at bedside ___ Midline T-spine incision, healing well with some scabbing: [x]Clean, dry, intact [x]Staples removed at bedside ___ Pertinent Results: ___ 12:35PM BLOOD WBC-10.1* RBC-5.29 Hgb-16.3 Hct-48.1 MCV-91 MCH-30.8 MCHC-33.9 RDW-13.5 RDWSD-44.9 Plt ___ ___ 06:41AM BLOOD WBC-8.4 RBC-4.86 Hgb-15.1 Hct-45.6 MCV-94 MCH-31.1 MCHC-33.1 RDW-13.6 RDWSD-46.7* Plt ___ ___ 08:49AM BLOOD WBC-6.7 RBC-4.90 Hgb-15.2 Hct-47.4 MCV-97 MCH-31.0 MCHC-32.1 RDW-13.6 RDWSD-48.7* Plt ___ ___ 06:41AM BLOOD ___ PTT-31.0 ___ ___ 06:41AM BLOOD Plt ___ ___ 08:49AM BLOOD ___ PTT-30.0 ___ ___ 08:49AM BLOOD Plt ___ ___ 12:35PM BLOOD Glucose-99 UreaN-15 Creat-1.1 Na-138 K-4.9 Cl-100 HCO3-22 AnGap-16 ___ 06:41AM BLOOD Glucose-86 UreaN-18 Creat-1.0 Na-143 K-5.4* Cl-104 HCO3-25 AnGap-14 ___ 08:49AM BLOOD Glucose-93 UreaN-16 Creat-1.0 Na-139 K-5.3* Cl-103 HCO3-25 AnGap-11 ___ 12:35PM BLOOD Calcium-10.1 Phos-3.7 Mg-2.2 ___ 06:41AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2 ___ 08:49AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.2 ___ 07:23AM BLOOD WBC-5.9 RBC-4.80 Hgb-14.8 Hct-45.7 MCV-95 MCH-30.8 MCHC-32.4 RDW-13.5 RDWSD-47.5* Plt ___ ___ 07:23AM BLOOD Plt ___ ___ 07:23AM BLOOD Glucose-97 UreaN-20 Creat-1.0 Na-142 K-5.4* Cl-105 HCO3-26 AnGap-11 Final Report: MRI THORACIC AND LUMBAR SPINE ___ COMPARISON: MR thoracic spine ___, CT lumbar spine ___, MR lumbar spine ___ and ___. FINDINGS: THORACIC: The patient is status post interval removal of a spinal cord stimulator with posterior bilateral laminectomies and decompressions extending from the level of T8-T9 through T11-T12. Extensive, expected postoperative changes are seen. Additionally, there is a large T1 mildly hyperintense,, T2 hyperintense, minimally peripherally enhancing fluid collection which tracks through the posterior surgical incision, into the decompressive laminectomy site, exerts mass effect on the posterior epidural space. It measures 4 cm in anterior-posterior diameter, and 7.5 cm proximal to distal, 1.5 cm transversely. It abuts posterior epidural space at T9 through T11. This results in near complete effacement of the thecal sac from T9-T11, with severe canal stenosis and moderate cord compression. No definite abnormal cord signal seen at these levels. Similarly, and there is no evidence for abnormal intramedullary enhancement. Throughout the remainder of the visualized thoracic spinal canal, there is epidural lipomatosis which appears similar to the previous examination contributing to moderate central canal narrowing diffusely, and moderate to severe at T5, T6, T7 levels. At T8-9, a slightly right paracentral disc protrusion indents the ventral thecal sac, contacting the ventral cord and deforming it, combining with a posterior epidural fluid collection to result in mild-to-moderate canal stenosis. The thoracic vertebral body bone marrow is normal in signal characteristic. There is kyphosis centered within the mid thoracic spine that is slightly exaggerated. Compression deformities involving the T11 and T12 superior endplates appear chronic in nature. Mild anterior wedging of T7 also appears chronic in nature. Patent foramina. LUMBAR: The patient is status post previous L1-L5 bilateral laminectomies and decompression, with posterior spinal fusion at L1-L2. Extensive postoperative changes are again noted, all of which appears similar dating back to ___. This includes exaggerated lordosis seen at L1-L2 with irregularity of the superior and posterior L2 vertebral body. Intervertebral disc spacers are seen at L1-L2, L3-L4, and L4-L5. There is partial osseous fusion at L3-L4 and near complete fusion at L4-L5. T2 hyperintense, T1 hypointense, nonenhancing fluid collections are seen at multiple levels. A dominant collection is seen surrounding the right L2 pedicle screw with ventral extension and partial encasement of the thecal sac causing mild canal stenosis. This appearance is unchanged dating back to the prior examination. Similarly, smaller T2 hyperintense cystic collections seen posterior to the epidural space at L2-L3 are unchanged. ___ type 2 degenerative endplate changes are prominent at L1-L2 and L2-L3. No suspicious osseous lesion is detected. The conus terminates at L1-L2. Appearance of the thecal sac at L4, L5 level at and nerve roots within it is consistent with acne aditus, stable. T12-L1: There is no spinal canal or neural foraminal stenosis. L1-L2: There is mild canal narrowing secondary to compression from the previously described postoperative seroma which extends and partially encases the thecal sac. Otherwise, moderate bilateral neural foraminal narrowing is unchanged. L2-L3: Posterior disc bulging is noted without appreciable canal stenosis, but with moderate bilateral neural foraminal narrowing which appears modestly progressed from the previous examination. Minimal L2-L3 anterolisthesis. L3-L4 through L5-S1: There is no spinal canal or neural foraminal stenosis, aside from mild bilateral L5-S1 foraminal narrowing. There is no evidence for abnormal intramedullary, leptomeningeal, or epidural enhancement. There is extensive fatty atrophy of the bilateral paraspinal musculature. A T2 hyperintense right renal cyst is noted. Partially seen is probable left thyroid nodule measuring 2.3 cm, incompletely covered IMPRESSION: 1. Laminectomies T8-9 through T11. Fluid collection at the laminectomy bed extending to the skin surface, with complex appearance, likely postoperative with blood products within it given mildly intrinsic bright T1. Severe central canal narrowing at this level, with cord compression without definite cord signal abnormality. 2. Thoracic epidural lipomatosis, contributing to moderate to severe overall central canal narrowing. 3. L1-L5 bilateral laminectomies, L1-L2 posterior spinal fusion, with extensive postoperative changes. Overall, the lumbar spine alignment and postop appearance has minimally changed dating back to ___. This includes multiple probable postoperative seromas. 4. Background multilevel spondylosis of the lumbar spine, as above, overall mildly progressed from the previous examination. 5. Arachnoiditis in the lumbar spine, stable. Final Report -- ULTRASOUND-GUIDED ASPIRATION --___ COMPARISON: MRI of the lumbar spine from ___. PROCEDURE: Ultrasound-guided drainage of right paravertebral soft tissue collection. OPERATORS: Dr. ___, radiology trainee and Dr. ___, attending radiologist. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a prone position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, 18G ___ needle was inserted into the right paravertebral fluid collection, and approximately 40 cc of clear fluid was aspirated with a sample sent for microbiology evaluation. The needle was removed and sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: No sedation was administered for this procedure. FINDINGS: There is a loculated fluid collection within the soft tissues of the right paravertebral region measuring 4.9 x 4.0 cm. IMPRESSION: Successful US-guided drainage of the right paravertebral soft tissue collection. Samples was sent for microbiology evaluation. ___ 3:30 pm FLUID,OTHER LEFT PARA SPINAL COLLECTON POST-OP. 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 (Preliminary): pending as of ___ ANAEROBIC CULTURE (Preliminary): pending as of ___ Medications on Admission: Dilaudid 4mg, 1 tab PO TID, Aspirin 81mg daily, Acetaminophen 1000 mg PO Q8H, Bisacodyl 10 mg PO/PR DAILY:PRN constipation, Docusate Sodium 100 mg PO BID, Polyethylene Glycol 17 g PO DAILY:PRN constipation, Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Gabapentin 300 mg PO BID IN AM AND MID DAY RX *gabapentin 300 mg 1 to 2 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 2. Tizanidine 4 mg PO BID:PRN spasms RX *tizanidine 4 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Acetaminophen 1000 mg PO Q8H 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Docusate Sodium 100 mg PO BID 6. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN ___ - Severe 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: fluid collection of thoracic spine surgical bed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE INDICATION: ___ year old man with spinal cord stimulator removal and T8-T12 laminectomy on ___ TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: MR thoracic spine ___, CT lumbar spine ___, MR lumbar spine ___ and ___. FINDINGS: THORACIC: The patient is status post interval removal of a spinal cord stimulator with posterior bilateral laminectomies and decompressions extending from the level of T8-T9 through T11-T12. Extensive, expected postoperative changes are seen. Additionally, there is a large T1 mildly hyperintense,, T2 hyperintense, minimally peripherally enhancing fluid collection which tracks through the posterior surgical incision, into the decompressive laminectomy site, exerts mass effect on the posterior epidural space. It measures 4 cm in anterior-posterior diameter, and 7.5 cm proximal to distal, 1.5 cm transversely. It abuts posterior epidural space at T9 through T11. This results in near complete effacement of the thecal sac from T9-T11, with severe canal stenosis and moderate cord compression. No definite abnormal cord signal seen at these levels. Similarly, and there is no evidence for abnormal intramedullary enhancement. Throughout the remainder of the visualized thoracic spinal canal, there is epidural lipomatosis which appears similar to the previous examination contributing to moderate central canal narrowing diffusely, and moderate to severe at T5, T6, T7 levels. At T8-9, a slightly right paracentral disc protrusion indents the ventral thecal sac, contacting the ventral cord and deforming it, combining with a posterior epidural fluid collection to result in mild-to-moderate canal stenosis. The thoracic vertebral body bone marrow is normal in signal characteristic. There is kyphosis centered within the mid thoracic spine that is slightly exaggerated. Compression deformities involving the T11 and T12 superior endplates appear chronic in nature. Mild anterior wedging of T7 also appears chronic in nature. Patent foramina. LUMBAR: The patient is status post previous L1-L5 bilateral laminectomies and decompression, with posterior spinal fusion at L1-L2. Extensive postoperative changes are again noted, all of which appears similar dating back to ___. This includes exaggerated lordosis seen at L1-L2 with irregularity of the superior and posterior L2 vertebral body. Intervertebral disc spacers are seen at L1-L2, L3-L4, and L4-L5. There is partial osseous fusion at L3-L4 and near complete fusion at L4-L5. T2 hyperintense, T1 hypointense, nonenhancing fluid collections are seen at multiple levels. A dominant collection is seen surrounding the right L2 pedicle screw with ventral extension and partial encasement of the thecal sac causing mild canal stenosis. This appearance is unchanged dating back to the prior examination. Similarly, smaller T2 hyperintense cystic collections seen posterior to the epidural space at L2-L3 are unchanged. ___ type 2 degenerative endplate changes are prominent at L1-L2 and L2-L3. No suspicious osseous lesion is detected. The conus terminates at L1-L2. Appearance of the thecal sac at L4, L5 level at and nerve roots within it is consistent with acne aditus, stable. T12-L1: There is no spinal canal or neural foraminal stenosis. L1-L2: There is mild canal narrowing secondary to compression from the previously described postoperative seroma which extends and partially encases the thecal sac. Otherwise, moderate bilateral neural foraminal narrowing is unchanged. L2-L3: Posterior disc bulging is noted without appreciable canal stenosis, but with moderate bilateral neural foraminal narrowing which appears modestly progressed from the previous examination. Minimal L2-L3 anterolisthesis. L3-L4 through L5-S1: There is no spinal canal or neural foraminal stenosis, aside from mild bilateral L5-S1 foraminal narrowing. There is no evidence for abnormal intramedullary, leptomeningeal, or epidural enhancement. There is extensive fatty atrophy of the bilateral paraspinal musculature. A T2 hyperintense right renal cyst is noted. Partially seen is probable left thyroid nodule measuring 2.3 cm, incompletely covered IMPRESSION: 1. Laminectomies T8-9 through T11. Fluid collection at the laminectomy bed extending to the skin surface, with complex appearance, likely postoperative with blood products within it given mildly intrinsic bright T1. Severe central canal narrowing at this level, with cord compression without definite cord signal abnormality. 2. Thoracic epidural lipomatosis, contributing to moderate to severe overall central canal narrowing. 3. L1-L5 bilateral laminectomies, L1-L2 posterior spinal fusion, with extensive postoperative changes. Overall, the lumbar spine alignment and postop appearance has minimally changed dating back to ___. This includes multiple probable postoperative seromas. 4. Background multilevel spondylosis of the lumbar spine, as above, overall mildly progressed from the previous examination. 5. Arachnoiditis in the lumbar spine, stable. NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the telephone on ___ at 7:06 pm, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: ULTRASOUND-GUIDED ASPIRATION INDICATION: ___ year old man with worsening left lower extremity pain and LBP.// Evaluation of fluid collection. Gram stain and culture. COMPARISON: MRI of the lumbar spine from ___. PROCEDURE: Ultrasound-guided drainage of right paravertebral soft tissue collection. OPERATORS: Dr. ___, radiology trainee and Dr. ___, attending radiologist. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a prone position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, 18G ___ needle was inserted into the right paravertebral fluid collection, and approximately 40 cc of clear fluid was aspirated with a sample sent for microbiology evaluation. The needle was removed and sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: No sedation was administered for this procedure. FINDINGS: There is a loculated fluid collection within the soft tissues of the right paravertebral region measuring 4.9 x 4.0 cm. IMPRESSION: Successful US-guided drainage of the right paravertebral soft tissue collection. Samples was sent for microbiology evaluation. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Back pain Diagnosed with Low back pain temperature: 98.9 heartrate: 120.0 resprate: 18.0 o2sat: 100.0 sbp: 178.0 dbp: 100.0 level of pain: 9 level of acuity: 3.0

Dear Mr. ___, you were admitted for lumbar back ___ and left lower extremity ___. Your discharge instructions are largely unchanged since your recent hospitalization from ___ - ___. Recent Surgery on ___ • **you recently underwent complete removal of your spinal cord stimulator (leads and pulse generator)on ___ • **you subsequently underwent laminectomy from T8-T10 with removal of scar and hematoma from the epidural space on ___ • Your incision was closed with staples and sutures which were removed on ___ while you were admitted. --- ON ___ you underwent Ultra Sound guided aspiration of your ___ fluid collection. 40ml of clear fluid was removed and sent for culture and analysis. Your dressings to the site of this aspiration have been removed, and your skin is healing well. Activity • You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours. • Heavy lifting, running, climbing, or other strenuous exercise should be avoided until your follow-up appointment. • You may take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much too soon. • Do not go swimming or submerge yourself in water for four weeks • The dressing covering your incision(s) has been removed. You may use a damp washcloth to remove any dried blood or iodine from your skin but do not scrub directly on your incisions. • You may take a shower and get your incision wet but remember to pat them dry afterwards. ___ and Medications • Resume your home ___ medications. Since you are already prescribed ___ medicines and are followed by the ___ Clinic, you should plan to resume your ___ Clinic home ___ medication regimen. Prescriptions for gabapentin and tizanadine have been provided to you following this admission per the recommendations of the inpatient ___ Service. Please be sure to attend your outpatient follow-up appointment with Dr. ___ as outlined below. • You should use Acetaminophen (Tylenol) as well. • Do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. What You ___ Experience: • Mild tenderness along the incisions. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription ___ medications), try an over-the-counter stool softener, prescriptions for stool softener have also been provided to you. Gabapentin, increasing dose: ---- You may up-titrate/increase your dose of gabapentin as needed for ___. You are currently taking 300mg gabapentin in the morning and mid day, with 600mg at bedtime. In ___ days if you are not suffering from side-effects including increased drowsiness, you may increase your morning dose to 600mg. In an additional ___ days, if you are not suffering from side-effects including increased drowsiness, you may increase your midday dose to 600mg. Therefore in ___ days, you may increase your dosing regimen to 600mg in the morning, midday, and at bedtime. Do not increase your dose of gabapentin to greater than 600mg three times a day. Call Your Doctor at ___ for: • severe headache, or headaches that are worst when sitting up or standing, and are better when laying flat. • Severe ___, swelling, redness or drainage from the incision site. • Fever greater than 101.5 degrees Fahrenheit • Severe Constipation • Blood in your stool or urine • Nausea and/or vomiting • Extreme sleepiness • Severe headaches not relieved by ___ relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: morphine / linezolid / Heparin Analogues Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ RHF with h/o recurrent UTI and non-convulsive status epilepticus who is well known to our service with multiple past admissions for AMS who now presents with ___ weeks of confusion. This is characterized by her sister as the inability to speak sensibly, and repeating the same words or phrases over and over again (of note, perseveration has been noted in clinic notes even during times when Ms. ___ mental status was not acutely altered). It appears that on occasion, she has also gotten agitated during this time with "excessive motor activity". She may have gotten LZP at her nursing facility earlier today per administration record, although ___ is unsure of this. Personally, she has not seen any actual seizure activity. The only other piece of information she stressed to me is that about ___ week ago, Ms. ___ had an episode of "her tongue feeling thick" and hanging out of the side of her mouth. In the ED, inital VS were 98.7 65 160/65 20 97% RA. She was given ceftriaxone first, then meropement given infected-appearing U/A and previous UCx sensitivities. In the past, urine cultures have grown VRE, MDR gram negatives and ___ species. At times, decision was made not to treat Ms. ___ (which always appear contaminated) until culture data are available). Unable to obtain ROS Past Medical History: - Seizure disorder - Neurogenic bladder with recurrent urinary tract infections - Hypertension - Anemia - Hyperlipidemia - Paroxysmal atrial fibrillation - Gastroesophageal reflux disease - Severe osteoarthritis of her left hip - Small bowel obstruction s/p laparotomy in ___ - Lumbar discectomy in ___. T6-9 laminectomy done in ___ ___ done due to residual fluid left in spinal canal. Non-ambulatory since then. - UGIB ___ duodenal ulcer ___ Social History: ___ Family History: Father deceased at age ___ from a heart virus. Her brother is alive but had leukemia as well as complications of a brain bleed and he also had coronary artery disease status post MI. Physical Exam: 98.7 65 160/65 20 97% ra General: NAD but somnolent, lying in bed - Head: NC/AT, no conjunctival pallor or icterus, no oropharyngeal lesions - Neck: Supple, no nuchal rigidity. No lymphadenopathy. - Cardiovascular: carotids with normal volume & upstroke; jugular veins nondistended, venous waveform normal with a > v; RRR, no M/R/G - Respiratory: Nonlabored, clear to auscultation with good air movement bilaterally to limited auscultation in anterior fields - Abdomen: transverse cesarean scar, obese but nondistended, normal bowel sounds, no tenderness/rigidity/guarding - Extremities: Warm, no cyanosis/clubbing/edema, palpable radial/dorsalis pedis pulses. Nl cap refill. Neurologic Examination: Mental Status: Somnolent but arousable. Extremely perseverative in speech and motor activity (e.g., waving arms up and down) to the extent that any formal mental status examination is virtually impossible. Able to provide own name but not DOB, age or current date. Knows that she is at BI. Follows some simple commands inconsistently. Starts crying during extremity examination. Cranial Nerves: [II] Pupils: equal in size and briskly reactive to light and accomodation. VF full to threat [III, IV, VI] EOM intact as far as can be ascertained by pt tracking examiner's face in room. [V] V1-V3 with symmetrical sensation to light touch. [VII] No facial asymmetry. [VIII] Hearing grossly intact. [IX, X] Palate elevation symmetric. [XII] Tongue shows no atrophy, emerges in midline. Motor: Normal bulk and tone. No pronation, drift or asterixis though this could not formally be tested. Moves arms symmetrically against gravity and wiggles toes. Sensory: Intact to tickle or pinch througout Reflexes [Bic] [Tri] [___] [Quad] [Ankle] L ___ 1 0 R ___ 1 0 Plantar response flexor bilaterally. Prominent grasp, snout reflex present. Pertinent Results: ___ 09:35PM LACTATE-0.9 ___ 09:30PM GLUCOSE-78 UREA N-19 CREAT-0.7 SODIUM-148* POTASSIUM-4.0 CHLORIDE-114* TOTAL CO2-26 ANION GAP-12 ___ 09:30PM estGFR-Using this ___ 09:30PM WBC-5.6 RBC-3.47* HGB-10.7* HCT-32.3* MCV-93 MCH-30.7 MCHC-33.0 RDW-15.9* ___ 09:30PM WBC-5.6 RBC-3.47* HGB-10.7* HCT-32.3* MCV-93 MCH-30.7 MCHC-33.0 RDW-15.9* ___ 09:30PM PLT COUNT-126* ___ 07:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 07:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 07:45PM URINE RBC-16* WBC->182* BACTERIA-MANY YEAST-NONE EPI-<1 TRANS EPI-2 ___ 07:45PM URINE WBCCLUMP-MANY MUCOUS-RARE CT head ___vidence for acute intracranial process. CXR ___ Chronic changes within the right lung base with chronic pleural thickening. Chronic anterior dislocation of the left shoulder. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Pregabalin 50 mg PO DAILY 2. Pregabalin 150 mg PO QPM 3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain 4. Omeprazole 20 mg PO DAILY 5. LACOSamide 200 mg PO BID 6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze, SOB 7. Fondaparinux 2.5 mg SC DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Cephalexin 250 mg PO Q24H 10. Baclofen 5 mg PO TID spasm 11. Atorvastatin 40 mg PO DAILY 12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB wheeze 13. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever 14. TraZODone 25 mg PO HS insomnia 15. Lorazepam 0.5 mg PO Q4H:PRN seizures 16. Artificial Tears ___ DROP BOTH EYES DAILY 17. Citalopram 20 mg PO DAILY 18. Calcium Carbonate 500 mg PO QID:PRN GI upset 19. Guaifenesin ___ mL PO Q6H:PRN cough 20. Vitamin D 1000 UNIT PO DAILY 21. Multivitamins W/minerals 1 TAB PO DAILY 22. Senna 1 TAB PO BID:PRN constipation 23. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 24. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever 2. Artificial Tears ___ DROP BOTH EYES DAILY 3. Atorvastatin 40 mg PO DAILY 4. Baclofen 5 mg PO TID spasm 5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 6. Citalopram 20 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Fondaparinux 2.5 mg SC DAILY 9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze, SOB 10. LACOSamide 200 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Pregabalin 50 mg PO DAILY 13. Pregabalin 150 mg PO QPM 14. Senna 1 TAB PO BID:PRN constipation 15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB wheeze 16. Calcium Carbonate 500 mg PO QID:PRN GI upset 17. Guaifenesin ___ mL PO Q6H:PRN cough 18. Lorazepam 0.5 mg PO Q4H:PRN seizures 19. Multivitamins W/minerals 1 TAB PO DAILY 20. Omeprazole 20 mg PO DAILY 21. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain 22. TraZODone 25 mg PO HS insomnia 23. Vitamin D 1000 UNIT PO DAILY 24. Vancomycin 1000 mg IV Q 12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Confusion Discharge Condition: Discharge condition: fair Mental status: back to baseline Ambulatory status: activity as tolerated Neuro exam: non-focal Followup Instructions: ___ Radiology Report HISTORY: Seizure. TECHNIQUE: Upright AP view of the chest. COMPARISON: ___ and ___. FINDINGS: The study is somewhat limited due to patient rotation. Right PICC has been removed. The heart size remains moderately enlarged. The mediastinal and hilar contours are unchanged. Blunting of the right costophrenic angle with right basilar patchy opacity appears unchanged, likely reflecting chronic pleural thickening with associated atelectasis or scarring. Left lung is clear. No new areas of focal consolidation are demonstrated. There is no pneumothorax or new pleural effusion. Chronic left anterior shoulder dislocation is re- demonstrated. Cervical spinal fusion hardware is incompletely visualized. IMPRESSION: Chronic changes within the right lung base with chronic pleural thickening. Chronic anterior dislocation of the left shoulder. Radiology Report HISTORY: ___ female with recurrent seizures, now with change in seizure type and slurred speech. TECHNIQUE: Helically acquired axial CT images through the head were performed without intravenous contrast. Coronal, sagittal, and thin slice bone reconstructed images were created and reviewed. COMPARISON: ___. FINDINGS: There is no CT evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. There is preservation of gray-white matter differentiation. The basal cisterns appear patent. Prominent ventricles and sulci suggest age related involutional changes. White matter hypodensity is likely secondary to sequelae of chronic small vessel ischemic disease. Cavernous carotid calcifications are mild. Extraaxial punctate calcifications are again noted predominantly adjacent to the anterior temporal lobes and within the Sylvian fissures bilaterally. No acute bony abnormality is detected. The visualized portions of the paranasal sinuses and mastoid air cells appear well aerated. IMPRESSION: No CT evidence for acute intracranial process. Radiology Report PICC LINE PLACEMENT INDICATION: IV access needed for antibiotics. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Dr. ___, Dr. ___ Dr. ___ the procedure. TECHNIQUE: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Ultrasound images were obtained before and immediately after establishing intravenous access. A 4.5F peel-away sheath was then placed over an 018 guidewire and a single lumen ___ PICC line measuring 30 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Ultrasound and fluoroscopically guided single lumen PICC line placement via the right brachial venous approach. Final internal length is 30 cm, with the tip positioned in SVC. The line is ready to use. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Seizure Diagnosed with ALTERED MENTAL STATUS , URIN TRACT INFECTION NOS temperature: 98.7 heartrate: 65.0 resprate: 20.0 o2sat: 97.0 sbp: 160.0 dbp: 65.0 level of pain: 0 level of acuity: 2.0

Dear Ms ___, It was a pleasure taking care of you during your stay. You were brought to the hospital because of confusion. We think your confusion may be due to either an infection or seizure. There are some medication changes: - We ADDED VANCOMYCIN IV one gram every 12 hours for treatment of urinay tract infection. The last dose will be on ___. Please take the rest of your medications as previously prescribed. Please call your doctor or go to the nearest emergency room if you experience any of the danger signs listed below

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: prilocaine / lidocaine Attending: ___. Major Surgical or Invasive Procedure: N/a attach Pertinent Results: ADMISSION LABS: ___ 04:50PM BLOOD WBC-10.2* RBC-5.54 Hgb-16.7 Hct-50.9 MCV-92 MCH-30.1 MCHC-32.8 RDW-16.0* RDWSD-52.0* Plt ___ ___ 04:50PM BLOOD ___ PTT-28.8 ___ ___ 10:55AM BLOOD D-Dimer-1068* ___ 04:50PM BLOOD Glucose-297* UreaN-16 Creat-1.1 Na-136 K-6.8* Cl-100 HCO3-21* AnGap-15 ___ 04:50PM BLOOD ALT-27 AST-42* AlkPhos-81 TotBili-1.6* ___ 04:50PM BLOOD cTropnT-0.05* proBNP-387* ___ 08:30PM BLOOD Calcium-9.0 Phos-1.7* Mg-1.5* Cholest-181 ___ 04:50PM BLOOD %HbA1c-7.0* eAG-154* ___ 08:30PM BLOOD Triglyc-108 HDL-54 CHOL/HD-3.4 LDLcalc-105 ___ 08:30PM BLOOD TSH-0.90 ___ 09:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG ___ 09:30AM BLOOD HCV Ab-NEG ___ 05:03PM BLOOD ___ pO2-20* pCO2-65* pH-7.26* calTCO2-31* Base XS--1 ___ 05:03PM BLOOD Lactate-3.5* K-5.9* ___ 05:03PM BLOOD O2 Sat-18 ___ 04:30PM URINE Blood-TR* Nitrite-NEG Protein-100* Glucose-1000* Ketone-TR* Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG ___ 04:30PM URINE RBC-4* WBC-3 Bacteri-NONE Yeast-NONE Epi-0 PERTINENT STUDIES: CXR ___: Moderate pulmonary edema, slightly more pronounced on the right. Probable bibasilar atelectasis. ___: 1. Coarsened liver echotexture and nodular morphology. 2. Cholelithiasis without finding to suggest acute cholecystitis. 3. Splenomegaly, spleen measures 14.1 cm. ___: Sinus rhythm Nonspecific intraventricular conduction delay Nonspecific ST-T wave abnormalities ___ TTE: Mild symmetric left ventricular hypertrophy with normal cavity size and mild global systolic dysfunction with relative preservation of apical function c/w a nonischemic process. Normal right ventricular cavity size and systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure. ___: Mild symmetric left ventricular hypertrophy with normal cavity size and mild global systolic dysfunction with relative preservation of apical function c/w a nonischemic process. Normal right ventricular cavity size and systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure. ___: LENIs No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ CTA chest: 1. No evidence of central pulmonary embolism. Streak artifact limiting evaluation of segmental and subsegmental branches. 2. Diffuse bilateral, scattered ground-glass opacities, with lower lobes predominant ___ nodularity, likely reflecting infectious/inflammatory process, with aspiration pneumonia in the differential. 3. Nodular contour of the liver, with partially visualized splenomegaly, may reflect sequela of cirrhosis/chronic liver disease, hepatology consultation is recommended. 4. Cholelithiasis without evidence of cholecystitis in the partially visualized gallbladder. 5. Small hiatal hernia. ___ MR Cardiac: Please note that this report only pertains to extracardiac findings. The liver is nodular in contour and heterogeneous in appearance, suggestive of cirrhosis. The spleen is enlarged up to 15 cm. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. Mildly dilated left ventricle with borderline/ mild global hypokinesis and low normal systolic function. Normal right ventricular cavity size with normal function. Normal origin of the right and left main coronary arteries. Right coronary artery visualized patent to the mid vessel; LMCA and proximal LAD and LCx also visualized patent. No perfusion defect was identified at rest or stress. There is mid-wall early and late gadolinium enhancement in basal inferoseptum c/w nonischemic cardiomyopathy. Mild to moderate mitral regurgitation. DISCHARGE LABS: ___ 07:45AM BLOOD WBC-7.2 RBC-4.53* Hgb-14.0 Hct-41.6 MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 RDWSD-49.8* Plt ___ ___ 07:45AM BLOOD Glucose-196* UreaN-22* Creat-1.1 Na-134* K-5.6* Cl-97 HCO3-20* AnGap-17 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. FLUoxetine 5 mg PO DAILY 3. Loratadine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Vitamin A Dose is Unknown PO DAILY 6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 7. ___ Gold (pot bicarb-sod bicarb-cit ac) 344-1,050-1,000 mg oral Q6H:PRN 8. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID 9. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) QHS Discharge Medications: 1. Amoxicillin 500 mg PO Q8H Duration: 7 Days RX *amoxicillin 500 mg 1 capsule(s) by mouth three times a day Disp #*25 Capsule Refills:*0 2. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. CARVedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Spironolactone 25 mg PO DAILY RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Torsemide 30 mg PO DAILY RX *torsemide 20 mg 1.5 tablet(s) by mouth once a day Disp #*45 Tablet Refills:*0 7. Vitamin A ___ UNIT PO DAILY Continue to take your same home dose of Vitamin A 8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 9. ___ Gold (pot bicarb-sod bicarb-cit ac) 344-1,050-1,000 mg oral Q6H:PRN 10. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID 11. FLUoxetine 5 mg PO DAILY 12. Loratadine 10 mg PO DAILY 13. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) QHS 14. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Bradycardic arrest Vasovagal syncope Heart Failure with Moderately Preserved EF Diabetes Mellitus Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with sob // eval for pulm overload TECHNIQUE: Upright AP view of the chest COMPARISON: None. FINDINGS: Cardiac silhouette size is moderately enlarged. There is central mediastinal venous distension with perihilar alveolar opacities, right greater the left in vascular indistinctness compatible with moderate pulmonary edema, asymmetrically more pronounced on the right. No large pleural effusion or pneumothorax. More focal opacities in the lung bases suggestive of atelectasis. No acute osseous abnormality. IMPRESSION: Moderate pulmonary edema, slightly more pronounced on the right. Probable bibasilar atelectasis. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old man with elevated T Bili, AST, new heart failure // ? acute hepatobiliary pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None FINDINGS: LIVER: The liver is nodular in echotexture. The contour of the liver is macrolobulated. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 6 mm GALLBLADDER: Cholelithiasis (1.3 x 1.7 x 0.4 cm) without gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 14.1 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 13.0 cm Left kidney: 12.3 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Coarsened liver echotexture and nodular morphology. 2. Cholelithiasis without finding to suggest acute cholecystitis. 3. Splenomegaly, spleen measures 14.1 cm. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ yo M presentin with bradycardic arrest now with hypoxemic respiratory failure // evaluate 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, color flow, and spectral doppler 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: CTA CHEST WITH CONTRAST INDICATION: ___ year old man with bradycardic arrest after dental tooth extraction concerning for lidocaine reaction vs. ischemia vs. PE. Positive D-dimer // ?PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.4 s, 31.4 cm; CTDIvol = 15.2 mGy (Body) DLP = 476.8 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 6.6 mGy-cm. Total DLP (Body) = 485 mGy-cm. COMPARISON: Ultrasound from ___. FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the lobar level without filling defect to indicate a pulmonary embolus. Limited evaluation of the segmental and subsegmental branches given streak artifact. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. Trace pericardial effusion. Mildly prominent lymph node measuring 1 cm in short axis anterior to the pericardium, likely reactive. Symmetric bilateral gynecomastia. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Diffuse, scattered ground-glass opacities with lower lobe predominant ___ nodularity likely reflecting infectious/inflammatory process, with aspiration pneumonia in the differential. Trachea and mainstem bronchi are patent. No focal consolidation or suspicious pulmonary lesions. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is notable for lobular contour of the liver. Cholelithiasis without evidence of cholecystitis in the partially visualized gallbladder. Small hiatal hernia. Partially visualized splenomegaly. BONES: No destructive osseous lesions. IMPRESSION: 1. No evidence of central pulmonary embolism. Streak artifact limiting evaluation of segmental and subsegmental branches. 2. Diffuse bilateral, scattered ground-glass opacities, with lower lobes predominant ___ nodularity, likely reflecting infectious/inflammatory process, with aspiration pneumonia in the differential. 3. Nodular contour of the liver, with partially visualized splenomegaly, may reflect sequela of cirrhosis/chronic liver disease, hepatology consultation is recommended. 4. Cholelithiasis without evidence of cholecystitis in the partially visualized gallbladder. 5. Small hiatal hernia. RECOMMENDATION(S): Hepatology consultation. Radiology Report EXAMINATION: T935 INDICATION: ___ year old man with recent bradycardic arrest following dental procedure inRequesting Stress MRI to evaluate for ischemia given bradyca TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology. COMPARISON: CTA chest ___, abdominal ultrasound on ___ IMPRESSION: Please note that this report only pertains to extracardiac findings. The liver is nodular in contour and heterogeneous in appearance, suggestive of cirrhosis. The spleen is enlarged up to 15 cm. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by UNKNOWN Chief complaint: Cardiac arrest, Transfer Diagnosed with Cardiac arrest, cause unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Mr. ___, You were admitted to the hospital because you lost consciousness and required CPR during a dental procedure. You were found to have decreased heart squeeze function, also called heart failure. Please see below for more information on your hospitalization. It was a pleasure participating in your care! What happened while you were in the hospital? - You received medicine through your IV to remove excess fluid - You were seen by an allergist What should you do after leaving the hospital? - Please take your medications as listed below and follow up at the listed appointments. - Please weigh yourself every morning at the same time with the same amount of clothing. If your weight goes up or down by more than 3 lb in one day or 5 lb in one week, please contact your doctor ___. We wish you the best! - 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: respiratory distress Major Surgical or Invasive Procedure: Intubation Central line placement History of Present Illness: ___ year old female with a history of breast cancer s/p L breast mastectomy ___ years ago), squamous cell carcinoma of the larynx s/p radiation and chemotherapy ___ years ago), and COPD on home 4L, and recent admission (___/) for aspiration pneumonitis/COPD exacerbation who presents with sudden onset dyspnea since this afternoon. She reports that she may have aspirated on yogurt and this feels like prior COPD exacerbations. She denied recent travel. In the ED, initial vitals: 98.5 128 ___ 96% 4L NC. Exam notable for RR 30, tachycardia, decreased breath sounds bilaterally. Labs notable for WBC 16.9 with 89.7%, lactate 1.5, calcium 10.9. Imaging revealed CXR with spiculated left lower lobe mass. Prominent background interstitial markings as well as complete collapse of the right lower lobe and right apical consolidation are all unchanged. There is likely a small right pleural effusion. No pneumothorax is seen. CTA revealed no PE. She received 3L NS, IV methylprednisolone, vanco/cefepime/levofloxacin. She initially improved, but desaturated to ___ and became cyanotic. Sats improved with PPV, however, due to increased work of breathing, she was intubated (*Note, she was DNI, however, decided with family that she wanted to be intubated). She was started on levophed for SBP 77/50. On transfer, vitals were: 98.4 90 99/53 16 99% ett. 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, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Multiple lung nodules on CT concerning for malignancy (___) Breast Ca s/p mastectomy Throat Ca s/p chemo and radiation COPD on home 4L GERD Thyroid Disease Hx Singles & post-Shingles Pain Social History: ___ Family History: No family history of clotting disorders, hypertension, diabetes. Physical Exam: On Admission: GENERAL: Intubated, sedated, chronically ill appearing HEENT: Sclera anicteric, MMM NECK: supple, JVP not elevated, no LAD LUNGS: Decreased bretah sounds at right base, wheezing throughout 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: Warm, well-perfused On Discharge: Vitals- 97.6 (98.6) 121/66 (121/66-135/65) 104 (100-109) 20 (___) 100% 4L NC (98-100% 4L NC). General- Alert, oriented, no acute distress. Cachectic and chronically ill appearing, sitting comfortably in bed. HEENT- Sclerae anicteric, MMM, edentulous Lungs- Decreased breath sounds at the bases, scattered wheezes, no rales, ronchi CV- Borderline tachcyardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- motor function grossly normal Skin: New faint macular blanching rash on abdomen, no rash on extremities, chest Pertinent Results: On Admission: ___ 03:19AM BLOOD WBC-29.2*# RBC-2.69* Hgb-7.2* Hct-24.3* MCV-90 MCH-26.8 MCHC-29.6* RDW-14.9 RDWSD-48.4* Plt ___ ___ 03:19AM BLOOD Neuts-96.2* Lymphs-1.4* Monos-1.5* Eos-0.0* Baso-0.1 Im ___ AbsNeut-28.09*# AbsLymp-0.42* AbsMono-0.44 AbsEos-0.00* AbsBaso-0.03 ___ 03:19AM BLOOD Glucose-175* UreaN-22* Creat-0.8 Na-139 K-4.6 Cl-106 HCO3-28 AnGap-10 ___ 03:19AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.2 ___ 04:55PM BLOOD ___ pO2-52* pCO2-57* pH-7.39 calTCO2-36* Base XS-7 On Discharge: ___ 11:22AM BLOOD WBC-10.2*# RBC-3.71* Hgb-9.9* Hct-33.2* MCV-90 MCH-26.7 MCHC-29.8* RDW-15.2 RDWSD-48.3* Plt ___ ___ 05:30AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Tear Dr-OCCASIONAL ___ 05:30AM BLOOD Ret Aut-1.8 Abs Ret-0.05 ___ 11:22AM BLOOD Glucose-148* UreaN-20 Creat-0.7 Na-141 K-3.2* Cl-102 HCO3-25 AnGap-17 ___ 05:30AM BLOOD LD(LDH)-154 TotBili-0.1 ___ 03:19AM BLOOD proBNP-227 ___ 11:22AM BLOOD Calcium-9.7 Phos-1.6* Mg-1.7 ___ 05:30AM BLOOD calTIBC-179* Ferritn-390* TRF-138* Microbiology: ___ Urine culture - negative ___ Sputum culture - extensive contamination ___ Respiratory viral culture - negative ___ MRSA screen - negative ___ Blood culture - no growth to date Imaging: ___ CXR Spiculated left lower lobe mass is re- demonstrated. Right apical opacity is again seen. There is persistent blunting of the right costophrenic angle, small pleural effusion and atelectasis. No definite new focal consolidation is identified. ___ CTA 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Slight interval increase in the dominant spiculated mass in the left lower lobe measuring 4.1 x 4.0 cm. 3. Unchanged spiculated mass at the right apex measuring 1.4cm. Confluent hilar lymphadenopathy. No changed in right lower lobe collapse. 4. Diffuse septal thickening with nodular opacities bilaterally measuring up to 5 mm concerning for lymphangitic spread with metastatic nodules. Cardiology: EKG ___: Sinus tachycardia. Tall peaked P waves with rightward P wave axis consistent with right atrial abnormality and in the context of low limb lead voltage suggests pulmonary pathology. Compared to the previous tracing of ___ the rate has slowed. Clinical correlation is suggested. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. Levothyroxine Sodium 112 mcg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Gabapentin 600 mg PO BID 6. Gabapentin 300 mg PO DAILY 7. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN pain 8. Ipratropium Bromide Neb 1 NEB IH Q6H 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Unknown Discharge Medications: 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. Gabapentin 600 mg PO BID 3. Gabapentin 300 mg PO DAILY 4. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN pain 5. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___) 6. Levothyroxine Sodium 224 mcg PO 1X/WEEK (___) 7. Omeprazole 20 mg PO DAILY 8. Sertraline 100 mg PO DAILY 9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 10. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN shortness of breath 11. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP INH daily Disp #*30 Capsule Refills:*0 12. Levofloxacin 500 mg PO ONCE Duration: 1 Dose Take on ___. RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once Disp #*1 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Recurrent aspiration COPD exacerbation New diagnosis of squamous cell carcinoma in lung (source unclear) Secondary: Multiple lung nodules on CT concerning for malignancy Chronic obstructive lung disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with dyspnea, tachypnea, recent ___ lung biopsy // evaluyate for acute process TECHNIQUE: Single frontal view of the chest COMPARISON: Multiple priors including ___ and ___ FINDINGS: Spiculated left lower lobe mass is re- demonstrated. Right apical opacity is again seen. There is persistent blunting of the right costophrenic angle, small pleural effusion and atelectasis. No definite new focal consolidation is identified. IMPRESSION: No significant interval change Radiology Report INDICATION: ___ woman with shortness of breath, tachypnea, history of malignancy, evaluate for PE. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 79.8 mGy-cm COMPARISON: CTA chest from ___ FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is significance calcified and noncalcified plaque at the aortic arch causing contour irregularity. Atherosclerotic calcifications extend into the descending thoracic aorta as well as the proximal left subclavian artery. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. THere is no definite supraclavicular or axillary lymphadenopathy. There is unchanged confluent hilar lymphadenopathy bilaterally as well as mediastinal lymphadenopathy, unchanged since prior study. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is a trace right pleural effusion. No pneumothorax is seen. The endotracheal tube terminates 1.3 cm above the carina. The central airways are patent. Evaluation of the lung parenchyma is limited due to respiratory motion. There is persistent complete collapse of the right lower lobe. The dominant spiculated mass in the left lower lobe measures 4.1 x 4.0 cm, previously 3.6 x 3.7 cm, perhaps slightly increased in size in the interim. The nodular opacity at the right apex measures 1.3 x 1.5 cm, previously 1.4 x 1.4 cm, unchanged since prior study. There are now areas of nodular opacity in bilateral lung measuring up to 5 mm in the right upper lobe (03:105, 48) compatible with metastatic disease. There is prominent bilateral septal thickening likely reflecting lymphangitic spread of tumor. Limited images of the upper abdomen are unremarkable. Enteric tube is partially visualized. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Slight interval increase in the dominant spiculated mass in the left lower lobe measuring 4.1 x 4.0 cm. 3. Unchanged spiculated mass at the right apex measuring 1.4cm. Confluent hilar and mediastinal lymphadenopathy. No changed in right lower lobe collapse. 4. Diffuse septal thickening with nodular opacities bilaterally measuring up to 5 mm concerning for lymphangitic spread with metastatic nodules. Radiology Report INDICATION: ___ female with sudden dyspnea. Evaluate for pneumothorax. TECHNIQUE: Portable frontal chest radiograph was obtained. COMPARISON: Same day chest radiograph performed at 16:28. FINDINGS: Compared to the most recent prior dura has been no significant interval change. Again seen is a spiculated left lower lobe mass. Prominent background interstitial markings as well as complete collapse of the right lower lobe and right apical consolidation are all unchanged. There is likely a small right pleural effusion. No pneumothorax is seen. IMPRESSION: No significant interval change since prior study. No pneumothorax. Radiology Report INDICATION: ___ woman status post intubation, evaluate for tube placement. TECHNIQUE: Chest PA and lateral COMPARISON: Same day chest radiograph performed at 21:39. FINDINGS: The tip of the endotracheal tube is situated 9 mm above the carina. There has also been interval placement of an enteric tube with tip projecting over the left upper quadrant. Remaining findings within the chest including a large spiculated mass in the left lower lobe and a spiculated nodule at the right apex, right lower lobe collapse and background prominent interstitial markings are all unchanged. The cardiac silhouette is stable. There is no pleural effusion or pneumothorax. IMPRESSION: Tip of the endotracheal tube is situated 9 mm above the carina. Radiology Report INDICATION: ___ woman with right IJ placement, evaluate for line placement. TECHNIQUE: Single portable supine view of the chest. COMPARISON: Chest radiograph performed 2 hours prior on ___. FINDINGS: A right IJ terminates at the cavoatrial junction. The remaining appearance of the lung is unchanged since prior study. IMPRESSION: Right IJ terminates at the cavoatrial junction. No changed to the rest of findings within the chest. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, ACUTE RESPIRATORY FAILURE temperature: 98.5 heartrate: 128.0 resprate: 30.0 o2sat: 96.0 sbp: 108.0 dbp: 72.0 level of pain: nan level of acuity: 1.0

Dear. Ms. ___, It was a pleasure taking part in your care at ___. You were admitted becaue of low oxygen at home. You needed to have a breathing tube to help you breathe. We found that one of the lobes of your right lung was collapsed, which was most likely a result of aspiration into that area. You were also treated with antibiotics for possible pneumonia and steroids for possible COPD exacerbation contributing to your symptoms. We were able to take the breathing tube out quickly and you were stable on your home oxygen of 4 Liters. We discussed with you, as have prior physicians, that you continue to apsirate will all food types. You wish to continue to eat, and to reduce the risk of aspiration as much as we are able, you can eat liquids that are nectar-thickened and pureed foods. You also had a biopsy of the mass in your left lung as an outpatient, and the results showed cancer. This is most likely lung cancer, and given that you have multiple spots in both lungs, it is advanced. You should talk to your primary care physician after discharge who will refer you to an oncologist. The oncologist will discuss any further imaging that is necessary. They will also discuss how to progress going forward, but we did discuss with you that given your other illnesses, chemotherapy options may be limited. You were seen by physical therapy, who felt you were at your baseline physical activity level and safe to return home with your daughter and physical therapy at home. We wish you the best, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / simvastatin Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Much of the history is obtained from the ED documentation, as Mr. ___ is very uncooperative as well as being confused. He is beligerent and cursing through much of the interview. Mr. ___ is a ___ year old male with pmh significant for HLD, past CVA, and colon cancer initially resected in ___ (refused adjuvant chemo), now with metastatic disease including several brain lesions with edemea. He presented to the ED today with confusion and a febrile illness. He states his landlady forced him to come though he did not want to come to the hospital. He refuses to answer remainder of questioning with the exception of confirming that he is moving to ___ next week, and no longer wants to seek care for his cancer treatment. Arrival Vitals: 99.8 108 132/81 16 90% ra Transfer vitals: 98.5 99 164/64 21 96% Peak temp of 103.8 Lines: #20 in LAC Fluids: 1L NS absorbed Drips: 1L NS at 75cc/hr In the ED patient confused and at times becoming loud and beligerent. Pt dislodged two IVs. Very unsteady gait. MEDS given: 1g acetaminophen PR, Vanco, Rocephin, Ampicillin, and Acyclovir. 2mg total Ativan for agitation. - Head CT: "Multiple bilateral hyperdense metastatic lesions surrounding vasogenic edema are relatively stable compared to the prior examination. There is no evidence of acute hemorrhage or vascular territorial infarct. Localized mass effect is stable. There is no interval development of a midline shift or herniation". - LP performed with bland CSF Patient recently referred to hospice per Dr. ___. Also, according to a phone conversation documented by heme/onc, Mr. ___ planned to move to ___ and was not planning to follow-up with heme/onc at ___. Review of Systems: Refusing to answer. Past Medical History: PAST ONCOLOGIC HISTORY: Patinet was treated for a localized colon cancer in ___ at ___ cancer was resected on ___. Per report, Mr. ___ declined adjuvant chemotherapy. He does not recall whether he met with a medical oncologist at the time or what the stage of his disease. He did well until ___ when he presented to the emergency department with back pain. CT identified multiple lung lesions, and he was then referred for a PET CT imaging. This too identified multiple bilateral FDG-avid lung lesions and was concerning for a primary lung cancer. However, CT-guided biopsy on ___ showed adenocarcinoma consistent with colon primary, staining positive for CK20 and CDX2, and negative for CK7 and TTF-1. PAST MEDICAL HISTORY: 1. Colon cancer resected ___ at ___, recurred ___ with diffuse lung and brain metastases (as above) 2. Hypercholesterolemia. 3. History of stroke in ___, maintained on warfarin. 4. History of tobacco abuse. 5. History of alcohol abuse. 6. History of cataracts. Social History: ___ Family History: The patient's mother may have been treated for breast cancer and died at ___ years of unknown cause. His father died suddenly at ___ years. A sister died at ___ years. Another brother is living with advanced lung cancer. He has no children. He does not know his family ___ medical history. His HCP is his friend ___, who is a ___. Physical Exam: Admission Exam: Vitals - T: 98.9 BP:170/96 HR:88 RR:16 02 sat:97% on RA General: Chronically ill appearing male, agitated, cursing, but not in acute distress HEENT: Poor dentition, limited exam. Neck: Supple. CV: Normal rate regular rhythm Lungs: Clear, limited exam Abdomen: Soft NT, ND GU: No foley Ext: No edema . Discharge Exam: AVSS Alert and Oriented Pertinent Results: CBC COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 07:10 10.6 4.10* 12.0* 34.0* 83 29.2 35.3* 13.9 230 ___ 07:00 11.6* 4.10* 11.8* 34.0* 83 28.8 34.6 13.8 240 ___ 07:25 9.4 4.01* 12.0* 33.2* 83 30.0 36.2* 13.7 188 ___ 07:15 11.0 4.60 13.7* 38.1* 83 29.7 35.9* 13.8 203 ___ 11:00 13.2* 5.39 15.6 44.8 83 29.0 34.9 13.6 270 . Chemistries RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 07:10 233*1 21* 0.7 129* 4.4 96 25 12 ___ 07:00 283*1 23* 0.6 128* 4.3 97 22 13 ___ 07:25 ___ 125* 4.0 93* 20* 16 ___ 07:15 ___ 125* 3.6 90* 20* 19 ___ 11:00 180*1 25* 1.0 129* 3.9 89* 21* 23* . ___ 11:00AM BLOOD ALT-30 AST-30 AlkPhos-69 TotBili-1.6* ___ 07:25AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.0 ___ 10:59AM BLOOD Lactate-2.2* . IMAGING: CT Head W/O Contrast -- Preliminary Result+ Dictated (___) Multiple bilateral hyperdense metastatic lesions surrounding vasogenic edema are relatively stable compared to the prior examination. There is no evidence of acute hemorrhage or vascular territorial infarct. Localized mass effect is stable. There is no interval development of a midline shift or herniation. . CSF: ANALYSIS WBC RBC Polys Lymphs Monos ___ 16:30 41 0 82 9 9 . ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL EMERGENCY WARD ___ URINE URINE CULTURE-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD Radiology Report INDICATION: ___ man with colon cancer with mets, presenting with altered mental status and cough/hypoxia. Evaluate for infection. COMPARISON: Prior chest radiograph from ___. TECHNIQUE: AP and lateral chest radiographs. FINDINGS: The cardiac, mediastinal and hilar contours are within normal limits. Again seen are numerous cavitary nodules and masses within both lungs diffusely. No overt pulmonary edema is seen, no pleural effusion or pneumothorax is present. Note is made of scarring within the lung apices. IMPRESSION: Extennsive pulmonary metastases. No definite lobar consolidation concerning for pneumonia. Radiology Report INDICATION: Metastatic colon cancer, presenting with altered mental status and cough, evaluate for intracranial hemorrhage. COMPARISON: Non-contrast head CT from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without contrast. Coronal and sagittal reformatted images were generated. FINDINGS: Redemonstrated are multiple hyperdense metastatic lesions in both cerebral hemispheres, stable to minimally increased in size compared to the prior study. Again seen is vasogenic edema surrounding these lesions with associated local mass effect with effacement of the sulci and occipital horn of the right lateral ventricle, relatively unchanged. There is no midline shift or evidence of herniation. No interval hemorrhage or acute infarct is identified. Please note however, givent he hyperdense appearance of the metastatic lesions, intralesional hemorrhage is impossible to exclude. No fracture is seen. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities remain clear. Orbits are unremarkable. IMPRESSION: Multiple hyperdense metastatic lesions, marginally increased, with surrounding edema. No herniation. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Altered mental status Diagnosed with FEVER, UNSPECIFIED, ALTERED MENTAL STATUS temperature: 99.8 heartrate: 108.0 resprate: 16.0 o2sat: 90.0 sbp: 132.0 dbp: 81.0 level of pain: 13 level of acuity: 1.0

You were admitted to the hospital with confusion. This was most likely due to dehydration and high sugar levels from your steroids. Please continue to take all of your medications, we have started you on insulin.

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Trauma: pedestrian struck with lower ext. crush injury Major Surgical or Invasive Procedure: ___: 1. Washout and debridement open fractures site right and left tibia down to and inclusive of bone. 2. Application uniplanar external fixator right and left tibia. 3. Closed reduction of distal tibia fractures bilateral with manipulation. 4. Application of uniplanar external fixator right femur. 5. Closed treatment right femur fracture with manipulation. ___: 1. Removal of external fixator under anesthesia, right lower extremity. 2. Irrigation and debridement, fracture, skin to bone, right tibia. 3. Retrograde femoral nail, right femur. 4. Anterior grade tibial nail, right tibia. 5. Debridement, fracture open skin to bone, left tibia, under separate prep and drape. ___: On the right lower extremity 1. A free gracilis flap. 2. Pedicled soleus flap. 3. Split-thickness skin graft 8 x 20. 4. Antibiotic impregnated cement spacer to tibia. 5. Surgical preparation site 20 x 8 cm. Left side 1. Pedicled soleus flap. 2. Split-thickness skin graft 8 x 17. 3. Surgical preparation of site 8 x 17 cm. 4. Excision of fibula with open fracture. ___: 1. Irrigation and debridement, fracture open skin to bone, left tibia. ___: 1. Irrigation and debridement, fracture open skin to bone, left tibia. 2. Removal of external fixator under anesthesia, left tibia. 3. Open reduction, internal fixation, Schatzker 6, bicondylar tibial plateau fracture. 4. Intramedullary nailing, left tibial shaft fracture. ___: Tracheostomy placement ___: RLE Split-thickness skin grafting, 14 x 5 cm. ___: PEG placement ___: Trach downsized to #6, non-cuffed, passey muir valve placed History of Present Illness: ___ year old female who was brought into the hospital by EMS as a pedestrian struck. She was pinned between 2 cars, crushing both lower extremities. She had initially no pulses at the scene but transient lower extremity pulses while in route. She reports severe pain in both legs that recalls no other injuries and reports no pain in the head, neck, chest, hips, or arms. Past Medical History: Emphysema on 2.5L home o2. HTN HLD GERD Social History: ___ Family History: Noncontributory Physical Exam: Admission Physical Examination: General: Severe Distress HEENT: Eyes: Lids Normal; . NCAT, midface stable. Neck: No Lymphadenopathy, No Meningismus and Supple; in surgical immobilization Respiratory: No Resp Distress, Chest non-tender and Normal Breath Sounds Cardio-Vascular: No murmur, No rub and RRR Abdomen: Non-tender and Soft Back: No Midline Tenderness and Non-tender; kyphotic, long midline scar Extremity: Bilateral lower extremity open fractures below-the-knee with clear deformity, thready dp pulse bilaterally, diffuse pain throughout; difficult to assess sensation distal to fractures due to extreme pain Neurological: Alert, Oriented X3, No Gross Weakness and Speech Normal Skin: No rash, No Petechiae, Warm and Dry Psychological: Mood/Affect Normal and Normal Memory/Judgment Discharge Physical Exam: VS: 97.9 PO 92/60 76 19 95 RA Gen: A&O x3 HEENT: Trach site CDI CV: HRR Pulm: LS dim at bases Abd: soft NT/ND. GT site CDI GU: Foley with cyu Ext: RLE/LLE multiple healed incisions, donor graft site on each thigh, grafts to bilat shins. Pertinent Results: Initial Labs: ___ 04:15PM BLOOD freeCa-0.92* ___ 04:15PM BLOOD Hgb-11.3* calcHCT-34 O2 Sat-90 COHgb-4 MetHgb-0 ___ 04:15PM BLOOD Glucose-134* Lactate-3.2* Na-134 K-3.6 Cl-105 ___ 04:15PM BLOOD ___ pO2-77* pCO2-55* pH-7.22* calTCO2-24 Base XS--5 Intubat-INTUBATED ___ 06:30PM BLOOD Calcium-8.2* Phos-4.1 Mg-1.4* ___ 04:05PM BLOOD Lipase-43 ___ 06:30PM BLOOD Glucose-124* UreaN-6 Creat-0.6 Na-137 K-3.6 Cl-106 HCO3-21* AnGap-14 ___ 04:05PM BLOOD ___ 04:05PM BLOOD ___ PTT-27.8 ___ ___ 04:49PM BLOOD Plt ___ ___ 04:49PM BLOOD Neuts-73.1* Lymphs-16.5* Monos-8.5 Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.23* AbsLymp-1.41 AbsMono-0.72 AbsEos-0.03* AbsBaso-0.02 ___ 04:05PM BLOOD WBC-7.7 RBC-3.44* Hgb-10.8* Hct-33.0* MCV-96 MCH-31.4 MCHC-32.7 RDW-14.7 RDWSD-51.1* Plt ___ Interval Labs: ___ 02:51AM BLOOD freeCa-1.10* ___ 02:43AM BLOOD freeCa-1.05* ___ 03:26PM BLOOD Glucose-121* Lactate-1.8 Na-134 K-4.6 Cl-102 ___ 06:57PM BLOOD Type-ART Temp-34.3 pO2-186* pCO2-42 pH-7.34* calTCO2-24 Base XS--2 ___ 09:09PM BLOOD Type-ART pO2-60* pCO2-49* pH-7.33* calTCO2-27 Base XS-0 ___ 09:18AM BLOOD Type-ART pO2-76* pCO2-44 pH-7.34* calTCO2-25 Base XS--2 ___ 02:43AM BLOOD Type-ART Rates-/___ Tidal V-380 PEEP-5 pO2-75* pCO2-43 pH-7.45 calTCO2-31* Base XS-4 Intubat-INTUBATED Vent-SPONTANEOU ___ 02:00AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0 ___ 05:20AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8 ___ 01:45AM BLOOD ALT-26 AST-42* AlkPhos-257* TotBili-1.1 ___ 05:20AM BLOOD Glucose-103* UreaN-10 Creat-0.4 Na-140 K-3.2* Cl-100 HCO3-30 AnGap-13 ___ 02:03AM BLOOD ___ PTT-32.7 ___ ___ 05:28AM BLOOD Plt ___ ___ 03:24PM BLOOD WBC-8.6 RBC-2.45* Hgb-7.3* Hct-21.7* MCV-89 MCH-29.8 MCHC-33.6 RDW-16.5* RDWSD-52.9* Plt Ct-75* ___ 05:28AM BLOOD WBC-15.3* RBC-3.11* Hgb-9.3* Hct-30.9* MCV-99* MCH-29.9 MCHC-30.1* RDW-18.0* RDWSD-63.0* Plt ___ ___ 02:18AM BLOOD WBC-9.7 RBC-2.71* Hgb-8.1* Hct-25.3* MCV-93 MCH-29.9 MCHC-32.0 RDW-16.3* RDWSD-52.6* Plt ___ ___ 05:28AM BLOOD WBC-15.3* RBC-3.11* Hgb-9.3* Hct-30.9* MCV-99* MCH-29.9 MCHC-30.1* RDW-18.0* RDWSD-63.0* Plt ___ Imaging: ___: CXR: 1. No acute cardiopulmonary process. 2. Suspect acute fractures at the left superior and inferior pubic rami. ___: Lower Extremity Fluro: Right and left is not clearly labeled on the images. Numerous fluoroscopic images demonstrate placement of external fixation pins in the calcaneus and proximal tibial shaft and in the proximal femoral shaft. There are displaced fractures seen of the mid femoral shaft with a prominent butterfly fragment, of the proximal tibial metaphysis, and a severely comminuted fracture through the distal lower leg involving the tibia and fibula. Please refer to the operative note for additional details. The total intraservice fluoroscopic time was 47.7 seconds. ___: CT Head: 1. No acute intracranial abnormality 2. Peripheral calcification of the cavernous portion of the left internal carotid artery measuring 1.6 x 1.4 x 1.1 cm, highly suspicious for an underlying aneurysm. ___: CT A/P: 1. Extensive comminuted open fractures involving the bilateral lower extremities as described. The bilateral anterior tibial and peroneal arteries are not visualized distal to the level of the mid tibia, concerning for vascular injury. 2. Multiple pelvic fractures as described. There is no evidence of active extravasation or large extraperitoneal hematomas. Multiple pelvic fractures including displaced left iliac fracture and left superior and inferior pubic rami fractures. Slight widening of the left sacroiliac joint and offset of the pubic symphysis joint. Posterior to fracture fragments of the left ilium 3. Small amount of simple ascites without evidence of traumatic injury to the intra-abdominal organs. 4. Small bilateral pleural effusions without evidence of acute intrathoracic injury. ___: CT C-spine: 1. Widening of the anterior disc space at C6-C7 which may reflect underlying ligamentous injury 2. High-density material in the posterior epidural space at C5-C6 and C6-C7, reflective of acute hemorrhage. ___: CTA b/l ___: 1. Extensive comminuted open fractures involving the bilateral lower extremities as described. The bilateral anterior tibial and peroneal arteries are not visualized distal to the level of the mid tibia, concerning for vascular injury. 2. Multiple pelvic fractures as described. There is no evidence of active extravasation or large extraperitoneal hematomas. 3. Small amount of simple ascites without evidence of traumatic injury to the intra-abdominal organs. 4. Small bilateral pleural effusions without evidence of acute intrathoracic injury. ___: MR C-spine: 1. No evidence of an epidural hematoma. No cord signal abnormalities identified. 2. No evidence of acute ligamentous injury identified within the anterior longitudinal ligaments. Previously noted widening of the anterior aspect of the C6-C7 vertebral body is likely degenerative in etiology. 3. Cervical spondylosis, as described in detail above most pronounced at C4-5 and C5-6. 4. Unchanged left internal carotid artery aneurysm, previously demonstrated by head CT on ___. ___: R Hand x-ray (PA/LAT/Oblique): 1. Diffuse osteopenia. 2. Prominent soft tissue swelling. 3. Suspected old healed distal right radial fracture. Clinical correlation to confirm this is requested. 4. Equivocal nondisplaced fracture in the proximal metaphysis of the fourth metacarpal bone, seen only on one view. Alternatively, this could reflect changes due to remote healed fracture or bony ridging at the base of the metacarpal. Medications on Admission: Verapamil ER 180mg daily Duloxetine ER 60mg daily Simvastatin 40mg daily Gabapentin 300mg qhs Klor-con 1 tab BID Folic acid 1mg daily Omeprazole 20mg daily Bupropion XL 300 qam Klonazepam 0.5mg qam & 1mg qhs Trazodone 100mg qhs Reglan 10mg daily Valsartan 80 mg daily Magnesium oxide Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing 4. Aspirin 121.5 mg PO DAILY 5. Bisacodyl 10 mg PR QHS 6. BuPROPion 150 mg PO BID 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 8. ClonazePAM 1 mg PO QHS 9. Docusate Sodium 100 mg PO BID 10. Fleet Enema ___AILY:PRN constipation 11. Ipratropium Bromide MDI ___ PUFF IH Q4H:PRN wheeze 12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 13. Lactulose 15 mL PO DAILY 14. Mineral Oil ___ mL PO DAILY:PRN constipation 15. Multivitamins 1 TAB PO DAILY 16. OxycoDONE Liquid 15 mg PO Q4H:PRN Pain - Moderate hold for increased sedation, resp. rate <8 17. Polyethylene Glycol 17 g PO DAILY 18. QUEtiapine Fumarate 25 mg PO BID 19. Senna 8.6 mg PO BID 20. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY to left hand eschar 21. Thiamine 100 mg PO DAILY 22. Verapamil 40 mg PO Q8H hold for SBP <90 or HR <60 hold for systolic blood pressure <110, hr <60 23. Simvastatin 10 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Trauma: [] Bilateral lower long bone fractures [] Bilateral, open, comminuted lower extremity wounds [] Multiple pelvic fractures: comminuted fracture of the left iliac wing and fractures of the left superior and inferior pubic rami, with minimal diastasis of the left SI joint and pubic symphysis [] Subacute fractures of the right sixth and seventh ribs posteriorly Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE. INDICATION: ___ year old woman with s/p polytrauma with spinal epidural hematoma and concern for decreased arm movement. // Eval for ligamentous injury and worsening epidural hematoma. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 and gradient echo imaging were next performed. After administration of 5 mL of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was performed. COMPARISON: CT cervical spine from ___. Head CT dated ___ FINDINGS: Alignment is normal. Note is made of exaggerated lordosis of the cervical spine. Mild retrolisthesis is seen involving C3 on C4. There is no evidence of anterior longitudinal ligamentous disruption. No prevertebral soft tissue swelling is seen. Vertebral body heights appear to be unremarkable. Diffuse disc desiccation is seen throughout the cervical spine. On the left internal carotid artery at the cavernous segment, there is an unchanged left internal carotid artery aneurysm (image 4, series 3, 5 and 8), previously demonstrated by CT of the head on ___. C2-C3: There is no significant spinal canal or neural foraminal narrowing. C3-C4: Mild central disc bulge is seen resulting in mild spinal canal narrowing. Uncovertebral and facet joint osteophytes contribute to moderate right and mild left neural foraminal narrowing. C4-C5: Central disc bulge is seen resulting in mild-to-moderate canal narrowing. Facet joint and uncovertebral arthropathy contributes to severe left and moderate right neural foraminal narrowing. C5-C6: Mild central disc bulge is seen resulting in mild spinal canal narrowing. Uncovertebral and facet joint arthropathy contributes to moderate left and mild right neural foraminal narrowing. C6-C7: There is no significant spinal canal narrowing. Facet joint and uncovertebral arthropathy contributes to mild-to-moderate right neural foraminal narrowing. C7-T1: There is no significant spinal canal or neural foraminal narrowing. There is no evidence of an epidural collection. No underlying cord signal abnormalities are seen. No paravertebral or paraspinal soft tissue abnormalities are identified. IMPRESSION: 1. No evidence of an epidural hematoma. No cord signal abnormalities identified. 2. No evidence of acute ligamentous injury identified within the anterior longitudinal ligaments. Previously noted widening of the anterior aspect of the C6-C7 vertebral body is likely degenerative in etiology. 3. Cervical spondylosis, as described in detail above most pronounced at C4-5 and C5-6. 4. Unchanged left internal carotid artery aneurysm, previously demonstrated by head CT on ___. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ h/o emphysema on home o2 presents after being pinned between 2 cars with R femur fracture, R tib plateau, R midshaft tibia fx, L tib plateau, L distal tibia fx now s/p I D and ex-fix of R femur, R and L ankle with known spinal epidural hematoma, ?c6-7 ligamentous injury // intubated, daily eval intubated, daily eval IMPRESSION: Compared to chest radiograph ___. Patient still intubated, but the ET tube has been partially withdrawn, tip is now 5.5 cm from the carina and care should be taken not to start any further. Lungs are hyperinflated but grossly clear. Normal cardiomediastinal and hilar silhouettes and pleural surfaces. Radiology Report EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT INDICATION: ___ s/p ped struck by two cars with right hand bruising. Eval for fx. // ___ s/p ped struck by two cars with right hand bruising. Eval for fx. TECHNIQUE: Right hand, 3 portable views. An overlying IV is in place. COMPARISON: None. FINDINGS: There is diffuse osteopenia, which can limit detection of nondisplaced fractures. There is prominent surrounding soft tissue swelling. Dorsal angulation of distal radial articular surface is suggestive of an old healed distal radial fracture. Clinical correlation is requested to confirm this. Small corticated ossicle noted adjacent to the ulnar styloid. No acute fractures identified about the distal radius or ulna. No dislocation is detected. On one view, a faint linear lucency is seen at the base of the fourth metacarpal, raising the possibility of a nondisplaced fracture. Otherwise, no fractures detected about the right hand. Osteoarthritis of the first CMC, triscaphe, and multiple IP joints noted. IMPRESSION: 1. Diffuse osteopenia. 2. Prominent soft tissue swelling. 3. Suspected old healed distal right radial fracture. Clinical correlation to confirm this is requested. 4. Equivocal nondisplaced fracture in the proximal metaphysis of the fourth metacarpal bone, seen only on one view. Alternatively, this could reflect changes due to remote healed fracture or bony ridging at the base of the metacarpal. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ w/ RUE swelling, tachycardia, eval for DVT // ___ w/ RUE swelling, tachycardia, eval for DVT 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 right and left subclavian veins. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachia and basilic veins are patent, compressible, and show normal color flow and augmentation. The central aspect of the right cephalic vein is patent and compressible and shows normal color flow. The mid and peripheral aspects of the right cephalic vein is noncompressible and does not show normal color flow consistent with thrombus Peripheral right upper extremity soft tissue edema IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. There is soft tissue edema within the right peripheral upper extremity. There is thrombus in the mid and peripheral right cephalic vein, which is considered a superficial vein. Radiology Report INDICATION: ___ year old woman s/p polytrauma with right arm swelling // eval for fracture IMPRESSION: Right shoulder: No acute fractures or dislocations are seen. There are mild degenerative changes of both the AC and glenohumeral joints. There is a deformity of the superolateral humeral head suggestive of a ___ deformity related to prior anterior shoulder dislocation. Right elbow: Evaluation for joint effusion is limited due to patient positioning and technique. However, no displaced fractures or dislocations are seen. There is slight lateral elbow soft tissue swelling. Radiology Report EXAMINATION: FEMUR (AP AND LAT) IN O.R. RIGHT INDICATION: ORIF RT FEMUR TECHNIQUE: Intraoperative fluoroscopic images of the femur obtained without a radiologist present COMPARISON: None FINDINGS: Intraoperative fluoroscopic images show the steps of ORIF of femur within intramedullary rod, proximal and distal interlocking screws incompletely imaged. The laterality of this examination is not indicated. IMPRESSION: The laterality of this examination is not labeled on these images but is presumed to be a ORIF of the right femur. For further details please refer to the operative report in the ___ medical record. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) IN O.R. RIGHT INDICATION: ORIF RIGHT TIB/FIB TECHNIQUE: Intraoperative fluoroscopic images of the right tibia/ fibula obtained without a radiologist present COMPARISON: Trauma series 10 ___ FINDINGS: The laterality of these images is not labeled but is presumed to be the right tibia/fibula per the requisition. Intraoperative radiographs show ORIF of severely comminuted tibial and fibular fractures. There is no intramedullary rod in the tibia with proximal and distal interlocking screws. IMPRESSION: Intraoperative radiographs. ORIF of the tibia. For further details please refer to the operative report in the ___ medical record. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) LEFT IN O.R. INDICATION: LEFT TIB/FIB FX; S/P EX FIX TECHNIQUE: Frontal lateral radiographs of the left tibia/fibula. COMPARISON: Trauma series 10 ___ FINDINGS: Portable radiographs of the tibia/fibula show external fusion hardware with screws in the upper tibial shaft and calcaneus. There are markedly comminuted fractures of the distal tibial and fibular shafts. There is also fracture of the proximal tibial metadiaphysis with involvement of the tibial plateau. There is also fracture of the proximal fibular neck. Multiple skin staples are in place. Incidentally, there are vascular calcifications in the distal thigh. IMPRESSION: Severely comminuted tibial shaft, tibial plateau, fibular shaft and fibular neck fractures. External fixation hardware is in place with screws in the tibia and calcaneus. Radiology Report EXAMINATION: CHEST PORT LINE/TUBE PLCT 1 EXAM INDICATION: ___ year old woman with NGT placement for feed // Please confirm NGT placement Please confirm NGT placement IMPRESSION: Compared to chest radiographs ___. New heterogeneous opacification at the base of the right lung could be pneumonia. A different appearing abnormality obscures the left diaphragmatic contour. It could be new consolidation, pleural effusion or delayed expression of left diaphragmatic injury. Lateral view is recommended if feasible. Mediastinum normal. Upper lungs clear. No pneumothorax. ET tube in standard placement. Esophageal drainage tube ends in the mid stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ worsening hypotension in icu eval for cardiopulm change // ___ w/ worsening hypotension in icu eval for cardiopulm change ___ w/ worsening hypotension in icu eval for cardiopulm change IMPRESSION: Comparison to ___. Stable appearance of the monitoring and support devices. The patient continues to be rotated. Mild to moderate left pleural effusion is unchanged. Subsequent areas of retrocardiac atelectasis as well as the parenchymal opacity at the right lung bases is stable. No new parenchymal changes. No evidence of pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p polytrauma, remains intubated // eval for interval change eval for interval change IMPRESSION: Compared to chest radiographs ___ and ___ at 00:54. Bibasilar consolidation has developed since ___, worsened on the right since ___, and accompanied by new small left pleural effusion. Findings suggest aspiration pneumonia. Upper lungs clear. No pneumothorax. Heart size normal. Hyperinflation is probably due to emphysema. ET tube and nasogastric drainage tube are in standard placements. Radiology Report EXAMINATION: Portable upright chest INDICATION: ___ year old woman with poly-trauma // s/p right IJ placement TECHNIQUE: Portable upright chest x-ray COMPARISON: Comparison is made to chest x-rays dated from ___ through ___. FINDINGS: Heart size normal. The mediastinal silhouette is normal. The lungs are clear. There are bibasilar consolidation left greater than right likely consistent with a developing pneumonia. There is interval placement of a right jugular central venous catheter with the tip terminating in the distal SVC. There is no pneumothorax. Post ET tube and nasogastric tube again seen and unchanged in position. IMPRESSION: Interval placement of right jugular central venous catheter terminating in the distal SVC and no pneumothorax. Bibasilar opacifications left greater than right suggestive of developing pneumonia. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ intubated in icu // ___ intubated in icu ___ intubated in icu IMPRESSION: Comparison to ___. No relevant change is seen. The tip of the endotracheal tube projects 4 cm above the carina. The course of the feeding tube is stable. Stable correct position of the right internal jugular vein catheter. Minimal increase in extent of the pre-existing pleural effusion on the left. Otherwise the appearance of the lung parenchyma and the pleura is unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ intubated eval for cardiopulm change // ___ intubated eval for cardiopulm change IMPRESSION: With the exception of slight decrease in size of bilateral pleural effusions, there has not been a relevant change in the appearance of the chest since the previous study of 1 day earlier. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) LEFT INDICATION: ORIF LEFT LOWER LEG IN O.R. IMPRESSION: Fluoroscopic documentation of left lower extremity orif. No radiologist was present. Radiology Report EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT INDICATION: ___ year old woman s/p crush injury between 2 cars. Has significant left elbow swelling // eval for fracture TECHNIQUE: Frontal, oblique, and lateral view portable radiographs of the left elbow COMPARISON: None available FINDINGS: No fracture, dislocation, or degenerative change is detected. No suspicious lytic lesion is identified. The lateral radiograph is suboptimal for the assessment of a joint effusion. There is however soft tissue swelling around the olecranon. No soft tissue calcification or radiopaque foreign body is detected. IMPRESSION: No evidence of fracture or dislocation of the left elbow. Soft tissue swelling is present. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ h/o emphysema on home o2 presents after being pinned between 2 cars with R femur fracture, R tib plateau, R midshaft tibia fx, L tib plateau, L distal tibia fx. // please eval for pulmonary edema. Desatting despite increasing vent settings. Received blood transfusions and significant volume of fluids during surgery today. IMPRESSION: In comparison to ___ radiograph, allowing for differences in patient positioning, there has not been a relevant change in the appearance of the chest. Radiology Report EXAMINATION: Chest and pelvis radiograph INDICATION: ___ female with Trauma TECHNIQUE: Portable views of the chest and pelvis were obtained COMPARISON: None available FINDINGS: CHEST: There is mild-to-moderate dextroconvex scoliosis in the thoracic spine. The lungs are grossly clear without evidence of focal consolidation. There is no pleural effusion, pneumothorax, or pulmonary edema. The cardiomediastinal silhouette, pleural surfaces, and hilar contours are unremarkable. Endotracheal tube is seen terminating 2.9 cm above the carina. PELVIS: There is some obliquity in patient positioning. Hardware fusion device is noted in the lumbosacral spine. Subtle cortical defect in the left superior pubic ramus and left inferior pubic ramus may reflect acute fracture. Some soft tissue ossific densities are noted projecting over the bilateral thighs, possibly phleboliths or sequela of old injury. Moderate amount of stool burden is noted in the visualized bowel loops. IMPRESSION: 1. No acute cardiopulmonary process. 2. Suspect acute fractures at the left superior and inferior pubic rami. Radiology Report EXAMINATION: DX BILATERAL FEET INDICATION: ___ w/ BLE injuries please obtain bilateral AP and lateral and oblique foot XR // ___ w/ BLE injuries please obtain bilateral AP and lateral and oblique foot XR TECHNIQUE: Three views right foot, three views left foot obtained at patient's bedside. COMPARISON: None available. FINDINGS: Fine bony detail is obscured by the overlying back slabs. Right foot: An intramedullary nail in the distal tibia transfixing a comminuted distal tibial fracture is incompletely visualized. There appears to be a fracture through the posterior aspect of the calcaneus with a displaced bony fragment approximately 5 cm above the level of the posterosuperior calcaneus. Fractures of the bases of the first and second metatarsals were better demonstrated on the prior CTA. Left foot: An intramedullary nail and distal tibia is incompletely visualized. No fracture of the calcaneus is seen. The known fracture of the cuboid is not clearly demonstrated on the current study. Radiology Report EXAMINATION: FEMUR (AP AND LAT) RIGHT PORT INDICATION: ___ h/o emphysema on home o2 presents after being pinned between 2 cars with R femur fracture, R tib plateau, R midshaft tibia fx, L tib plateau, L distal tibia fx now s/p I D and ex-fix of R femur, R and L ankle // right femur fracture right femur fracture TECHNIQUE: AP and lateral views of the right femur. COMPARISON: Intraoperative right femur radiographs ___. FINDINGS: An intramedullary rod and fixation screws traverse the shaft of the right femur. A comminuted fracture in the distal right femur is noted with slight medial and posterior displacement of a butterfly type fracture fragment and slight lateral and anterior displacement of the dominant distal fracture fragment. There are ghost tracks noted in the proximal and mid right femur. . Overlying skin staples are present. At the upper periphery of the films, a small portion of lumbar spinal fixation hardware is noted, not fully evaluated. At the distal periphery of these films, the proximal most portion of the tibial IM rod is noted, also not fully evaluated. IMPRESSION: Status post internal fixation of right femoral fracture with comminuted fracture of the mid to distal right femur appear. Although there is some displacement of the fragments, overall alignment is anatomic. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) BILAT INDICATION: ___ h/o emphysema on home o2 presents after being pinned between 2 cars with R femur fracture, R tib plateau, R midshaft tibia fx, L tib plateau, L distal tibia fx now s/p I D and ex-fix of R femur, R and L ankle // bilateral tibial fx bilateral tibial fx TECHNIQUE: Frontal and lateral views of the mid bilateral tibia and fibulas. COMPARISON: Intraoperative tibia-fibula radiographs ___ Tubular fibula radiographs ___ FINDINGS: Right tibia and fibula: There is an intramedullary rod and fixation screws through the shaft of the right tibia. There is a an oblique fracture in the proximal tibia, a comminuted fracture in the distal to mid portion of the tibia with radiopaque material, and a comminuted fracture in the distal portion of the right tibia. Overall alignment is anatomic status post fixation. There is a comminuted fracture in the mid to distal right fibula as well as an incomplete fracture in the lateral aspect of the distal fibula. There is irregularity of the posterior aspect of the calcaneus with 2 ossified bodies overlying superior to the calcaneus which is concerning for possible calcaneal fracture/Achilles avulsion. This is not directly imaged due to overlying splint. At the upper edge of these films, the distal most portion of a femoral IM rod is noted. Left tibia and fibula: There is an intramedullary rod with fixation screws in the shaft of the left tibia with lateral and medial buttress plates along the proximal tibia. There is a tibial plateau comminuted fracture which extends to the proximal tibia as well as a comminuted fracture of the mid to distal tibia with overlying radiodense iatrogenic material. . There is a overriding transverse fracture of the proximal right fibular neck,, a comminuted fracture in the mid left fibula, and a large gap of bone missing in the mid to distal fibula. The lateral view raises the possibility of an additional fracture site at the distal most fibula. Ghost tracks are noted in the bilateral tibias. IMPRESSION: Status post internal fixation of bilateral multifocal tibia fractures as detailed above, including a left tibial plateau fracture. Multifocal fractures of both right and left fibula also present, also detailed above. Irregular appearance to the posterior right calcaneus, with 2 ossific type densities noted in the lower calf soft tissues, along the expected course of the Achilles tendon. Clinical correlation is requested. This area is partially obscured by splint, but the appearance raises the possibility of a posterior calcaneal fracture, possibly with Achilles tendon avulsion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ intubated eval for cardiopulm change // ___ intubated eval for cardiopulm change ___ intubated eval for cardiopulm change IMPRESSION: In comparison with the study of ___, the monitoring and support devices are stable. However, there has been an increase in the layering pleural effusions bilaterally with compressive atelectasis at the bases. This makes it somewhat difficult to assess the pulmonary vessels, which are mildly engorged an ill-defined, consistent with some elevation in pulmonary venous pressure. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p polytrauma, extubated reintubated for respiratory failure // eval ET tube placement TECHNIQUE: Chest single view COMPARISON: ___ 05:44 FINDINGS: Enteric tube tip is in the proximal stomach, should be advanced. Right IJ central line tip in the low SVC, similar. Endotracheal tube tip in good position. Bilateral moderate pleural effusions are stable. Bibasilar opacities, likely atelectasis stable. Increased heart size, pulmonary vascularity, stable. No pneumothorax. Thoracolumbar curve. Mild vertebral body height loss L1, stable. IMPRESSION: Stable exam. Enteric tube tip is in the proximal stomach, should be advanced. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p polytrauma, extubated reintubated for respiratory failure // eval for interval change eval for interval change IMPRESSION: Comparison to ___. No change in appearance of the monitoring and support devices. Stable bilateral moderate pleural effusions with subsequent areas basilar atelectasis. No cardiomegaly. No pneumothorax. Radiology Report EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT INDICATION: ___ h/o emphysema on home o2 presents after being pinned between 2 cars with R femur fracture, R tib plateau, R midshaft tibia fx, L tib plateau, L distal tibia fx; s/p ORIF's, free flap. Has VAP. With left thumb laxity. // ? soft tissue damage / fracture left thumb TECHNIQUE: Left hand three views. COMPARISON: None. FINDINGS: No fracture or dislocation is detected. There is marked narrowing of first CMC joint, consistent with severe osteoarthritis. This is associated with subluxation at the first CMC joint, which can occur secondary to osteoarthritis. There is mild radial subluxation of the first proximal phalanx with respect to the distal first metacarpal and minimal first MCP spurring. The IP joint is congruent, without gross degenerative change. There is severe diffuse osteopenia. Small focus of lucency seen at distal tuft of the fifth digit noted. Allowing for overlying materials, no radiopaque foreign body detected . Mild soft tissue swelling noted. IMPRESSION: No fracture or dislocation detected involving the left thumb. Severe first CMC osteoarthritis. Associated subluxation can occur due to osteoarthritis. Minimal subluxation at the first MCP joint, of indeterminate acuity. The appearance is compatible with mild laxity of the ulnar collateral ligament. If this represents a site of the patient's new-onset symptoms, this could reflect an injury to the ulnar collateral ligament. Small focus of lucency in the distal tuft of the left small finger distal phalanx. Unless there is focal tenderness in this location, this would likely be accounted for by degenerative changes. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new trach s/p prolonged intubation // eval for change TECHNIQUE: Single frontal view of the chest COMPARISON: ___. IMPRESSION: Left lower lobe consolidation has increased, concerning for pneumonia. Tracheostomy tube is in standard position. Right IJ catheter tip is in the lower SVC. NG tube tip is out of view below the diaphragm. Large bilateral pleural effusions are grossly stable allowing the difference in positioning of the patient. There is no evident pneumothorax. Radiology Report INDICATION: ___ year old woman s/p polytrauma s/p trach now with hypoxia // eval for interval change TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from earlier in the day FINDINGS: A tracheostomy tube is present. An enteric tube extends into the stomach. The tip of the right internal jugular central venous catheter extends into the distal SVC. Unchanged left lower lobe consolidation as well as layering bilateral pleural effusions. No pneumothorax identified. IMPRESSION: No significant interval change since the prior radiograph. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p polytrauma s/p trach // eval for interval change eval for interval change IMPRESSION: ET tube tip as 5.5 cm above the carinal. Right internal jugular line tip is at the level of cavoatrial junction. NG tube tip is in the stomach. Heart size and mediastinum are stable. Bilateral pleural effusions are moderate. There is no pneumothorax. Radiology Report INDICATION: Bilateral ankle fracture. External fixation. COMPARISON: None. IMPRESSION: Dictating radiologist was not present during the procedure. Right and left is not clearly labeled on the images. Numerous fluoroscopic images demonstrate placement of external fixation pins in the calcaneus and proximal tibial shaft and in the proximal femoral shaft. There are displaced fractures seen of the mid femoral shaft with a prominent butterfly fragment, of the proximal tibial metaphysis, and a severely comminuted fracture through the distal lower leg involving the tibia and fibula. Please refer to the operative note for additional details. The total intraservice fluoroscopic time was 47.7 seconds. Radiology Report EXAMINATION: CHEST PORT LINE/TUBE PLCT 1 EXAM INDICATION: ___ year old woman needing dobhoff placement // please come for x-rays to follow protocol for dobhoff placement please come for x-rays to follow protocol for dobhoff placement IMPRESSION: In comparison with the earlier study of this date, on the final image the opaque tip of the Dobhoff tube is in the lower stomach. Increasing opacification at the left base could be consistent with pleural fluid and atelectasis, though in the appropriate clinical setting it would be difficult to exclude superimposed pneumonia. Radiology Report EXAMINATION: FEMUR (AP AND LAT) RIGHT INDICATION: ___ year old woman s/p R. femur ORIF // s/p R. femur ORIF TECHNIQUE: Right femur two views COMPARISON: ___ FINDINGS: Intramedullary rod across mid diaphyseal fracture. Arterial calcifications. IMPRESSION: Intramedullary rod across mid diaphyseal fracture. Radiology Report EXAMINATION: KNEE (2 VIEWS) BILATERAL INDICATION: ___ s/p ORIF R/L femur // ___ s/p ORIF R/L femur TECHNIQUE: Bilateral knee two views COMPARISON: ___ FINDINGS: Right knee: Intramedullary rods in the femur, tibia across fractures. Surgical clips proximal leg. Pretibial soft tissue swelling. Arterial calcifications Left knee: Intramedullary rod, side plate, screws across complex fracture of the proximal tibia. Arterial calcifications. Proximal fibular fracture. Old tibial screw tracks in place. IMPRESSION: Postoperative changes, internal fixation bilaterally across fractures. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) BILATERAL INDICATION: ___ s/p ORIF R/L Tibia ORIF. // ___ s/p ORIF R/L Tibia ORIF. TECHNIQUE: Bilateral tibia fibula, two views each COMPARISON: ___ FINDINGS: Right Side: Intramedullary rod across complex tibial fracture, including proximal metaphyseal fracture, and fracture of the mid to distal thirds of the diaphysis, including. Fracture of the distal fibula. Surgical clips. Fracture of the medial malleolus. Fracture of the posterior calcaneus. Left side: Intramedullary rod, side plates across complex proximal tibial fracture, with intra-articular extension. Fracture of the mid-to-distal third of the diaphysis interval mild change of the orientation of the fracture. . Fracture of the mid to distal fibula, with resection of a component. Arterial calcifications. . IMPRESSION: Complex fractures, postoperative changes. Radiology Report EXAMINATION: CT OF THE CHEST ABDOMEN PELVIS AND LOWER EXTREMITIES INDICATION: ___ year old woman with bilateral lower extremity fractures, dopplerable ___ pulses // Polytrauma. Please obtain CT chest/abd/pelvis and CTA BLEs TECHNIQUE: Axial multidetector CT images were obtained through the thorax, abdomen, pelvis, and bilateral lower extremities before and after the uneventful administration of intravenous contrast in the arterial phase. Then, delayed imaging through the abdomen and pelvis and runoffs of the lower extremities were performed. Reformatted coronal and sagittal images through the chest, abdomen, pelvis, and lower extremities were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 17.9 s, 140.6 cm; CTDIvol = 3.4 mGy (Body) DLP = 473.3 mGy-cm. 2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP = 14.4 mGy-cm. 3) Spiral Acquisition 18.0 s, 141.9 cm; CTDIvol = 10.4 mGy (Body) DLP = 1,475.5 mGy-cm. 4) Spiral Acquisition 7.6 s, 59.9 cm; CTDIvol = 6.2 mGy (Body) DLP = 374.0 mGy-cm. 5) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 6.2 mGy (Body) DLP = 318.5 mGy-cm. Total DLP (Body) = 2,656 mGy-cm. COMPARISON: None. FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber, with moderate atherosclerosis and no evidence of acute injury. The heart, pericardium, and great vessels are within normal limits. Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. No pericardial effusion is seen. There are coronary artery calcifications. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal hematoma. An NG tracheal tube is in place. PLEURAL SPACES: There are small bilateral pleural effusions. No pneumothorax. LUNGS/AIRWAYS: There is no evidence of acute injury to the lungs. Mild subsegmental atelectasis at the lung bases are noted. There is mild centrilobular emphysema, predominantly at the lung apices. 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: A small amount of simple ascites is seen in the abdomen and pelvis. HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Two subcentimeter well-defined round hypodensities are seen in the right lobe of the liver, too small to characterize but likely represent small cysts or biliary hamartomas. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. A 3 cm simple cyst is seen in the midpole of the left kidney. Additional subcentimeter cortical hypodensities are seen in the left kidney, too small to characterize but statistically likely to represent cysts. On made and nonobstructive stone is seen in the right kidney. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: A small hiatal hernia is noted. The stomach is otherwise unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is mild diverticulosis of the sigmoid colon. The appendix is not visualized. PELVIS: A Foley catheter is seen within the bladder. There is no evidence of contrast extravasation to suggest a bladder rupture on the delayed images. Simple free fluid is seen within the pelvis. REPRODUCTIVE ORGANS: Small calcified fibroids are noted within the uterus, not well visualized. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. BONES AND SOFT TISSUES: There are subacute fractures of the right sixth and seventh ribs posteriorly. There is an old sternal fracture. There are chronic appearing compression fractures of the T7 and L1 vertebral bodies, with levoconvex scoliosis of the lumbar spine. Hardware for posterior fusion of L5 and S1 is noted. There is a comminuted fracture of the left iliac wing and fractures of the left superior and inferior pubic rami, with minimal diastasis of the left SI joint and pubic symphysis. In the right lower extremity, there is a comminuted fracture of the distal right femoral diaphysis with valgus angulation. There are small intramuscular hematomas surrounding the fracture. There are complex comminuted open fractures of the right tibia and fibula. The fractures involve the proximal metadiaphysis of the tibia, the mid to distal shaft, and the distal metaphysis extending into the joint with involvement of the medial malleolus. At the mid to distal tibial shaft, there is a large cutaneous defect with subcutaneous air. Fractures of the right fibula are seen in the proximal to distal diaphysis, and in the lateral malleolus with involvement of the syndesmosis. In the right foot, there are mildly displaced comminuted fractures of the posterior calcaneus, an intra-articular fracture of the calcaneus anteriorly involving the calcaneal cuboid joint, and minimally displaced fractures at the base of the first and second metatarsals. In the left lower extremity, there is a comminuted intra-articular fracture of the left proximal tibial metadiaphysis with depression of the medial tibial plateau (Schatzker VI), and a comminuted fracture of the distal tibial diaphysis extending into the metaphysis. The tibial plafond is not involved. A large cutaneous defect is seen along the mid to distal tibial diaphysis with subcutaneous air. In the left fibula, and there is a comminuted impacted fracture of the proximal metaphysis, and a comminuted fracture extending from the mid diaphysis down to the distal metaphysis. In the left foot, there is a minimally displaced comminuted intra-articular fracture of the cuboid. There is external fixation of the right femur and bilateral tibia. VASCULAR: There is no evidence of active extravasation in the abdomen and pelvis. There are extensive atherosclerotic changes of the abdominal aorta with soft and calcified plaque. The celiac axis, SMA, bilateral renal arteries, and ___ are patent. There is severe narrowing of the right common, external, and internal iliac arteries. On the left, there is severe narrowing the common and external iliac arteries, with complete occlusion of the left internal iliac artery. A left-sided femoral line is in place. In the right lower extremity, there is moderate to severe stenosis of the common and superficial femoral arteries. The popliteal artery is patent. The tibialis anterior and peroneal arteries are patent down to the mid lower leg, at the level of the large cutaneous defect. The dorsalis pedis artery is not visualized. The posterior tibial artery and plantar arch are patent. In the left lower extremity, there is severe narrowing of the common femoral artery. The superficial femoral artery and popliteal artery are patent. The anterior tibial and peroneal arteries are patent down to the mid lower leg, at the level of the large cutaneous defect. The dorsalis pedis artery is not visualized. The posterior tibial artery and plantar arch are patent. IMPRESSION: 1. Extensive comminuted open fractures involving the bilateral lower extremities as described. The bilateral anterior tibial and peroneal arteries are not visualized distal to the level of the mid tibia, concerning for vascular injury. 2. Multiple pelvic fractures as described. There is no evidence of active extravasation or large extraperitoneal hematomas. 3. Small amount of simple ascites without evidence of traumatic injury to the intra-abdominal organs. 4. Small bilateral pleural effusions without evidence of acute intrathoracic injury. NOTIFICATION: The findings were discussed with Dr. ___ Dr. ___, ___. by ___, M.D. on the telephone on ___ at 12:10 AM, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman s/p pinned between 2 cars with multiple lower extremity fractures // eval for acute process TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 19.0 cm; CTDIvol = 47.6 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass effect. The ventricles and sulci are mildly prominent suggestive of generalized parenchymal volume loss. An endotracheal tube and orogastric tube are present. There is peripheral calcification of the cavernous portion of the left internal carotid artery measuring 1.6 x 1.4 x 1.1 cm, highly suspicious for an underlying aneurysm. No osseous abnormalities seen. There is mucosal thickening of the right maxillary sinus, ethmoid air cells, left sphenoid sinus and several of mastoid air cells, likely related to the intubation. The orbits are unremarkable apart from bilateral lens replacements. IMPRESSION: 1. No acute intracranial abnormality 2. Peripheral calcification of the cavernous portion of the left internal carotid artery measuring 1.6 x 1.4 x 1.1 cm, highly suspicious for an underlying aneurysm. Radiology Report EXAMINATION: CT C-SPINE W/CONTRAST INDICATION: ___ year old woman s/p pinned between 2 cars with multiple lower extremity fractures // eval for fractures TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.0 s, 19.6 cm; CTDIvol = 36.8 mGy (Body) DLP = 720.6 mGy-cm. Total DLP (Body) = 721 mGy-cm. COMPARISON: None available FINDINGS: There is exaggerated lordosis of the cervical spine. A minimal retrolisthesis of C3 on C4 is present. Additionally there is widening of the anterior disc space at C6-C7 which may reflect underlying ligamentous injury. There is a small amount of high-density material noted in the epidural space posteriorly at the levels of C5-C6 and C6-C7 reflective of acute hemorrhage. No fractures are identified.There is no significant canal or foraminal narrowing. The presence of endotracheal tube limits the assessment for prevertebral soft tissue swelling. The thyroid is unremarkable. Emphysematous changes are noted at both lung apices as well as a partially imaged pleural based lesion at the right lung apex. IMPRESSION: 1. Widening of the anterior disc space at C6-C7 which may reflect underlying ligamentous injury 2. High-density material in the posterior epidural space at C5-C6 and C6-C7, reflective of acute hemorrhage. Findings were communicated to and acknowledged by Dr. ___ Dr. ___ By ___, MD at ___ and ___ respectively, 20 minutes after discovery of findings. RECOMMENDATION(S): MRI of the cervical spine to assess the extent of injuries. Gender: F Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Ped struck Diagnosed with Traumatic shock, initial encounter, Ped on foot injured pick-up truck, pk-up/van in traf, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: unable level of acuity: 1.0

Dear Ms. ___, You were admitted to ___ for bilateral lower extremity fractures and underwent Right tibial and femoral nail, L tibia ORIF, tracheostomy, G-tube placement. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: General Surgery: 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. Wound care instructions: *For the left lower extremity you will need daily dressing changes that consist of warm soap and water applied with 4x4 sterile gauze. This should be allowed to dry and followed by thin layer of A&D ointment over which xeroform should be applied over the wound. Next please take ___ sterile gauze 4x4's and unfold them to create large area with multiple layers of dressing. Place this over the xeroform bandages. Lastly, wrap the extremity in Webril gauze. *For the right lower extremity you will need daily dressing changes that consist of xeroform applied to wounds followed by ___ sterile gauze 4x4's and unfold and layer them to create large area with multiple layers of dressing. Lastly, wrap the extremity in Webril gauze.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Right IJ tunneled catheter History of Present Illness: ___ hx DM (metformin controlled), HTN, HLD, GERD presents with substernal chest pressure prior to arrival. Chest pain onset during watching TV and unrelated with exertion or arm movement. Pleuritic in nature. No recent URIs, no subjective SOB. Pt says the pain went away without intervention. Also had mild concomitant back pain. Reported to have rhythm strips concerning for lateral ST depressions. Received SL NTG x 3, ASA, with normalization. Pt has noted some ankle edema but says this symptom comes and goes. Denies orthopnea, increasing SOB, significant weight gain (although she does not weigh herself regularly). At baseline she says she is 130lbs. Denies cough, fevers/chills, hematuria, new medications. In ED initial vitals were T 99.3 HR 94 BP 201/75 RR 34 SpO2 95% RA. Noted to have abnormal chem 7 with K of 5.4, HCO 12, BUN 91, Cr 9.0 (baseline 1.3 in ___. A troponinemia to 0.07 with CKMB 5. Noted to have HgB 6.2 under a baseline of 11.9. EKG showed NSR at 95 with almost LVH by voltage criteria without ST changes. Bedside echo showed no pericardial effusion. Renal ultrasound in ED showed atrophic and echogenic kidneys suggesting chronic kidney disease. No hydro, nephrolithiasis. Multiple cysts bilaterally showed no complex features. Guaic was negative. Of note: UOP was only 30ccs in the ED. Pt was given 2mg IV morphine, SL Nitro, Ativan, 2 units PRBC and 10mg IV Labetalol prior to MICU transfer. Past Medical History: HTN HLD DM A1c 7.2% in ___ GERD Social History: ___ Family History: Mother ___ @ ___: DM Father ___ @ ___: Heart Disease Brother died in ___ DM Sister Died in ___ lung cancer 2 living brothers Physical ___: ADMISSION PHYSICAL EXAM: General: Comfortable, AOx3, responds appropriately to questions, fine tremor, perseverative HEENT: Sclera anicteric, MMM, oropharynx clear, no periorbital edema Neck: supple, JVP elevated to mandible, +HJR, no LAD Lungs: bilateral crackles to ___ lung b/l, mild wheezes diffusely, rales CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema, warm, well perfused, 2+ pulses DISCHARGE PHYSICAL EXAM: VS - 98.0 147(147-171)/38(38-47) 57(56-63) 18 98%RA Weight: 64.7 on ___ on ___ ___ BS: ___ General: Well appearing, lying comfortably in bed, NAD HEENT: Anicteric sclerae, ___, EOMI, MMM Neck: supple, full ROM, no LAD, JVP not elevated, tunneled cath site bandage c/d/i CV: RRR, no mrg Lungs: Decreased breath sounds at bases bilaterally Abdomen: nl BS, soft, NTND, no HSM GU: no Foley Ext: Bilateral symmetric 2+ pitting edema to ankle. Neuro:AAOx3 (person,place,year), CNIII-XII intact, equal strength throughout all extremities, no asterixis Pertinent Results: PERTINENT BLOOD: ___ 07:50PM BLOOD WBC-7.4 RBC-2.07* Hgb-6.2* Hct-19.3* MCV-94 MCH-29.9 MCHC-32.0 RDW-15.4 Plt ___ ___ 12:58AM BLOOD WBC-10.3 RBC-2.51* Hgb-7.5* Hct-22.8* MCV-91 MCH-29.8 MCHC-32.7 RDW-15.4 Plt ___ ___ 06:45AM BLOOD WBC-3.3* RBC-2.20* Hgb-6.6* Hct-20.6* MCV-94 MCH-29.9 MCHC-31.9 RDW-15.3 Plt ___ ___ 07:20AM BLOOD WBC-6.6 RBC-2.79* Hgb-8.4* Hct-25.2* MCV-90 MCH-29.9 MCHC-33.2 RDW-15.4 Plt ___ ___ 07:15AM BLOOD WBC-6.7 RBC-2.77* Hgb-8.3* Hct-25.6* MCV-92 MCH-30.2 MCHC-32.6 RDW-14.5 Plt ___ ___ 07:50PM BLOOD Glucose-239* UreaN-91* Creat-9.0* Na-143 K-5.4* Cl-114* HCO3-12* AnGap-22* ___ 06:45AM BLOOD Glucose-197* UreaN-123* Creat-10.0* Na-142 K-5.4* Cl-109* HCO3-12* AnGap-26* ___ 07:20AM BLOOD Glucose-231* UreaN-164* Creat-11.4* Na-138 K-5.0 Cl-104 HCO3-12* AnGap-27* ___ 07:15AM BLOOD Glucose-164* UreaN-40* Creat-4.2*# Na-139 K-3.7 Cl-100 HCO3-29 AnGap-14 ___ 12:58AM BLOOD TotProt-5.4* Calcium-7.2* Phos-7.9* Mg-1.6 Iron-31 ___ 07:40PM BLOOD Calcium-8.0* Phos-10.7* Mg-2.0 ___ 07:20AM BLOOD Calcium-7.4* Phos-12.4* Mg-2.0 ___ 07:15AM BLOOD Calcium-7.6* Phos-4.4 Mg-1.8 ___ 07:50PM BLOOD ALT-9 AST-14 LD(LDH)-231 CK(CPK)-95 AlkPhos-49 TotBili-0.2 ___ 07:50PM BLOOD cTropnT-0.07* ___ 12:58AM BLOOD CK-MB-4 cTropnT-0.06* ___ 12:31PM BLOOD CK-MB-3 cTropnT-0.07* ___ 12:31PM BLOOD Ret Aut-2.0 ___ 07:50PM BLOOD Hapto-128 ___ 12:58AM BLOOD calTIBC-285 Ferritn-89 TRF-219 ___ 12:58AM BLOOD TSH-1.7 ___ 12:00PM BLOOD %HbA1c-5.5 eAG-111 ___ 12:58AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 12:58AM BLOOD HCV Ab-NEGATIVE ___ 07:35AM BLOOD ANCA-NEGATIVE B ___ 07:35AM BLOOD ___ ___ 12:58AM BLOOD PEP-NO SPECIFI ___ 07:35AM BLOOD ANTI-GBM-Test <1.0 ___ 12:58AM BLOOD C3-101 C4-22 ___ 11:20PM BLOOD Lactate-1.5 URINE: ___ 11:00PM URINE RBC-4* WBC-5 Bacteri-MOD Yeast-NONE Epi-1 TransE-1 ___ 11:00PM URINE Blood-SM Nitrite-NEG Protein-600 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:58AM URINE ___ Bacteri-FEW Yeast-NONE ___ 12:58AM URINE Hours-RANDOM UreaN-425 Creat-70 Na-47 K-44 Cl-48 TotProt-1225 Prot/Cr-17.5* ___ 02:30PM URINE Hours-RANDOM Creat-25 TotProt-327 Prot/Cr-13.1* MICRO: ___ URINE CULTURE: ESCHERICHIA COLI. >100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL MORPHOLOGIES. CITROBACTER FREUNDII COMPLEX. ___ ORGANISMS/ML. EKG ___ Sinus rhythm. Prominent voltage in leads I and aVL for left ventricular hypertrophy. Delayed R wave transition. No previous tracing available for comparison. IMAGING: ___ R LENIs: No evidence of DVT within the right lower extremity. ___ Cardiovascular ECHO: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, posteriorly directed jet of mild to moderate (___) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Preserved biventricular systolic function. Increased left ventricular filling pressure. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Left pleural effusion. ___ Rena1 U/S: 1. Atrophic and echogenic appearance of the kidneys is compatible with chronic kidney disease. No hydronephrosis or nephrolithiasis. Multiple cysts bilaterally show no complex features. No hydronephrosis. 2. Small right pleural effusion. ___ CXR: Pulmonary edema with large left and small right pleural effusions is concerning for heart failure. Post diuresis films to exclude underlying LLL pneumonia is recommended Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Simvastatin 20 mg PO DAILY 3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 4. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 5. Omeprazole 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. Simvastatin 20 mg PO DAILY 3. Amlodipine 5 mg PO DAILY 4. Carvedilol 25 mg PO BID 5. Furosemide 80 mg PO BID 6. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 7. Nephrocaps 1 CAP PO DAILY 8. PredniSONE 40 mg PO DAILY 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 11. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Chest pain Hypertensive urgency Kidney failure Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Chest pain. COMPARISON: None. FINDINGS: A moderate-to-large left pleural effusion with lower lobe consolidation, which may represent atelectasis or pneumonia, is seen. The left heart border is obscured by this process. A small right pleural effusion is also seen. Indistinctness of the hilar markings is indicative of pulmonary edema. The upper mediastinal contour appears within normal range for size. There is no pneumothorax. IMPRESSION: Pulmonary edema with large left and small right pleural effusions is concerning for heart failure. Post diuresis films to exclude underlying LLL pneumonia is recommended. Radiology Report INDICATION: ___ female with new acute kidney disease. Evaluate for evidence of hydronephrosis. COMPARISON: None available. TECHNIQUE: Grayscale and color Doppler images of both kidneys were obtained. FINDINGS: The right and left kidneys measure 8.4 and 8.9 cm respectively. No hydronephrosis, but the kidneys are echogenic with loss of corticomedullary differentiation suggesting chronic medical renal disease. Multiple cysts are noted in both kidneys, without internal flow or obvious complex features. There is no nephrolithiasis. A small right pleural effusion is incidentally noted. IMPRESSION: 1. Atrophic and echogenic appearance of the kidneys is compatible with chronic kidney disease. No hydronephrosis or nephrolithiasis. Multiple cysts bilaterally show no complex features. No hydronephrosis. 2. Small right pleural effusion. Radiology Report HISTORY: ___ female with acute on chronic renal failure. Tunneled hemodialysis catheter needed for hemodialysis. COMPARISON: Chest x-ray ___ CLINICIANS: Dr. ___ physician) and Dr. ___ (fellow). The attending was present throughtout the entirety of the procedure. Anesthesia: 0.5 mg of Versed and was used for the procedure. 1% lidocaine and lidocaine mixed with epinephrine were used for local anesthesia. PROCEDURE: 1. Right internal jugular venous access. 2. Subcutaneous tunneling from the right internal jugular vein to the right upper chest. 3. Placement of a 19 cm cuff to tip double lumen hemodialysis catheter. FINDINGS: The procedure was discussed in detail with the patient and risks and benefits emphasized. Informed written consent was obtained. When the patient arrived in the angiography suite, they were placed supine on the procedure table. The right upper chest was prepped and draped in usual sterile fashion. A preprocedural time out was performed per ___ protocoll. Under continuous ultrasound guidance, the right internal jugular vein, which was patent and compressible, was accessed using a micropuncture needle. A Nitinol wire was then passed into the right side of the heart and the needle exchanged for a micropuncture sheath. The inner dilator and Nitinol wire were removed and ___ wire was advanced through the heart into the IVC under fluoroscopic guidance. A measurement was obtained from this wire and the wire was then secured to the drape. The direction of the tunnel was determined and the tunnel tract was anesthetized with lidocaine with epinephrine. The catheter was tunneled underneath the skin. The right internal jugular vein sheath was removed and the tract was dilated. The catheter was inserted into the peel-away sheath and advanced into the right atrium. Final fluoroscopic image demonstrated the tip terminating in the right atrium. Good blood return from both lumens. The catheter was secured to the skin using Vicryl sutures. The venotomy site was closed using a subcutaneous stitch. The patient left the department in stable condition. No complications. IMPRESSION: Uncomplicated placement of a right-sided double-lumen 19 cm tip to cuff tunneled hemodialysis catheter via the internal jugular vein. Tip in right atrium. Ready to use. Radiology Report MEDICAL HISTORY: This patient is an ___ woman with diabetes and hypertension complicated by chronic renal failure. We are asked to perform vein mapping prior to left arteriovenous fistula. FINDINGS: Venous duplex ultrasound was performed on the left upper extremity. This demonstrated a patent basilic and cephalic vein. Basilic vein measurements range from 0.59 cm to 0.19 cm and 0.38 to 0.27 cm in the cephalic vein. Brachial arteries were patent and did not have significant calcifications. IMPRESSION: Patent left basilic and cephalic veins with measurements as shown. Patent brachial and radial arteries with no significant calcifications. Radiology Report HISTORY: ___ female with swelling in the right leg. Please evaluate for DVT. COMPARISON: None. FINDINGS: Grayscale and Doppler evaluation of the right common femoral, superficial femoral, and popliteal veins was performed demonstrating normal compressibility, blood flow, and response to augmentation. The posterior tibial and peroneal veins of the right upper calf appear patent with normal compressibility and blood flow demonstrated. IMPRESSION: No evidence of DVT within the right lower extremity. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, ANEMIA NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dear Ms. ___, It was a pleasure being part of your care team at ___. You were evaluated for chest pain and kidney failure. Your chest pain resolved shortly after arriving at the hospital and did not return. We ran several tests to determine the cause of your kidney failure and it appears to have occurred gradually over the past few years. You will need to continue the dialysis sessions which you started at the hospital three times/week and follow up with your kidney doctor to discuss further management. It was a pleasure taking care of you.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: fish / Spiriva with HandiHaler / Lithium Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with a history of Churg ___, COPD on 2___, esophageal dysmotility, aspiration PNA s/p PEG tube and history of PE s/p IVC filter presents to ED after having one day history of chest pain and shortness of breath. He reports having chronic rib cage pain associated with coughing. He reports since last night he has been having chest tightness like asthma and worsening of his rib cage pain for the past day which has lasted for hours. He reports that he felt shortness of breath like asthma again later on the day when his chest pressure had subsided.He does not report fevers, chills, vomiting, or diarrhea. He is currently on J-tube feedings due to his persistent reflux leading to recurrent aspiration pneumonia. He is on prednisone due to his eosinophilic lung disease which has been slowly tapered. He states he is taking his medications as he is instructed. He was recently hospitilized from ___ - ___ for aspiration pneumonia treated with augment. He was also hospitalized from ___ for pneumonia. In the ED, initial VS: 98.4 65 92/58 18 95% 4L. CXR demonstrated persistent and possibly worsening bilateral infiltrates. Labs notable for normal lactate and absence of leukocytosis. He was given solumedrol, albuterol nebs and levoquin for COPD exacerbation and subsequently admitted to medicine service for further evaluation and management. On the floor, he reports he feels better after steroids/nebs/abx in the ED. REVIEW OF SYSTEMS: Reports chronic constipation Denies headache, vision changes, rhinorrhea, congestion, sore throat, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena Past Medical History: Suspected Churg ___ Recurrent aspiration pneumonia h/o PE s/p IVC filter MS ___ in ___, presenting with optic neuritis and lower extremity weakness) chronic back pain s/p spinal fusion depression bipolar disorder hypothyroidism henia repair multiple spinal compression fractures (thought to be secondary to prednisone use) COPD with 2L NC at home OSA with CPAP at home Social History: ___ Family History: Not discussed this admission Physical Exam: ADMISSION EXAM VS - 97.8 121/70 62 20 95%___ GENERAL - Alert, interactive, NAD HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - able to complete sentences, rhonchi at bases b/l, faint wheezes diffusely ABDOMEN - NABS, soft/NT/ND, G tube site with no purulent drainage or surrounding erythema EXTREMITIES - WWP, trace edema b/l LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact DISCHARGE EXAM VS - 98.9 97.8 106-139/54-69 ___ 91-92% RA-95-97%___ GENERAL - Alert, interactive, NAD, chronically ill appearing HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD HEART - PMI non-displaced, Somewhat distant heart sounds, RRR, nl S1-S2, no MRG LUNGS - able to complete sentences, improved aeration compared to yesterday. Rhonchi at bases b/l, faint wheezes diffusely ABDOMEN - Mild TTP LLQ, G tube site with no purulent drainage or surrounding erythema EXTREMITIES - WWP, no edema b/l. B/l calf ttp R>L no erythema or swelling LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS ___ 09:50PM WBC-5.5 RBC-3.40* HGB-10.3* HCT-32.1* MCV-94 MCH-30.2 MCHC-32.0 RDW-15.0 ___ 09:50PM NEUTS-51.5 ___ MONOS-5.7 EOS-16.2* BASOS-0.3 ___ 09:50PM PLT COUNT-235 ___ 09:50PM GLUCOSE-80 UREA N-15 CREAT-0.5 SODIUM-139 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 ___ 10:10PM LACTATE-1.0 Cardiac Enzymes ___ 09:50PM BLOOD cTropnT-<0.01 ___ 07:20AM BLOOD CK-MB-2 cTropnT-<0.01 MICRO ___ RESPIRATORY CULTURE-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING DISCHARGE LABS ___ 07:30AM BLOOD WBC-6.1# RBC-3.41* Hgb-10.3* Hct-32.0* MCV-94 MCH-30.3 MCHC-32.3 RDW-15.7* Plt ___ ___ US IMPRESSION: 1. No evidence of deep vein thrombosis in either leg. 2. Unusual echogenicities is with posterior shadowing suggestive of dystrophic calcifications in the superficial tissues of the left calf. A lower extremity x-ray suggested to evaluate for soft tissue calcifications. CT CHEST FINDINGS: Again seen is moderate, apical-predominant centrilobular and paraseptal emphysema. Scattered areas of perifissural and subpleural scarring are unchanged. There is no evidence of interstitial abnormality or fibrosis. Prior peribronchiolar ground-glass opacities in all lobes have nearly resolved. Persistent consolidative collapse in the right middle lobe is nearly lobar and in the left lower lobe, segmental. There is minimal associated air trapping. Regional varicoid bronchiectasis and bronchiolectasis indicate longstanding inflammation. There are no obstructing endobronchial lesions. There is a small amount of retained secretions in the trachea. Tiny tracheal diverticula are noted at the thoracic inlet and carina. Chain suture is noted in the posterior segment of the left lower lobe from prior VATS resection. There are no pleural effusions. Heart is normal in size, with a trace physiologic pericardial effusion. Moderate calcifications are noted throughout the thoracic aorta, coronary arteries, and posterior descending artery. Right coronary artery stent is in appropriate position. The central pulmonary arteries are unremarkable. Relative hypoattenuation of the blood pool is compatible with anemia. Intrathoracic lymph nodes have increased, measuring 11 mm in the aortopulmonary window. 7-mm in the precarinal, and 9 mm in the subcarinal stations. Examination is not tailored for subdiaphragmatic evaluation, but reveals percutaneous gastrostomy tube in appropriate position. Nonspecific hypodensity noted in hepatic segments ___. There is a 4.2 x 2.8 cm exophytic cyst arising from the right renal interpole. Dense calcifications in the upper abdominal aorta and splenic artery. The bones are diffusely demineralized. Multiple old healed bilateral rib fractures are noted. There has been interval progression of anterior compression deformities in the T7 and T10-L3 vertebrae. Vertebroplasty changes are noted in T7 and T12, with 50% and 80% respective loss of height, and 2-mm retropulsion of T12 into the spinal canal. IMPRESSION: 1. Chronic adhesive atelectasis right middle and left lower lobes. 2. No current findings of eosinophilic or interstitial lung disease. 3. Severe atherosclerosis. 4. Progression of multilevel compression deformities, with T7 and T12 vertebroplasty. Medications on Admission: 1. albuterol sulfate 90 mcg HFA 2 puffs as needed for SOB 2. Pravastatin 40 mg PG qhs 3. Azathioprine 150 mg PG qhs 4. Celexa 30 mg PG qhs 5. Fentanyl patch 50 mcg/hr q72 6. Neurontin 800 mg PG TId 7. Duoneb q6 hours 8. Lansoprazole 30 mg PG ___ 9. Levothyroxine 25 mcg PG ___ 10. Metoclopramide 2.5 mg PG QID 11. Morphine 25 mg PG 5xday as needed for pain 11. Mucomyst neb 300 mg q6 prn 12. KCl 40 meq PG ___ 13. Prednisone 4 mg ___ qdaily 14. Protein power 1 scoop BID 15. Quetiapine 100 mg PG ___ 16. Risperidone 1 mg PG q6 prn agitation 17. Bactrim DS PG QOD 18. Trazodone 25 mg PG qhs 19. Tylenol ___ PG ___. Aspirin 81 PG ___ 21. Bisacodyl 10 PR ___ 22. CaCO3 500 mg TID 23. Vitamin D3 1000 units PG ___ 24. Colace 100 mg PG BID 25. Senna 8.6 PG BID Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every four (4) hours. 2. pravastatin 20 mg Tablet Sig: Two (2) Tablet ___ (___). 3. azathioprine 50 mg Tablet Sig: Three (3) Tablet ___ (___). 4. citalopram 20 mg Tablet Sig: 1.5 Tablets ___. 5. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Transdermal Q72H (every 72 hours): Please add 12 mcg patch as well. 6. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) for 1 doses: In addition to 50 mcg patch. 7. gabapentin 800 mg Tablet Sig: One (1) Tablet ___ three times a day. 8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours. 9. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1) Tablet,Rapid Dissolve, ___ ___. 10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___ (___). 11. metoclopramide 5 mg/5 mL Solution Sig: 2.5 mg ___ QIDACHS (4 times a day (before meals and at bedtime)). 12. morphine 10 mg/5 mL Solution Sig: Ten (10) mg ___ every six (6) hours as needed for Mild pain. 13. morphine 10 mg/5 mL Solution Sig: ___ (25) mg ___ every six (6) hours as needed for pain. 14. Med Mucomyst neb 300 mg q6 prn 15. potassium chloride 20 mEq Packet Sig: Two (2) ___ once a day. 16. prednisone 10 mg Tablet Sig: ASDIR Tablet ___ once a day: 30mg ___ for two days, then 20 mg for two days, then 10 mg ___. 17. quetiapine 25 mg Tablet Sig: Four (4) Tablet ___ (___). 18. risperidone 1 mg Tablet Sig: One (1) Tablet ___ every six (6) hours as needed for agitation. 19. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet ___ MWF (___). 20. trazodone 50 mg Tablet Sig: 0.5 Tablet ___ HS (at bedtime) as needed for insomnia. 21. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) ___ Q6H (every 6 hours). 22. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable ___. 23. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal ___. 24. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable ___ TID W/MEALS (3 TIMES A DAY WITH MEALS). 25. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule ___ once a day. 26. docusate sodium 50 mg/5 mL Liquid Sig: One (1) ___ BID (2 times a day). 27. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a day). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis Churg ___ syndrome Chronic musculoskeletal pain Secondary Diagnoses COPD Esophageal dysmotility 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: ___ male with chest pain and shortness of breath. Recently admitted for aspiration pneumonia. COMPARISON: ___. FINDINGS: There are low lung volumes, with improvement in bibasilar airspace opacity. Bilateral lower lung streaky opacities are slightly improved from prior study suggesting slight interval improvement in aeration. The cardiac silhouette is stable, and normal in size. The mediastinal contours are notable for calcification of the aortic arch. Vertebroplasty cement is noted at two vertebral body levels. Radiology Report HISTORY: ___ man with prior PE, new SOB and chest pain. COMPARISON: No previous exam for comparison. FINDINGS: Grayscale, color and spectral Doppler images were obtained of bilateral common femoral, femoral, popliteal and tibial veins. Normal flow, compression and augmentation is seen in all vessels. Note is made of an unusual appearance of superficial echogenic densities with posterior shadowing. This could represent calcifications or air within the superficial tissues of the left calf. IMPRESSION: 1. No evidence of deep vein thrombosis in either leg. 2. Unusual echogenicities is with posterior shadowing suggestive of dystrophic calcifications in the superficial tissues of the left calf. A lower extremity x-ray suggested to evaluate for soft tissue calcifications. Radiology Report INDICATION: ___ male prior smoker with COPD, eosinophilic lung disease, and recurrent aspiration pneumonias. Has new dyspnea. COMPARISON: Multiple chest CTs from ___ between ___ and ___. TECHNIQUE: With the patient in supine position, helical MDCT images were acquired through the chest without intravenous contrast at end-inspiration and expiration. 5, 2.5, and 1.25-mm axial images were generated in soft tissue and lung kernels . 1.3-mm coronal and 5-mm sagittal multiplanar reformats were also created. The patient was unable to tolerate prone positioning. FINDINGS: Again seen is moderate, apical-predominant centrilobular and paraseptal emphysema. Scattered areas of perifissural and subpleural scarring are unchanged. There is no evidence of interstitial abnormality or fibrosis. Prior peribronchiolar ground-glass opacities in all lobes have nearly resolved. Persistent consolidative collapse in the right middle lobe is nearly lobar and in the left lower lobe, segmental. There is minimal associated air trapping. Regional varicoid bronchiectasis and bronchiolectasis indicate longstanding inflammation. There are no obstructing endobronchial lesions. There is a small amount of retained secretions in the trachea. Tiny tracheal diverticula are noted at the thoracic inlet and carina. Chain suture is noted in the posterior segment of the left lower lobe from prior VATS resection. There are no pleural effusions. Heart is normal in size, with a trace physiologic pericardial effusion. Moderate calcifications are noted throughout the thoracic aorta, coronary arteries, and posterior descending artery. Right coronary artery stent is in appropriate position. The central pulmonary arteries are unremarkable. Relative hypoattenuation of the blood pool is compatible with anemia. Intrathoracic lymph nodes have increased, measuring 11 mm in the aortopulmonary window. 7-mm in the precarinal, and 9 mm in the subcarinal stations. Examination is not tailored for subdiaphragmatic evaluation, but reveals percutaneous gastrostomy tube in appropriate position. Nonspecific hypodensity noted in hepatic segments ___. There is a 4.2 x 2.8 cm exophytic cyst arising from the right renal interpole. Dense calcifications in the upper abdominal aorta and splenic artery. The bones are diffusely demineralized. Multiple old healed bilateral rib fractures are noted. There has been interval progression of anterior compression deformities in the T7 and T10-L3 vertebrae. Vertebroplasty changes are noted in T7 and T12, with 50% and 80% respective loss of height, and 2-mm retropulsion of T12 into the spinal canal. IMPRESSION: 1. Chronic adhesive atelectasis right middle and left lower lobes. 2. No current findings of eosinophilic or interstitial lung disease. 3. Severe atherosclerosis. 4. Progression of multilevel compression deformities, with T7 and T12 vertebroplasty. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CP Diagnosed with FOOD/VOMIT PNEUMONITIS temperature: 98.4 heartrate: 65.0 resprate: 18.0 o2sat: 95.0 sbp: 92.0 dbp: 58.0 level of pain: 8 level of acuity: 2.0

Dear Mr. ___, Thank you for coming to the ___ ___. You were admitted because you were having shortness of breath. We believe this is related to your churg ___ syndrome. We increased your prednisone dose. You will need to taper the dose of prednisone and follow up with your pulmonologist as directed. We are glad that you are feeling better. We also increased the dose of your fentanyl patch and adjusted the dose of morphine. Medication recommendations -Please take 30 mg prednisone ___ for 2 days then 20 mg ___ for two days then 10 mg ___ until you follow up with your pulmonologist -Please increase Fentanyl patch to 62 mg -Please take ___ mg morphine Q6 hours as needed for pain

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Upper GIB Major Surgical or Invasive Procedure: ___: EGD ___: Colonoscopy History of Present Illness: ___ y/o M w/PMHx diverticulosis, history of gastritis and history of GIB presents to ___ for evaluation of melena. Pt developed melena starting on ___ (2 days PTA). This was associated with light-headedness, dizziness and orthostatic symptoms. Mild SOB. He denies any abdominal pain, CP, vision changes. Of note, pt also had a fall in the setting of dizziness. No LOC headstrike. He fell on his Right elbow and continues to have significant pain in that arm. In the ED, initial vitals: 97.6 79 112/70 18 100% RA. Initialy hct was 27.7 (baseline ~40). Cr notably 1.5 (baseline 1.0). Pt was given 2x 1000cc NS boluses and admitted to the MICU for further monitoring pending potential endoscopy by GI on ___. On transfer, vitals were: 79 106/65 12 98% RA On arrival to the MICU, 98.8; 77; 105/47; 24; 98% RA. Pt reported feeling well, although he continued to complain of arm pain. Past Medical History: Diverticulosis Hx melena Nonischemic cardiomyopathy (EF 45% to 55%) History of DVT (reportedly ___ years ago) HTN Right posterior limb internal capsule stroke in ___ w/LLE weakness HLD Erectile dysfunction Social History: ___ Family History: Prostate cancer, CAD, HTN Physical Exam: ADMISSION PHYSICAL EXAM GENERAL: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Irregularl irregular, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, hyperactive BS, no rebound tenderness or guarding, no organomegaly. Rectum with some red blood around anus. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Right elbow TTP along both the medial and lateral aspects. No gross deformity of Right arm. SKIN: No skin breaks or rashes appreciated. NEURO: CNII-XII grossly intact DISCHARGE PHYSICAL EXAM Vitals: Tmax 99.6 Tcurr 98 P 79 BP 117/64 RR 18 O2 98%RA General- Sitting up in bed, alert and interactive, smiling, no acute distress HEENT- pupils 3mm and symmetric, sclera anicteric, mucus membranes slightly dry, 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- obese, soft, non-tender, non-distended, bowel sounds are normoactive, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, very slight tenderness of lateral right elbow on supination and pronation, full passive and active ROM, no deformity. Neuro- Face is symmetric, ___ strength throughout, normal gait Pertinent Results: ============== Admission labs ============== ___ 07:45PM GLUCOSE-163* UREA N-33* CREAT-1.5* SODIUM-139 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 ___ 07:45PM ALT(SGPT)-12 AST(SGOT)-11 ALK PHOS-54 TOT BILI-0.3 ___ 07:45PM LIPASE-33 ___ 07:45PM ALBUMIN-3.3* ___ 07:45PM WBC-8.6# RBC-2.90*# HGB-8.8*# HCT-27.7*# MCV-96 MCH-30.3 MCHC-31.8* RDW-14.2 RDWSD-49.4* ___ 07:45PM NEUTS-72.0* ___ MONOS-6.1 EOS-0.4* BASOS-0.2 IM ___ AbsNeut-6.18* AbsLymp-1.78 AbsMono-0.52 AbsEos-0.03* AbsBaso-0.02 ___ 07:45PM PLT COUNT-119* ___ 07:45PM ___ PTT-23.3* ___ ============= Pertinent Labs on discharge ============= ___ 06:53AM BLOOD WBC-6.5 RBC-2.53* Hgb-7.9* Hct-24.2* MCV-96 MCH-31.2 MCHC-32.6 RDW-15.6* RDWSD-50.0* Plt ___ ___ 06:53AM BLOOD Glucose-96 UreaN-9 Creat-1.0 Na-140 K-3.6 Cl-103 HCO3-26 AnGap-15 ___ 06:53AM BLOOD Calcium-7.9* Phos-4.1 Mg-1.9 HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). ============= Imaging and Endoscopy ============ ___ EGD Erosions in the stomach body and antrum Erosions in the duodenal bulb Otherwise normal EGD to third part of the duodenum ___ CTA 1. No evidence of active contrast extravasation within the alimentary tract. No significant intraluminal hemorrhage. 2. Colonic diverticulosis without diverticulitis. 3. Fusiform aneurysmal dilatation of the celiac axis. Focal short segment aneurysm at the origin of the left internal iliac artery. ___ Colonoscopy Diverticulosis of the whole colon Polyp in the rectum Cecum/Appendix was not able to be fully evaluated. Less than 5% of the colon was not examined and grossly no evidence of blood in that area. Otherwise normal colonoscopy to cecum ___ Right Humerus XRay Images of the humerus and forearm demonstrate degenerative changes with osteophytes and enthesophytes at the shoulder and at the elbow. There is irregularity of the humeral head but it appears well corticated and therefore this may be secondary to old trauma. Please note that these images were obtained of forearm and humerus in this were not optimally obtained to assess the elbow joint. If there is clinical suspicion of radial head fracture dedicated elbow images should be obtained. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Naproxen 220 mg PO PRN Pain 2. Carvedilol 25 mg PO BID 3. Pravastatin 80 mg PO QPM 4. Amlodipine 10 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. garlic 2,000 mg oral DAILY 7. Sildenafil 20 mg PO Frequency is Unknown 8. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Pravastatin 80 mg PO QPM 2. Pantoprazole 40 mg PO Q12H 3. Carvedilol 25 mg PO BID 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. garlic 2,000 mg oral DAILY 6. Sildenafil 20 mg PO DAILY:PRN erectile dysfunction 7. Aspirin 81 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Gastrointestinal bleed Diverticulosis Anemia Thrombocytopenia SECONDARY DIAGNOSES: Cardiomyopathy, non-ischemic Ischemic stroke Hypertension Urinary incontinence Erectile dysfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DX HUMERUS AND FOREARM INDICATION: ___ year old man with arm pain. // Evaluate for fracture. Please perform views of humerus, elbow, forearm and wrist. TECHNIQUE: Two views of the right humerus and two views of the right forearm COMPARISON: None IMPRESSION: Images of the humerus and forearm demonstrate degenerative changes with osteophytes and enthesophytes at the shoulder and at the elbow. There is irregularity of the humeral head but it appears well corticated and therefore this may be secondary to old trauma. Please note that these images were obtained of forearm and humerus in this were not optimally obtained to assess the elbow joint. If there is clinical suspicion of radial head fracture dedicated elbow images should be obtained Radiology Report EXAMINATION: CTA ABD WANDW/O C AND RECONS INDICATION: ___ year old man with hisotry of diverticulitis and gastritis now with active GI bleed (approx 800-1000cc of melena/red blood mix in last 12 hours). // Localization of GIB TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous, and delayed phase images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: This study involved 6 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 7.9 mGy (Body) DLP = 411.0 mGy-cm. 4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 5) Spiral Acquisition 6.6 s, 52.3 cm; CTDIvol = 23.9 mGy (Body) DLP = 1,248.1 mGy-cm. 6) Spiral Acquisition 6.6 s, 52.3 cm; CTDIvol = 23.9 mGy (Body) DLP = 1,248.3 mGy-cm. Total DLP (Body) = 2,917 mGy-cm. IV Contrast: 130 mL of Omnipaque COMPARISON: None. FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is a background of mild to moderate atherosclerotic disease. Fusiform aneurysmal dilatation of the celiac axis measuring up to 1.3 cm. Normal contrast opacification of the common hepatic artery, splenic, and left gastric artery. Mild narrowing of the SMA caliber proximally, without significant stenosis. Single right and single left renal arteries. On the right side, there is mild stenosis at the origin of the internal iliac artery, with poststenotic dilatation measuring up to 1.2 cm. Normal common iliac, external iliac, CFA, SFA, and profunda femoris. On the left side, mild to moderate atherosclerosis at the origin of the left common iliac artery, without significant stenosis. Normal external iliac, common femoral, SFA, and profunda femoris. Aneurysmal dilatation at the origin of the internal iliac artery measuring up to 1.8 cm with mural thrombus. GASTROINTESTINAL: No obvious area of contrast blush to indicate active GI bleeding. There is a small area of mild hyperdensity within the distal sigmoid, at the sigmoid rectal junction, favored to be related to particulate intraluminal debris (3B:320). Within the imaged alimentary tract, the stomach and small bowel are unremarkable in appearance. There is extensive colonic diverticulosis without evidence of diverticulitis. No significant intraluminal hemorrhage is appreciated. No free air or free fluid. OTHER FINDINGS: Minimal atelectasis appreciated within the bases bilaterally. No pleural or pericardial effusion. Normal attenuation of the liver. No intrahepatic or extrahepatic biliary ductal dilatation. No focal hepatic lesions. The gallbladder is unremarkable. The spleen, pancreas, and of bilateral adrenals are unremarkable. Bilateral renal cysts. No evidence of hydronephrosis. The bladder is unremarkable. No intra-abdominal lymphadenopathy. Multilevel degenerative changes within the spine. IMPRESSION: 1. No evidence of active contrast extravasation within the alimentary tract. No significant intraluminal hemorrhage. 2. Colonic diverticulosis without diverticulitis. 3. Fusiform aneurysmal dilatation of the celiac axis. Focal short segment aneurysm at the origin of the left internal iliac artery. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: BRBPR, Presyncope, Dizziness Diagnosed with GASTROINTEST HEMORR NOS, AC POSTHEMORRHAG ANEMIA temperature: 97.6 heartrate: 79.0 resprate: 18.0 o2sat: 100.0 sbp: 112.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted because of blood in your stool. Because your blood counts were low, you were treated in the intensive care unit and given 4 units of blood. You underwent an upper endoscopy, which showed erosions in the stomach and small intestine, but no active bleeding. You also underwent a colonoscopy, which showed diverticulosis. The exact source of the bleeding was not found. Your bleeding stopped, and your blood counts started to rise again. We added a new medication to your list, pantoprazole, which will help prevent future bleeding. We also temporarily stopped two of your blood pressure medications, amlodipine and lisinopril, because your blood pressure was normal in the hospital. We suggest that you touch base with your primary care doctor about when to restart these medicines. Finally, we started you on aspirin to help prevent future strokes. Best wishes, Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin Attending: ___. Chief Complaint: Bilateral lower extremity edema Major Surgical or Invasive Procedure: none History of Present Illness: ___ M w/ PMH HTN, CKD, renal artery stenosis, PAD sent from urgent care for leg swelling. He notes that for a week he's noted swelling in his legs that is not painful. He has not had swelling previously. He has exertional chest pain going up the stairs, and can only walk about a block before stopping, but limited by chronic leg cramps. He denies dyspnea or orthopnea but sleeps w/ 2 pillows. He takes his medications daily with no changes in the past month. He has been eating salty canned fish more frequently. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None - Moderate MR and Mild TR 3. OTHER PAST MEDICAL HISTORY PAD RENAL ARTERY STENOSIS - s/p R renal artery stent ___ CKD PULMONARY HYPERTENSION VALVULAR HEART DISEASE GASTROESOPHAGEAL REFLUX BENIGN PROSTATIC HYPERTROPHY DIVERTICULOSIS Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission Exam: VS: 98.6 PO 180 / 73 R Lying 66 20 96 RA GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD , JVP to angle of the jaw CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: Bibasilar crackles GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: 2+ pitting edema to the knees bilaterally PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes Discharge Exam: Vitals: Temp: 97.8 (Tm 98.8), BP: 139/65 (107-162/55-65), HR: 60 (53-68), RR: 16 (___), O2 sat: 97% (94-98), O2 delivery: RA Weight: 54.7kg (was 58.7 kg yesterday) Weight on admission: 60.1 kg General: Well-appearing, NAD. Normal mood and affect HEENT: No scleral icterus NECK: Supple, no JVD Lungs: Normal WOB. Diminished breath sounds at bases. No wheezes CV: RRR, normal S1 and S2. No m/r/g Abdomen: Soft, ND, NT to palpation. No renal bruits Ext: Warm to touch. No edema. PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION: CBC: ___ 10:47AM BLOOD WBC-7.4 RBC-3.65* Hgb-11.0* Hct-34.0* MCV-93 MCH-30.1 MCHC-32.4 RDW-14.3 RDWSD-48.5* Plt ___ BMP: ___ 06:58AM BLOOD Glucose-95 UreaN-49* Creat-2.3* Na-139 K-4.6 Cl-106 HCO3-22 AnGap-11 Trop: ___ 10:47AM BLOOD cTropnT-<0.01 Coags: ___ 07:55AM BLOOD ___ PTT-29.2 ___ STUDIES: TTE on ___: EF 67%. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Elevated PCWP and Grade II diastolic dysfunction suggested. Mild mitral regurgitation. Mild to moderate circumferential pericardial effusion without tamponade. CXR on ___: 1. Peribronchial opacities in the right lower lobe concerning for superimposed bronchopneumonia or aspiration changes. 2. Mild to moderate cardiomegaly, with mild interstitial edema. CXR on ___: There is mild cardiomegaly. No definite consolidation is seen. There are patchy opacities at the lung bases, more suggestive of atelectasis as opposed to pneumonia. There are no pneumothoraces. No overt pulmonary edema is seen. ___ Ultrasound Bilateral ___: No evidence of deep venous thrombosis in the right or left lower extremity veins. DISCHARGE: CBC: ___ 06:58AM BLOOD WBC-6.3 RBC-3.60* Hgb-10.8* Hct-33.0* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.7 RDWSD-46.5* Plt ___ ___ 06:58AM BLOOD WBC-6.3 RBC-3.60* Hgb-10.8* Hct-33.0* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.7 RDWSD-46.5* Plt ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO BID 2. amLODIPine 10 mg PO DAILY 3. Tamsulosin 0.4 mg PO QHS 4. Metoprolol Tartrate 100 mg PO BID 5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Lovastatin 40 mg oral DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. CARVedilol 25 mg PO BID 3. Lisinopril 20 mg PO QHS 4. amLODIPine 10 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Acute diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with leg swelling// r/o pna, chf TECHNIQUE: Chest PA and lateral COMPARISON: None available. FINDINGS: There is mild-to-moderate cardiomegaly. There is mild tortuosity of the thoracic aorta. There is suggestion of pulmonary vascular congestion with ___ B-lines suggestive of interstitial edema. There are prominent peribronchial opacities in the right lower lobe. IMPRESSION: 1. Peribronchial opacities in the right lower lobe concerning for superimposed bronchopneumonia or aspiration changes. 2. Mild to moderate cardiomegaly, with mild interstitial edema. NOTIFICATION: The findings were discussed with urgent care by ___, M.D. on the telephone on ___ at 12:06 pm, 5 minutes after discovery of the findings. Patient has been sent to the emergency department Radiology Report INDICATION: ___ year old man with new HF// interval change COMPARISON: Radiographs from ___ IMPRESSION: There is mild cardiomegaly. No definite consolidation is seen. There are patchy opacities at the lung bases, more suggestive of atelectasis as opposed to pneumonia. There are no pneumothoraces. No overt pulmonary edema is seen. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with b/l ___ swelling. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow 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 - RUSSIAN Arrive by WALK IN Chief complaint: B Leg swelling, ELEVATED BNP Diagnosed with Heart failure, unspecified temperature: 98.4 heartrate: 65.0 resprate: 20.0 o2sat: 98.0 sbp: 193.0 dbp: 73.0 level of pain: 0 level of acuity: 3.0

Dear Mr ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had shortness of breath when exerting yourself. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - We found that you had too much fluid on your lungs. We gave you medication to remove this fluid. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Please weigh yourself every day, and if your weight goes up by more than 3 lbs, please call your doctor. We wish you the best! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___ Chief Complaint: R foot infection Major Surgical or Invasive Procedure: ___: R foot I&D, debridement ___: R foot debridement, removal sesamoidectomies, plantar closure, dorsal packing History of Present Illness: Mr. ___ is a ___ year old patient who presents from the ___ with a R foot infection. He was seen by Dr. ___ today who recommended he present to the ED for admission and likely OR debridement. Over the past few days, the patient states he has noted fever, chills as well as increased erythema, edema, and drainage to right foot. He was placed on augmentin on ___ with no improvement of his symptoms. Podiatric surgery was consulted for further management. Past Medical History: PMH: -Diabetes -Cardiomyopathy -Hypertension -prior MI -prior CVA -Hyperlipidemia -CHF -GERD Social History: ___ Family History: Father diverticulitis Mother - healthy Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 97.6 91 129/107 18 98% RA GEN: NAD, pleasant CV: RRR Pulm: No respiratory distress GI: soft, NT, ND RLE: ___ pulses palpable. Cap refill < 3 seconds to all digits. Increase ___ temperture gradient to lower extremity. Erythema extending from hallux to just proximal to ankle. Ulceration to plantar ___ metatarsal with deep probing and purulence noted. Gross sensation is absent. PHYSICAL EXAM AT DISCHARGE VSS GEN: NAD, pleasant CV: RRR Pulm: No respiratory distress GI: soft, NT, ND ___: ___ pulses palpable. Cap refill < 3 seconds to all digits. C/D/I dressing to b/l feet. Patient able to flex and extend all toes and ankles b/l. Gross sensation is diminished b/l. Pertinent Results: ___ 12:01PM BLOOD WBC-13.1*# RBC-4.37* Hgb-14.1# Hct-40.3# MCV-92 MCH-32.3* MCHC-35.0 RDW-12.6 RDWSD-42.5 Plt ___ ___ 11:30AM BLOOD WBC-7.8 RBC-4.15* Hgb-13.2* Hct-38.8* MCV-94 MCH-31.8 MCHC-34.0 RDW-12.5 RDWSD-42.5 Plt ___ ___ 07:05AM BLOOD WBC-7.4 RBC-4.34* Hgb-13.4* Hct-40.7 MCV-94 MCH-30.9 MCHC-32.9 RDW-12.5 RDWSD-43.2 Plt ___ ___ 07:35AM BLOOD WBC-8.4 RBC-4.33* Hgb-13.7 Hct-41.8 MCV-97 MCH-31.6 MCHC-32.8 RDW-12.8 RDWSD-45.1 Plt ___ ___ 12:01PM BLOOD Neuts-79.4* Lymphs-9.2* Monos-9.8 Eos-0.5* Baso-0.3 Im ___ AbsNeut-10.37* AbsLymp-1.20 AbsMono-1.28* AbsEos-0.07 AbsBaso-0.04 ___ 03:30PM BLOOD ___ PTT-33.8 ___ ___ 12:01PM BLOOD Glucose-141* UreaN-19 Creat-1.2 Na-130* K-4.6 Cl-96 HCO3-20* AnGap-19 ___ 11:30AM BLOOD Glucose-194* UreaN-16 Creat-1.0 Na-133 K-3.9 Cl-98 HCO3-23 AnGap-16 ___ 07:05AM BLOOD Glucose-178* UreaN-15 Creat-0.9 Na-135 K-4.1 Cl-99 HCO3-25 AnGap-15 ___ 07:35AM BLOOD Glucose-156* UreaN-6 Creat-0.9 Na-137 K-4.5 Cl-100 HCO3-24 AnGap-18 ___ 11:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1 ___ 07:05AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9 ___ 07:35AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8 ___ 12:37PM BLOOD Lactate-1.7 ___ 03:30PM BLOOD VITAMIN C-PND ___ 06:00AM BLOOD WBC-8.8 RBC-4.40* Hgb-13.6* Hct-42.0 MCV-96 MCH-30.9 MCHC-32.4 RDW-12.9 RDWSD-44.6 Plt ___ ___ 06:00AM BLOOD Glucose-238* UreaN-7 Creat-0.8 Na-135 K-4.5 Cl-98 HCO3-28 AnGap-14 ___ 06:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7 BLOOD CULTURES X2: No growth ___ 2:01 pm SWAB Source: Right foot. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. 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. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 2 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 8:00 am TISSUE TISSUE RIGHT FOOT. **FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. TISSUE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. SENSITIVITIES PERFORMED ON CULTURE # 422-1979S ___. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 3:30 pm SEROLOGY/BLOOD LYME SEROLOGY (Pending): X-rays 3 views R foot ___: Plantar soft tissue ulceration at the level of the first MTP joint and concern for soft tissue gas. Cortical erosion at the lateral base of the first distal phalanx, new since ___, otherwise indeterminate age, acute osteomyelitis not excluded. Status post amputation of the distal phalanx of the second digit. Severe degenerative changes at the tibiotalar joint. X-rays 3 views R foot ___: No radiographic evidence of osteomyelitis. Severe degenerative changes unchanged. No short interval change Pathology ___: P Medications on Admission: -Augmentin 875 mg-125 mg BID -Colcrys 0.6 mg daily prn -Cozaar 50 mg tablet daily -Lantus 100 unit/mL Sub-Q 20 units twice a day -Omeprazole 20 mg daily -allopurinol ___ mg daily -aspirin 325 mg daily -carvedilol 3.125 mg BID -docusate sodium 100 mg daily -folic acid ___ mcg daily -glipizide 5 mg daily -magnesium oxide 400 mg BID -simvastatin 40 mg daily -thiamine 100 mg daily Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Carvedilol 3.125 mg PO BID 4. Gabapentin 300 mg PO TID 5. GlipiZIDE 5 mg PO DAILY 6. Glargine 20 Units Breakfast Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Losartan Potassium 50 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. Simvastatin 40 mg PO QPM 10. Thiamine 100 mg PO DAILY 11. Aquaphor Ointment 1 Appl TP TID:PRN breakdown to groin RX *white petrolatum [Aquaphor with Natural Healing] 41 % 1 application three times a day Refills:*3 12. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q 12 hours Disp #*14 Tablet Refills:*0 13. Fexofenadine 60 mg PO BID RX *fexofenadine 60 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*2 14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID RX *triamcinolone acetonide 0.1 % Apply to rash on arm and legs twice a day Refills:*2 15. Clotrimazole Cream 1 Appl TP BID RX *clotrimazole 1 % Apply to groin twice a day Disp #*30 Gram Gram Refills:*2 16. Clindamycin 300 mg PO Q8H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth q 8 hours Disp #*21 Capsule Refills:*0 17. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ capsule(s) by mouth q 4 to 6 hours Disp #*30 Capsule Refills:*0 18. walker Use to remain weightbearing to R heel DAILY RX *walker Use to remain weightbearing to R heel DAILY Disp #*1 Each Refills:*0 19. wheelchair Use for long distances miscellaneous DAILY RX *wheelchair Use for long distances Daily Disp #*1 Each Refills:*0 Discharge Disposition: Home Discharge Diagnosis: R foot infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: History: ___ with poorly healing foot ulcer // please eval for osteo or fracture or gas TECHNIQUE: Three views of the right foot COMPARISON: ___ FINDINGS: There appears to be a bandage overlying foot between the first and second toes. On the lateral view, soft tissue irregularity at the along the plantar aspect of the foot at the level of the first MTP joint, consistent with ulceration. There is concern for underlying soft tissue gas. Cortical erosion is seen at the lateral base of the first distal phalanx, new since the prior study from ___, but otherwise indeterminate age. Patient is status post amputation of the second toe at the level of the distal middle phalanx. Degenerative changes are seen at the first MTP joint. There are severe degenerative change at the tibiotalar joint with severe joint space narrowing, marginal sclerosis, subchondral cystic change in osteophytes. IMPRESSION: Plantar soft tissue ulceration at the level of the first MTP joint and concern for soft tissue gas. Cortical erosion at the lateral base of the first distal phalanx, new since ___, otherwise indeterminate age, acute osteomyelitis not excluded. Status post amputation of the distal phalanx of the second digit. Severe degenerative changes at the tibiotalar joint. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ year old man s/p R foot debridement including sesamoidectomies TECHNIQUE: Three views of the right foot. COMPARISON: Radiographs dated ___. FINDINGS: Unchanged is amputation of the second distal phalanx and osteophytosis of the first IP joint. There is severe joint space narrowing of the tibiotalar joint with sclerosis and significant new bone formation which is also unchanged. There are soft tissue changes seen along the plantar surface of the distal foot, but there is no underlying fracture or bony destruction. No vascular calcifications. IMPRESSION: No radiographic evidence of osteomyelitis. Severe degenerative changes unchanged. No short interval change Gender: M Race: WHITE Arrive by WALK IN Chief complaint: R Foot pain Diagnosed with ULCER OF OTHER PART OF FOOT, CELLULITIS OF FOOT temperature: 97.6 heartrate: 91.0 resprate: 18.0 o2sat: 98.0 sbp: 129.0 dbp: 107.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service due to a R foot infection. You were given IV antibiotics while here and taken to the OR twice for debridements. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain weightbearing to your R heel until your follow up appointment. Please do not place weight on the front of your R foot. 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. Both of your foot dressings will need to be changed daily. Can apply betadine and a dressing 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. You were also given creams for your rash as well as a medication called Fexofenadine to continue taking as your rash continues to improve. 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: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: severe anemia Major Surgical or Invasive Procedure: blood transfusion upper endoscopy colonoscopy History of Present Illness: ___ w/ PMH of prostate CA in remission, colon CA in remission, L MCA stroke in ___ with residual mild right-sided deficits, and afib/aflutter on dabigatran (recently increased), who is admitted from clinic after being found to have Hct 16.8 and guaiac positive stool. Pt states that he has been feeling completely well. No fatigue, no dyspena on exertion, no chest pain. No lightheadedness or fainting. No fevers, chills, night sweats, or weight loss. No nausea or vomiting. No abdominal pain. No diarrhea, no hematochezia, no melena, no bright red blood per rectum. Pt apparently went for routine clinic visits to his PCP, who ordered labs including Hct, and urology-oncologist, who performed a rectal exam and found brown stool that was guaiac positive. Pt was then sent to the ED after Hct returned 16.8. . In the ED, Pt's vitals were 98.4F 102 129/36 16 100%. Pt was started on 1 x pRBC transfusion and admitted to medicine for GI bleed. Pt was completely comfortable and mentating well. . Upon transfer, vitals were 97.4 po, 47, 126/60, 18, 100% RA . On arrival to the floor, vitals were 98.1F, 124/71, HR 48, RR 16, Sat 100% RA. . ROS: 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: -Cerebrovascular disease: s/p left MCA in ___ -Atypical Atrial Flutter/fibrillation, s/p partial ablation (previously not on Warfarin), now on dabigatran 150mg po bid per Dr. ___ s/p XRT- ___ in remission, followed by Dr. ___ colorectal CA, s/p surgery and chemo. In remission. -s/p Right Inguinal Hernia repair -s/p "knee surgery" -h/o renal stones- ___ Social History: ___ Family History: Father (___.)- stroke, MI. Mother (___.)- no known problems Physical Exam: Physical Exam on admission: VS - 98.1F, 124/71, HR 48, RR 16, Sat 100% RA. GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, pale conjunctiva NECK - supple, no thyromegaly, JVP ~8cm LUNGS - fine bilateral inspiratory crackles, winged scapula on R HEART - irreg irreg rhythm, brady rate, nl S1-S2, no MRG ABDOMEN - normal bowel sounds, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 2+ peripheral pulses (radials, DPs), 2+ lower extremity edema up to knees SKIN - no rashes or lesions RECTAL - deferred NEURO - A&Ox3, CNs II-XII grossly intact, mild slowing of speech, but fully interactive, making jokes, ___ strength in LUE, ___ strength in proximal RUE, ___ strength in bilateral lower extremities, sensation grossly intact throughout. Physical Exam: Gen: pale appearing elderly man in no acute distress, alert and interactive. VITALS: Tm 98.8, Tc 98.1, BP 116-142/66-71, HR 37-50, RR 16, Sat 98% RA. HEENT: PERRL, normal oropharynx Lungs: bibasilar mild inspiratory crackles CV: irreg irreg rhythm, brady rate, nl s1, s2, no m/r/g Abd: normal bowel sounds, soft, non-tender, no masses Ext: 2+ pulses in bilat radial and dp, 2+ edema in bilateral lower extremities, compression hose on. Pertinent Results: Admission labs: ___ 01:40PM BLOOD WBC-5.5 RBC-2.63* Hgb-5.0*# Hct-16.8* MCV-64*# MCH-19.0*# MCHC-29.8* RDW-17.7* Plt ___ ___ 01:40PM BLOOD Neuts-70.5* ___ Monos-8.7 Eos-1.9 Baso-0.4 ___ 01:40PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Ovalocy-OCCASIONAL Acantho-OCCASIONAL ___ 05:40AM BLOOD Ret Man-1.9* ___ 01:40PM BLOOD UreaN-18 Creat-0.8 ___ 01:40PM BLOOD ALT-17 AST-22 LD(LDH)-173 AlkPhos-67 TotBili-0.4 ___ 01:40PM BLOOD proBNP-1155* ___ 01:40PM BLOOD Iron-12* ___ 01:40PM BLOOD calTIBC-534* ___ Ferritn-4.0* TRF-411* ___ 01:40PM BLOOD Testost-306 ___ 01:40PM BLOOD CEA-1.6 PSA-0.3 ___ 05:40AM BLOOD WBC-6.6 RBC-3.21* Hgb-6.8*# Hct-21.9*# MCV-68* MCH-21.1*# MCHC-30.9* RDW-18.7* Plt ___ ___ 06:20AM BLOOD WBC-6.8 RBC-3.07* Hgb-6.2* Hct-20.9* MCV-68* MCH-20.0* MCHC-29.4* RDW-19.4* Plt ___ ___ 06:22AM BLOOD WBC-6.9 RBC-2.90* Hgb-6.0* Hct-20.1* MCV-69* MCH-20.6* MCHC-29.7* RDW-21.0* Plt ___ ___ 05:45AM BLOOD WBC-6.3 RBC-3.37* Hgb-7.4* Hct-24.0* MCV-71* MCH-21.8* MCHC-30.7* RDW-22.2* Plt ___ ___ Colonoscopy Large non-bleeding internal hemorrhoids were noted. Excavated Lesions Upon reaching the ileocolonic anastamosis, it was noted that there were ulcerations and surrounding friability on both sides of the anastamosis. There was bright red blood oozing from the borders of the ulcers. BI-CAP Electrocautery was applied for hemostasis successfully. Cold forceps biopsies were performed for histology at the ileocolonoic anastamosis. Impression: Internal hemorrhoids Ulcers at the ileocolonic anastamosis (thermal therapy, biopsy) Otherwise normal colonoscopy to ileocolonic anastamosis ___ Upper endoscopy Normal mucosa in the esophagus Normal mucosa in the stomach Normal mucosa in the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum ___ Echo The left atrium is moderately dilated. The left atrial volume is mildly increased. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is moderately dilated with normal free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global systolic function. Moderate right ventricular dilation with preserved function. Moderate-to-severe tricuspid regurgitation. Moderate mitral regurgitation. Moderate to severe pulmonary artery systolic hypertension. Upper endoscopy ___ Normal mucosa in the esophagus Normal mucosa in the stomach Normal mucosa in the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum Colonoscopy ___ Protruding Lesions Large non-bleeding internal hemorrhoids were noted. Excavated Lesions Upon reaching the ileocolonic anastamosis, it was noted that there were ulcerations and surrounding friability on both sides of the anastamosis. There was bright red blood oozing from the borders of the ulcers. BI-CAP Electrocautery was applied for hemostasis successfully. Cold forceps biopsies were performed for histology at the ileocolonoic anastamosis. Impression: Internal hemorrhoids Ulcers at the ileocolonic anastamosis (thermal therapy, biopsy) Otherwise normal colonoscopy to ileocolonic anastamosis. Recommendations: The patient will be notified of biopsy results in ___ weeks. Further treatment plans will depend on the biopsy results. Medications on Admission: dabigatran 150mg po bid (recently increased from 75mg po bid) Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: severe microcytic anemia iron deficiency bradycardia ulcerations near the ileo-colonic anastamosis severe pulmonary hypertension Secondary: atrial fibrillation / atrial flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with shortness of breath, anemia, bilateral crackles and lower extremity edema. Evaluate for pulmonary edema. COMPARISON: ___. CHEST, PA AND LATERAL VIEWS: There is no mass or consolidation. There is mild interstitial edema with small bilateral pleural effusions, right greater than left. The cardiomediastinal silhouette is stable. Hilar contours and pulmonary vasculature are normal. There is no pneumothorax. IMPRESSION: Mild interstitial edema with small bilateral pleural effusions. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: LOW HCT Diagnosed with ANEMIA NOS, HX OF COLONIC MALIGNANCY, HX-PROSTATIC MALIGNANCY temperature: 98.4 heartrate: 102.0 resprate: 16.0 o2sat: 100.0 sbp: 129.0 dbp: 36.0 level of pain: 0 level of acuity: 2.0

Mr. ___, You were sent to the hospital because you had very low levels of red blood cells (severe anemia). You likely have had a chronic slow bleed from your gastrointestinal tract. You received blood transfusions, and your blood levels remained stable. You were also treated with IV iron because your body iron levels were very low. You had two studies to find the location of this bleed, which showed that you had ulcers near the part of your colon that was operated on previously. There was some blood oozing from these ulcers, which were cauterized to stop the bleeding. After you had your studies, your condition was discussed by Dr. ___ Dr. ___ felt that you should go home on a baby aspirin daily and re-address your need for blood thinners at you appointment with them next ___. We have made the following changes to your medications: Please STOP taking dabigatran (Pradaxa). Do not restart this medication until instructed by your doctor. Please START taking aspirin 81 mg tabs (enteric coated), 1 tab by mouth daily.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tetanus Vaccines & Toxoid / Cipro / prednisone Attending: ___. Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with history of dementia, HTN, bladder cancer status post recent open radical cystectomy, bilateral salpingo-oopherectomy, partial vaginectomy, ileal conduit urinary diversion (at the end of ___, discharged ___ transferred from ___ due to hypotension and lack of ICU beds. The patient was admitted to this hospital ___ for management of urosepsis. She was ultimately discharged to rehab and has subsequently returned to home. Reportedly, her family noticed that her urine appeared cloudy and that she had a fever to 102°F which they brought her to an ___, where she was noted to have a positive UA. She received 3L normal saline, IV cipro, and IV zosyn. Her systolic pressure was in the ___ on presentation and decreased to the high ___ for which she was transferred to our hospital. Upon arrival, the patient reported cough and nausea with minimal emesis. She denies abdominal pain, chest pain, diarrhea. In the ED, initial VS were 98.8 100 82/53 16 98% RA Exam notable for active emesis, diffuse tenderness to palpation of the abdomen, yellow urine in urostomy back. She received IV acetaminophen, IV NS, and IV Zofran. Labs notable for a WBC of 19.7, H/H of 9.7/33, Plt 338. BMP with Na 139, K 4.7, Cl 113, HCO3 9, BUN/Cr ___, Mg 1.3, Alk Phos 136. Other LFTS WNL. UA with large leuk esterase and negative nitrites. CT A/P without evidence of intraabdominal infection. CXR showed left basilar atelectasis not significantly changed and no acute intrathoracic process. Upon arrival to the floor, the patient is alert and conversant and in no apparent distress. She reports that she is unsure why she came to the hospital. She denies all symptoms including fevers, chills, fatigue, headache, neck pain, chest pain, shortness of breath, abdominal pain. She denies vomiting. When I tell her that I heard she vomited here, she states "Oh, I don't remember." She does endorse feeling a little more confused than usual. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Small cell bladder cancer s/p recent radical cystectomy, bilateral salpingooophorectomy, partial vaginectomy, ileal conduit urinary diversion (___) - Hypothyroidism - Hyperlipidemia - Hypertension - History of Lyme - History of shingles Social History: ___ Family History: No family history of GU malignancy Physical Exam: EXAM ON ADMISSION VITALS: 97.8 PO 88 / 55 R Lying 80 24 96 RA 0 0 0 10 GENERAL: Alert and in no apparent distress, appears comfortable EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Mucous membranes dry CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, non-tender to palpation; Urostomy bag in RLQ with yellow urine, healthy pink tissue/skin around ostomy site 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, follows commands, alert to self and "hospital" as well as ___ but is unsure of the year PSYCH: pleasant, appropriate affect EXAM ON DISCHARGE AVSS, BPs much improved Lungs clear Heart regular Extremities warm and well perfused AAOx2-3, missing exact date Pleasant, really wanting to go home Urostomy well managed, dressing CDI, clear urine in bag Pertinent Results: LABS THIS ADMISSION ___ 12:50AM BLOOD WBC-19.7* RBC-3.46* Hgb-9.7* Hct-33.0* MCV-95 MCH-28.0 MCHC-29.4* RDW-16.4* RDWSD-58.1* Plt ___ ___ 07:50AM BLOOD WBC-13.8* RBC-2.94* Hgb-8.2* Hct-27.1* MCV-92 MCH-27.9 MCHC-30.3* RDW-17.0* RDWSD-57.2* Plt ___ ___ 07:50AM BLOOD ___ ___ 12:50AM BLOOD Glucose-119* UreaN-31* Creat-1.9* Na-139 K-4.7 Cl-113* HCO3-9* AnGap-17 ___ 09:40AM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-143 K-4.2 Cl-108 HCO3-21* AnGap-14 ___ 12:50AM BLOOD ALT-11 AST-18 AlkPhos-136* TotBili-0.6 ___ 12:50AM BLOOD Lipase-12 ___ 12:50AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.2 Mg-1.3* ___ 09:40AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.8 ___ 09:00PM BLOOD HBsAg-NEG ___ 09:00PM BLOOD HIV Ab-NEG ___ 09:00PM BLOOD HCV Ab-NEG ___ 01:04AM BLOOD Lactate-2.5* ___ 08:29AM BLOOD Lactate-1.6 IMAGING THIS ADMISSION CT A/P ___ 1. No evidence of intra-abdominal infection. 2. Postsurgical changes from radical cystectomy with ileal conduit, bilateral salpingo-oophorectomy and partial vaginectomy. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Mirtazapine 7.5 mg PO QHS Discharge Medications: 1. Amoxicillin 1000 mg PO Q8H Duration: 6 Days RX *amoxicillin 500 mg 2 tablet(s) by mouth three times daily Disp #*36 Tablet Refills:*0 2. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth every evening Disp #*30 Tablet Refills:*0 3. Sodium Bicarbonate 1300 mg PO BID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice daily Disp #*180 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Mirtazapine 7.5 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urinary tract infection Sepsis Metabolic acidosis 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: Portable AP chest INDICATION: ___ with recent bladder resection, here with fever, emesis// ?abscess TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph dated ___ FINDINGS: Lung volumes are low. There is left basilar atelectasis or or scarring is similar to prior study. The cardiomediastinal and hilar silhouettes are unchanged. There is no pulmonary edema. No pleural effusions. No pneumothorax. IMPRESSION: Left basilar atelectasis or scarring not significantly changed. There is no acute intrathoracic process. Radiology Report EXAMINATION: CT abdomen and pelvis without contrast INDICATION: ___ with recent bladder resection, here with fever, emesis//?abscess TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.0 s, 47.6 cm; CTDIvol = 20.2 mGy (Body) DLP = 962.8 mGy-cm. Total DLP (Body) = 963 mGy-cm. COMPARISON: CT dated ___ FINDINGS: LOWER CHEST: There is mild bibasilar atelectasis.. There is no evidence of pleural or pericardial effusion. 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. PANCREAS: The pancreas is atrophic, with normal attenuation, 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. An enteroenteric anastomosis is again seen in the right lower quadrant. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The patient is status post cystectomy with right lower quadrant ileal conduit. There is a small hematoma in the left deep pelvis (2:71) measuring approximately 1.0 x 1.6 cm. REPRODUCTIVE ORGANS: The patient is status post bilateral hysterectomy, bilateral salpingo-oophorectomy and partial vaginectomy. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. There are numerous clips along the iliac chains bilaterally. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Grade 1 anterolisthesis of L4 on L5 and L5 on S1 is again seen, as well as a mild compression deformity of the inferior endplate of the L2 vertebral body, unchanged from prior study. SOFT TISSUES: There is a with right lower quadrant ileostomy. Midline scarring of the anterior abdominal wall is again noted. IMPRESSION: 1. No evidence of intra-abdominal infection. 2. Postsurgical changes from radical cystectomy with ileal conduit, bilateral salpingo-oophorectomy and partial vaginectomy, including a 1.6 cm hematoma in the left deep pelvis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Hypotension, Transfer Diagnosed with Sepsis, unspecified organism, Severe sepsis with septic shock, Acidosis, Urinary tract infection, site not specified, Unspecified abdominal pain temperature: 98.8 heartrate: 100.0 resprate: 16.0 o2sat: 98.0 sbp: 82.0 dbp: 53.0 level of pain: 0 level of acuity: 2.0

You were admitted with a severe urinary tract infection with sepsis. You were treated with fluids, antibiotics, and other supportive medications and you improved. It was recommended you go to rehab but you refused. You are being discharged home with services at your request.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / Sulfa (Sulfonamide Antibiotics) / Lactose / Gluten Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo ___, anemia presents with pleuritic chest pain. Pain woke pt from sleep this am at 5:15 was sharp, non-radiating and was followed by the development of fatigue, myalgias, fever to 101, nausea, headache, sore throat and a dry cough. Induced emesis without relief of symptoms. No diarrhea, constipation, rhinorrhea. Received flu vaccine this season. In ED pt was ruled out for PE due to recent flight from ___ ___, CXR showed PNA. Pt received levofloxacin and tamiflu. ROS: 10 point ROS otherwise negative, except per above Past Medical History: -___ Esophagus -Anemia -Scoliosis -OA -Depression Social History: ___ Family History: no early cad or dm Physical Exam: Admission PE VS: Tm 101 Tc 98.2 109/66 90 18 100%ra Pain: 2 Gen: nad Heent: mmm Neck: +tender cervical LAD Chest: RLL crackles, LLL decreased breath sounds Abd: nabs, soft, nt/nd Ext: no e/c/c Neuro: alert, follows commands . Discharge PE VSS General: AAOX3 in NAD HEENT: OP clear, MMM CV: RRR, no RMG Lungs: CTAB no WRR, mildly decreased BS at bases Abdomen: NTND, active BS X4 quadrants, no HSM, no rebound Extremities: WWP, no edema, 2+ pulses are equal in BLE Neuro: MS and CN wnl, strength and sensation wnl . Pertinent Results: ___ 11:30AM GLUCOSE-93 UREA N-7 CREAT-0.5 SODIUM-128* POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-24 ANION GAP-14 ___ 11:30AM WBC-14.0*# RBC-4.50 HGB-9.6* HCT-30.8* MCV-68* MCH-21.3* MCHC-31.2 RDW-17.9* ___ 11:30AM NEUTS-91.0* LYMPHS-4.9* MONOS-3.9 EOS-0.2 BASOS-0 ___ 11:30AM PLT COUNT-398 ___ 11:30AM D-DIMER-2841* ___ 05:28PM LACTATE-1.8 ___ 11:31AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 11:31AM URINE COLOR-Straw APPEAR-Clear SP ___ CXR: ___ IMPRESSION: Subtle nodular opacity in the retrocardiac region seen only on lateral view which in the correct clinical setting may represent pneumonia. Possible hiatal hernia. CTA Chest: ___ IMPRESSION: 1. No acute aortic pathology or pulmonary embolism. 2. Multifocal pneumonia. 3. Moderate hiatal hernia and patulous upper esophagus. Circumferential, upper esopahgeal wall thickening could be due to esophagitis or chronic reflux. This may place the patient at risk for aspiration. EKG ___ Sinus rhythm. Low voltage in the precordial leads. Borderline left atrial abnormality. ST segment depressions in leads V3-V5 and T wave inversions in leads V3-V5 worrisome for myocardial ischemia. However, these were previously noted on previous tracing of ___. Clinical correlation is suggested. **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. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion 100 mg PO BID 2. Fluoxetine 20 mg PO DAILY 3. Gabapentin 600 mg PO QID 4. Omeprazole 40 mg PO BID 5. Vitamin D 1000 UNIT PO DAILY 6. Quetiapine Fumarate 100 mg PO QHS Discharge Medications: 1. Gabapentin 600 mg PO QID 2. Omeprazole 40 mg PO BID 3. Quetiapine Fumarate 100 mg PO QHS 4. Vitamin D 1000 UNIT PO DAILY 5. Levofloxacin 750 mg PO DAILY Duration: 6 Days RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*6 Tablet Refills:*0 6. BuPROPion 100 mg PO BID 7. Fluoxetine 20 mg PO DAILY 8. Outpatient Lab Work please have labs drawn 1 week (CBC) and fax to PCP ___ ___ (f) Dr. ___ ___ (p) Discharge Disposition: Home Discharge Diagnosis: community acquired pneumonia anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: None. CLINICAL HISTORY: Fever, sore throat, cough, question pneumonia. FINDINGS: PA and lateral views of the chest provided. Lungs appear clear bilaterally without definite signs of pneumonia or CHF. In the lateral view on the retrocardiac region, there is subtle nodular opacity, which in the correct clinical setting could indicate pneumonia. There is also retrocardiac opacity on the frontal view, which raises concern for a hiatal hernia. There is an old right clavicular shaft deformity. Bony structures are otherwise intact. IMPRESSION: Subtle nodular opacity in the retrocardiac region seen only on lateral view which in the correct clinical setting may represent pneumonia. Possible hiatal hernia. Radiology Report INDICATION: Pleuritic chest pain after a long flight. COMPARISON: Chest radiograph ___. TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed after administration of 100 mL Omnipaque intravenous contrast. Images are presented for display in the axial plane at 2.5 mm and 1.25 mm collimation. A series of multiplanar reformation images are submitted for review. CTA CHEST: The thoracic aorta is normal in caliber without evidence of dissection on this non-gated study. Pulmonary arterial vasculature is well visualized to the subsegmental level without filling defect to suggest pulmonary embolism. No pathologically enlarged axillary or mediastinal lymph nodes are identified, ranging up to 8 mm in the right lower paratracheal station and 11 mm in the subcarinal station. A right hilar lymph node is 1.0 x 1.4cm and a left hilar lymph node is 1.6 x 1.8 cm. The heart, pericardium and great vessels are within normal limits without significant coronary artery calcifications. There is no pleural or pericardial effusion. A 5-mm right thyroid nodule and a 7-mm left thyroid nodule are noted. A moderate hiatal hernia is seen with a patulous upper esophagus. Circumferential esophgeal wall thickening may be due to esophagitis or reflux. Lung window images demonstrate heterogeneous opacities in the left upper lobe and the bilateral lower lobes with some confluent opacity and volume loss in the left lower lobe. The findings are concerning for multifocal pneumonia and left lower lobe atelectasis. This study is not tailored for subdiaphragmatic evaluation. The imaged portions of the liver, gallbladder, spleen, pancreas, bilateral adrenal glands, kidney, and bowel are unremarkable. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. IMPRESSION: 1. No acute aortic pathology or pulmonary embolism. 2. Multifocal pneumonia. 3. Moderate hiatal hernia and patulous upper esophagus. Circumferential, upper esopahgeal wall thickening could be due to esophagitis or chronic reflux. This may place the patient at risk for aspiration. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN/FEVER Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA temperature: 101.0 heartrate: 99.0 resprate: 19.0 o2sat: 95.0 sbp: 138.0 dbp: 59.0 level of pain: 8 level of acuity: 3.0

You were admitted to ___ with complaints of chest pain, fatigue, muscle aches and fevers. You were found to have a pneumonia. You were treated with antibiotics and you improved. You will be sent home to complete a 7 day course of antibiotics, last dose should be on ___. Please see your PCP ___ ___ weeks of discharge. . Medication changes-see below

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cephalexin Attending: ___. Chief Complaint: AMS Major Surgical or Invasive Procedure: ___ - intubated ___ - extubated History of Present Illness: A ___ female was transferred from ___ with the concern of salicylate toxicity presenting with ASA level >70. She was found to have altered mental status in ED there and was intubated for airway protection. Lab was noted for ASA level > 70. Bicarbonate drip IV was started at OSH. Her chest x-ray was also concerning for right middle lobe pneumonia and she was started on ceftriaxone and azithromycin. Per patient's sister there is concern that she chronically uses multiple herbal supplements. Past Medical History: - History of uterine fibroids, s/p embolization leading to ovarian necrosis causing premature menopause, previously on hormone replacement therapy - History of hotflashes on clonidine - Had an "emotional breakdown" requiring hospitalization in ___ - Previous open repair of torn cartilage left knee Social History: ___ Family History: Mother deceased metastatic lung cancer. Her father deceased ___ of complications of type II diabetes mellitus and CAD (s/p MI). She has 1 fraternal twin sister, and 2 half brothers who are alive and in good health. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== GENERAL: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: ====================== VS: ___ 0815 Temp: 98.2 PO BP: 146/99 HR: 85 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: resting comfortably, NAD, AAOx3 HEENT: EOMI, PERRLA, anicteric sclera, MMM NECK: supple, non-tender, no LAD, JVP flat at 45 degrees CV: RRR no murmurs RESP: CTAB, no wheeze/crackles, breathing comfortably ___: soft, non tender, no distention, BS+ EXTREMITIES: moving all four extremities with purpose, hands and lower extremities appears mildly edematous but no obvious pitting SKIN: no rashes/lesions NEURO: A/O x3, grossly intact, speech fluent Pertinent Results: ADMISSION LAB RESULTS ===================== ___ 02:30AM BLOOD WBC-12.6* RBC-3.56* Hgb-10.6* Hct-31.0* MCV-87 MCH-29.8 MCHC-34.2 RDW-15.0 RDWSD-47.3* Plt ___ ___ 06:22AM BLOOD Glucose-146* UreaN-19 Creat-0.7 Na-138 K-3.2* Cl-104 HCO3-17* AnGap-17 ___ 02:30AM BLOOD ALT-40 AST-48* AlkPhos-43 TotBili-<0.2 ___ 06:22AM BLOOD Albumin-3.0* Calcium-6.1* Phos-3.5 Mg-1.7 ___ 02:30AM BLOOD ASA-57* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DISCHARGE LAB RESULTS ==================== ___ 05:11AM BLOOD WBC-7.7 RBC-3.87* Hgb-11.6 Hct-34.8 MCV-90 MCH-30.0 MCHC-33.3 RDW-14.7 RDWSD-47.8* Plt ___ ___ 05:11AM BLOOD Glucose-114* UreaN-8 Creat-0.6 Na-143 K-3.6 Cl-105 HCO3-24 AnGap-14 ___ 05:11AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.7 IMAGING ======= ___ CT Head Motion limited exam without evidence of acute intracranial abnormalities. ___ Echo Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. ___ CTA Head/Neck 1. Hypoplasia of the distal segment of the right vertebral artery. Moderate stenosis of the right P1 segment otherwise, no evidence of significant stenosis or occlusion in the carotids, left vertebral artery, or in the principal intracranial branches. 2. Unremarkable CTA of the neck. No stenosis of the cervical internal carotid arteries by NASCET criteria. 3. Nonspecific subcortical hypodensities could represent chronic small vessel disease. No acute intracranial hemorrhage or large territory infarct. 4. Small right pleural effusion bilateral ground-glass opacities in the visualized upper lobes of the lungs, could represent infection. 5. Additional findings described above. ___ CXR The endotracheal and gastric tubes have been removed. The right central venous catheter remains present. Increased lung volumes bilaterally. There is mild pulmonary vascular congestion without overt pulmonary edema. The size of the cardiac silhouette is within normal limits. Prominence of the vascular pedicle is however noted. No focal consolidation or pneumothorax. Trace bilateral pleural effusions are suspected. MICROBIOLOGY ============ - Blood cultures ___: negative - Urine cultures ___: negative - Sputum culture ___: rare growth commensal respiratory flora - Respiratory viral culture ___: negative - MRSA screen negative Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CloNIDine 0.1 mg PO TID Discharge Medications: 1. Benzonatate 100 mg PO TID Cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times per day as needed for cough Disp #*15 Capsule Refills:*0 2. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth in the morning before you eat Disp #*30 Capsule Refills:*0 3. Ramelteon 8 mg PO QHS:PRN insominia RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime as needed for insomnia Disp #*10 Tablet Refills:*0 4. CloNIDine 0.1 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Salicylate Toxicity, resolved Respiratory alkalsosis, anion gap metabolic acidosis, resolved Community acquired pneumonia Encephalopathy, improved 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: ___ woman with altered mental status. TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Total DLP 1605.47 mGy cm. COMPARISON: None. FINDINGS: The patient's head was scanned twice due to motion artifact on the initial scan, but motion artifact remains on repeated scan, limiting evaluation some levels. There is no evidence of hemorrhage, edema, mass effect, or acute major vascular territorial infarction. Ventricles, sulci, and basal cisterns are normal in size. No evidence for a fracture or suspicious bone lesions. There is mild mucosal thickening in the partially visualized right maxillary sinus. There is mild mucosal thickening within the bilateral ethmoid air cells extending into the left frontoethmoidal recess. Mastoid air cells are grossly well-aerated allowing for motion artifact. IMPRESSION: Motion limited exam without evidence of acute intracranial abnormalities. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: Endotracheal tube placement TECHNIQUE: Semi-upright AP view of the chest COMPARISON: None. FINDINGS: An endotracheal tube tip terminates approximately 3.4 cm from the carina. Enteric tube courses below the left hemidiaphragm, and off the inferior borders of the film. Heart size is top-normal. Mediastinal contour is normal. Pulmonary vasculature is not engorged. No focal consolidation, pleural effusion, or pneumothorax is demonstrated. No acute osseous abnormality is present. IMPRESSION: Endotracheal and enteric tubes in standard positions. No acute cardiopulmonary process. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with new central line access// central line placement TECHNIQUE: Frontal chest radiograph COMPARISON: Chest radiograph from ___ at 02:46. FINDINGS: The endotracheal tube tip projects over the distal thoracic trachea, unchanged. The enteric tube is seen below the diaphragm and out of view. There has been interval placement of the right internal jugular central venous catheter with tip projecting over the expected location of the distal SVC. There is no pneumothorax or pleural effusion. Compared to exam obtained 4 hours prior, there is subtle opacity in the right upper lung, which may be summation of shadows. There is mild prominence of the hilar structures in the setting of minimal heart size enlargement, possibly secondary to supine positioning. IMPRESSION: Right internal jugular central venous catheter with tip projecting over the distal SVC. No pneumothorax or pleural effusion. New asymmetric increased opacification in the right apex, which may be a summation of shadows. Attention on follow-up is recommended. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with possible ASA OD s/p intubation// interval change in pulm status TECHNIQUE: Semiupright AP portable chest COMPARISON: Comparison is made to ___. FINDINGS: A right central venous catheter is seen with its tip projecting over the distal SVC. Endotracheal tube tip projects 2.2 cm from the carina. A nasogastric tube is seen passing below the left hemidiaphragm with its side port projecting over the expected region of the stomach. Low lung volumes and increased opacification in the right infrahilar region appears new compared to most recent radiograph. In view of the clinical history the possibility of aspiration or pneumonia cannot be excluded. The cardiomediastinal silhouette appears stable compared to most recent exam. IMPRESSION: Increased opacification in the right infrahilar region is new compared to most recent radiograph. In view of the clinical history, the possibility of aspiration or pneumonia cannot be excluded. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:05 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old woman with AMS, difficulty finding words please evaluate for signs of stroke or mass. 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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. 2) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 13.3 mGy (Body) DLP = 504.0 mGy-cm. 3) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 14.9 mGy (Body) DLP = 7.4 mGy-cm. Total DLP (Body) = 511 mGy-cm. Total DLP (Head) = 748 mGy-cm. COMPARISON: Head CT from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of large territory infarction, hemorrhage, edema, or mass effect. The ventricles and sulci are normal in size and configuration. Bilateral subcortical hypodensities in the insula are nonspecific and probably represent chronic small vessel disease. The visualized portion of the paranasal sinuses demonstrate mild mucosal thick in the ethmoid, sphenoid, and right maxillary sinuses. The mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is moderate stenosis of the right P1 segment. Otherwise, the vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: The distal segment of the right vertebral artery is hypoplastic. Otherwise, the carotid and vertebral arteries and their major branches appear unremarkable with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the lungs demonstrate a small right pleural effusion. Bilateral ground-glass opacities in the pulmonary upper lobes are noted, could represent infection. A central line terminates in the superior vena cava. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Hypoplasia of the distal segment of the right vertebral artery. Moderate stenosis of the right P1 segment otherwise, no evidence of significant stenosis or occlusion in the carotids, left vertebral artery, or in the principal intracranial branches. 2. Unremarkable CTA of the neck. No stenosis of the cervical internal carotid arteries by NASCET criteria. 3. Nonspecific subcortical hypodensities could represent chronic small vessel disease. No acute intracranial hemorrhage or large territory infarct. 4. Small right pleural effusion bilateral ground-glass opacities in the visualized upper lobes of the lungs, could represent infection. 5. Additional findings described above. Radiology Report INDICATION: ___ year old woman with RUL pneumonia// evaluate pneumonia TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The endotracheal and gastric tubes have been removed. The right central venous catheter remains present. Increased lung volumes bilaterally. There is mild pulmonary vascular congestion without overt pulmonary edema. The size of the cardiac silhouette is within normal limits. Prominence of the vascular pedicle is however noted. No focal consolidation or pneumothorax. Trace bilateral pleural effusions are suspected. IMPRESSION: No focal consolidation is identified. Pulmonary vascular congestion is present. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by HELICOPTER Chief complaint: Intubated, Transfer Diagnosed with Altered mental status, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: unable level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ after you had toxicity from taking too much aspirin. WHAT WAS DONE FOR YOU? - You presented to the hospital in respiratory distress and had a breathing tube placed. You were initially in the medical intensive care unit and you were treated for aspirin toxicity. You fortunately suffered no serious consequences from aspirin toxicity. You had some confusion during your hospital stay but this improved significantly. - You were treated for a pneumonia with antibiotics and these were finished before you were discharged. WHAT TO DO NEXT? - Please take all of your medicines as instructed. Please follow up with your primary care providers as scheduled. - You were given prescriptions for cough medicine (pill called tessalon pearls/benzonatate) to take as needed. You should also try robitussin which you can buy at the local pharmacy at night for your cough. - You were started on a heart burn medicine called omeprazole. It was a pleasure taking care of you, 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: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. ___ is a ___ year old female with history of HTN, adult acne who presented to the ED with RUQ pain. THe patient about 2 months ago and earlier this month had been feeling intermittent sensations of epigastric burning, nonradiating, thought to be from what she thought was heartburn. She was taking ranitidine for this. She felt it was heartburn especially because her parents unfortunately passed away that time as well and was experiencing a lot of stress. She saw her PCP, ___ discovered abnormal LFTs and RUQ US was done on ___ that showed cholelithiasis. However, yesterday evening she ate a quiche at about 6PM, then at 8PM she noticed new acute onset of RUQ pain, different in characteristic from the previously thought heartburn sensation. She took Pepcid which did not help. She had associated nausea, but no vomiting. No fever, cough, SOB, diarrhea. Her last bowel movement was normal yesterday. At time of this interview she does not have any pain at rest, but does feel some She does not have a history of any prior abdominal or major surgery including C sections. ED: Found to have lipase ___ and Tbili 1.6, Dbili 1.1, AST 547, AST 518, ALP 165. Abdominal US was done showing cholelithiasis without findings of acute cholecystitis. Given zosyn, spironolactone, ranitidine, 1L NS Past Medical History: - Adult Acne - HTN - Cholelithiasis Social History: ___ Family History: Sister Living ___ HYPERTENSION BASAL CELL CARCINOMA Mother deceased ___ HYPERTENSION GLAUCOMA ANOMALOUS PULMONARY VENOUS RETURN WITH SHUNTING VASCULAR DEMENTIA SUBAORTIC WEBBING AORTIC VALVULAR DISEASE Father ___ ___ CORONARY ARTERY DISEASE PROSTATE CANCER NORMAL PRESSURE HYDROCEPHALUS Brother Living ___ HYPERTENSION Brother Living ___ ANAL CANCER Physical Exam: VITALS: Afebrile and vital signs stable GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, non-tender to palpation except in RUQ with deep palpation there is focal discomfort. BS present GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities PSYCH: pleasant, appropriate affect NEUROLOGIC: MENTATION: alert and cooperative. Oriented to person and place and time. Pertinent Results: AST: 518 --> 1037 ALT: 547 --> 474 Alk Phos: 165 --> 212 Lipase on admission: ___ WBC: 10.5 --> 4.1 Hgb: 14.1 --> 13.6 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Spironolactone 200 mg PO DAILY 2. Prempro (conj estrog-medroxyprogest ace) 0.3-1.5 mg oral DAILY 3. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250 mg-unit oral DAILY 4. minoxidil 2 % topical DAILY 5. Ranitidine 75 mg PO BID Discharge Medications: 1. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250 mg-unit oral DAILY 2. minoxidil 2 % topical DAILY 3. Prempro (conj estrog-medroxyprogest ace) 0.3-1.5 mg oral DAILY 4. Ranitidine 75 mg PO BID 5. Spironolactone 200 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Gallstone pancreatitis and cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with ruq pain, n/v// cholecystitis? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm. GALLBLADDER: Multiple small layering and mobile gallstones without gallbladder wall thickening or pericholecystic fluid. PANCREAS: The head and body of the pancreas are within normal limits. The tail of the pancreas is not visualized due to the presence of gas. SPLEEN: Normal echogenicity, measuring 9 point cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Cholelithiasis without findings of acute cholecystitis. Radiology Report INDICATION: History: ___ with pancreatitis// effusion? TECHNIQUE: Chest PA and lateral COMPARISON: ___ chest radiograph FINDINGS: The lungs are well expanded and clear. There is no focal consolidation. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is unremarkable. There is no free intraperitoneal air below the hemidiaphragm. IMPRESSION: 1. No acute cardiopulmonary process. Radiology Report EXAMINATION: MRCP INDICATION: ___ year old woman with cholelithiasis who presents with RUQ pain// elevated lipase, bilirubin, RUQ pain. Eval ?choledocholithiasis TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 7 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: CT scan of the abdomen and pelvis dated ___. FINDINGS: Lower Thorax: The lung bases are clear. No pleural or pericardial effusion. Liver: Homogeneous signal of the liver parenchyma. No significant hepatic steatosis. No focal liver lesions. Biliary: There are gallstones within the bladder lumen. There is mural hyper enhancement and marked pericholecystic edema consistent with acute cholecystitis. There is mild perfusional abnormality within the adjacent liver parenchyma. The intra and extrahepatic biliary tree are normal in caliber without evidence of biliary obstruction or choledocholithiasis. Pancreas: Normal T1 signal of the pancreas. No pancreatic ductal dilatation or mass. Spleen: The spleen is normal in size. Adrenal Glands: The adrenal glands are normal in size and morphology. Kidneys: The kidneys are unremarkable. No hydronephrosis. Gastrointestinal Tract: The stomach is unremarkable. The small and large bowel are normal in caliber. Lymph Nodes: No retroperitoneal or mesenteric adenopathy. Vasculature: Patent portal venous systems are patent. The abdominal aorta is normal in caliber. Osseous and Soft Tissue Structures: No suspicious osseous or soft tissue lesion is identified. IMPRESSION: 1. Findings are suggestive of acute calculus cholecystitis. 2. No evidence of biliary obstruction or choledocholithiasis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Right upper quadrant pain temperature: 96.9 heartrate: 115.0 resprate: 16.0 o2sat: 100.0 sbp: 152.0 dbp: 87.0 level of pain: 6 level of acuity: 3.0

You were admitted to ___ with gallstone pancreatitis and also gall stone cholecystitis. Your labs were with very elevated lipase and LFTs. Due to your not having many symptoms and imaging without evidence of a blockage at this time, it was discussed that removal of your gall bladder is the best course of action at this time.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: pollen Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a pleasant ___ with stage IV sigmoid adenocarcinoma s/p LAR (___) with subsequent POD involving spleen now s/p splenectomy/distal pancreatectomy/wedge gastrectomy (___) currently on palliative C1D25 Irinotecan and DVT on rivaroxaban who p/w diffuse abdominal pain, concern for malignant bowel obstruction. Sx started yesterday w/ diffuse abd pain, + nausea, no vomiting, + diarrhea at 2 am. Of note, recently admitted ___ for abdominal pain thought to be related to neoplasm but no acute pathology otherwise seen on CT. Discharged on dilaudid and apap. He subsequently represented to the ED with abdominal pain ___ and CT showed persistent R hydronephrosis iso malignant obstruction, 3 pelvic soft tissue masses (mild interval increase in size), and large mass in the splenectomy bed (no interval change). No SBO on this CAT scan. He presents this time to ED with diffuse abdominal pain, diarrhea, and nausea. Patient was afebrile and mildly hypertensive upon arrival. Labs were all largely unremarkable. Repeat CT A/P shows concern for SBO ___ omental implant in the L mid abdomen, additionally thickening of the bowel wall in the L mid abdomen concern for an additional submucosal metastatic lesion. Patient was administered dilaudid and IVF. He refused placement of an NGT in the ED. Colorectal was consulted, no acute indication for surgical intervention. Of note, patient last took xeralto at 12AM ___. Patient was admitted for IVF, bowel rest, serial abdominal exams. On arrival to the oncology service, pt noted he had zero abd pain and zero nausea. Admits to passing gas, no stool yet, and feeling "very hungry." Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): As per last ___ clinic note by Dr ___: "Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with progressive metastatic disease, KRAS mutated, MSI intact - ___ Colonscopy for weight loss of 26 lbs in a year revealed a fungating, circumferential mass of malignant appearance was found in the sigmoid colon at 18cm. Biopsy consistent with adenocarcinoma. CT torso revealed 3.7 cm segment of the mid sigmoid colon demonstrating circumferential wall thickening in keeping with tumor. There is no associated bowel obstruction at present time. Adjacent mesenteric lymph nodes measuring up to 6 mm in short axis dimension are noted. No evidence of metastatic disease within the chest, abdomen, or pelvis. - ___ MR pelvis revealed Ill-defined sigmoid mass, approximately 15 cm above the anal verge, as seen on the CT examination from ___, with extension across the muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5 cm mass abutting the anterior aspect of the rectum and posterior aspect of the seminal vesicles, 7 cm above the anal verge, is suspicious for a drop metastasis as it is not convincingly arising from rectal wall. This likely corresponds to the palpable finding on physical exam. Intrapelvic lymphadenopathy adjacent to the sigmoid mass, some with morphology suspicious for tumor involvement. - ___ Undderwent LAR. Path revealed colonic adenocarcinoma in the resected rectosigmoid colon. Tumor size was 3.6cm, low grade, staged pT3. Margins were negative. Of the 15 nodes examined, 6 were positive, thus staged pN2a. Finally, a separate nodule of adenocarcinoma was identified 9 cm distal to the primary tumor involving pericolonic adipose tissue, serosa, and muscularis propria, consistent with metastasis of the primary tumor. Furthermore, the resected peritoneal nodule showed metastatic adenocarcinoma with perineural invasion. Thus, this was staged pM1b. Of note, KRAS mutation was detected. - ___ to ___ admitted for abdominal pain, OSH CT was reviewed here and felt to be not concerning for any acute intra-abdominal process including leak or abcess however there was a high stool burden and gas. Pt discharged on bowel regimen. - ___ ED visit for abdominal pain, KUB reassuring, discharged after bowel regimen - ___ C1D1 XELOX (Xeloda 1000mg BID) - ___ to ___ Admission for n/v and abd pain. CT showed mildly dilated stomach and proximal small bowel, but no evidence of obstruction. He underwent NGT decompression with good bilious output and improvement in symptoms and was slowly advanced to regular diet. - ___ C1D1 XELOX (Xeloda 1000mg BID) - ___ to ___ admission for abd pain and constipation. CT showed multiple mildly distended loops of ileum with fecalized contents and a narrow caliber of the terminal ileum. Stool and air seen in the colon. Symptoms improved with aggressive bowel regimen. - ___ C3D1 XELOX (Xeloda 1500mg BID) - ___ C4D1 XELOX (Xeloda 1500mg BID) - ___ C5D1 XELOX (Xeloda 2000mg BID) - ___ C6D1 XELOX (Xeloda 2000mg BID) - ___ C7D1 XELOX (Xeloda 2000mg BID) - ___ CT torso with no evidence of recurrence or metastases - ___ colonoscopy showed multiple tiny 2 mm polypoid lesions which showed to be lymphoid aggregates on path - ___ CT torso with no evidence of recurrence or metastases - ___ CT abdomen in the ED for abdominal pain showed ___ - ___ CT abdomen in the ED for abdominal pain showed ___ but indeterminate liver lesion - ___ CT torso ___ with stable liver lesion - ___ Colonoscopy revealed a single polyp, pathology consistent with adenoma. - ___ CT torso showed a new lesion in the splenic hilum concerning for recurrence - ___ PET CT showed avid lesion in the spleen, no other sites of disease - ___ Splenectomy revealed metastatic colon cancer - ___ CT torso showed ___ - ___ CT torso extensive recurrence in the spenic bed and nodes, CEA rising - ___ Biopsy of the splenic bed confirmed metastatic adenocarcinoma - ___ CT torso showed increase in metastatic disease - ___ CT torso showed increase in metastatic and concerning new areas in the liver - ___ Admitted with malignant SBO - ___ C1D1 FOLFOX6 - ___ C1D15 FOLFOX (oxaliplatin at 65 ___ neuropathy) - ___ C2D1 FOLFOX (oxaliplatin at 65 ___ neuropathy - ___ CT torso shows stable disease - ___ Treatment delayed per patient preference - ___ C3D1 FOLFOX (oxaliplatin at 65 ___ neuropathy) - ___ Patient requested to defer dose, CEA rising - ___ C1D1 ___ PAST MEDICAL HISTORY (per OMR): as above Social History: ___ Family History: Negative for colon cancer, inflammatory bowel disease, uterine cancer. He does have history of lipomas in his family. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VITAL SIGNS: 97.7 PO 134 / 81 54 18 99 RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs LIMBS: WWP, no ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: CN III-XII intact, strength b/l ___ intact PSYCH: Thought process logical, linear, future oriented ACCESS: R Chest port site intact w/o overlying erythema, accessed and dressing C/D/I DISCHARGE PHYSICAL EXAM: ========================== VITAL SIGNS: 24 HR Data (last updated ___ @ 850) Temp: 98.8 (Tm 98.8), BP: 132/81 (132-149/80-83), HR: 53 (53-55), RR: 18, O2 sat: 99% General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, non distended, mildly tender to palpation in LLQ, no peritoneal signs LIMBS: WWP, no ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: CN III-XII intact, strength b/l ___ intact PSYCH: Thought process logical, linear, future oriented ACCESS: R Chest port site intact w/o overlying erythema, accessed and dressing C/D/I Pertinent Results: ADMISSION LABS: =============== ___ 04:00AM BLOOD WBC-8.0 RBC-3.62* Hgb-10.9* Hct-33.2* MCV-92 MCH-30.1 MCHC-32.8 RDW-14.5 RDWSD-48.7* Plt ___ ___ 04:00AM BLOOD Neuts-54.1 ___ Monos-13.3* Eos-10.9* Baso-0.5 Im ___ AbsNeut-4.33 AbsLymp-1.65 AbsMono-1.06* AbsEos-0.87* AbsBaso-0.04 ___ 04:00AM BLOOD Plt ___ ___ 09:25PM BLOOD PTT-45.9* ___ 04:00AM BLOOD Glucose-108* UreaN-12 Creat-1.1 Na-140 K-3.8 Cl-103 HCO3-25 AnGap-12 ___ 04:00AM BLOOD ALT-18 AST-16 AlkPhos-67 TotBili-<0.2 ___ 04:00AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.6 DISCHARGE LABS: ================ ___ 05:30AM BLOOD WBC-6.4 RBC-3.49* Hgb-10.5* Hct-32.2* MCV-92 MCH-30.1 MCHC-32.6 RDW-14.5 RDWSD-48.6* Plt ___ ___ 05:30AM BLOOD Plt ___ ___ 11:30AM BLOOD PTT-115.4* ___ 05:30AM BLOOD Glucose-104* UreaN-6 Creat-1.0 Na-141 K-3.6 Cl-102 HCO3-29 AnGap-10 ___ 05:30AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.8 IMAGING: ========= ___BD & PELVIS WITH CO IMPRESSION: 1. Findings concerning for small bowel obstruction secondary to a 3.2 cm omental implant in the left mid abdomen. No signs to suggest bowel ischemia. 2. Relatively hyperdense, asymmetric thickening of the bowel wall in the left mid abdomen (601:75, 2:48) likely represents an additional submucosal metastatic lesion. 3. Persistent moderate to severe right-sided hydroureteronephrosis with a delayed right nephrogram secondary to malignant obstruction of the right distal ureter, similar to prior. 4. Re-demonstration of the 3 previously noted omental implants in the abdomen/pelvis measuring up to 3.6 cm, similar to prior. 5. Re-demonstration of a large 7.1 cm mass in the splenectomy bed as well as a 2.2 cm omental implant fat in the liver dome. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with h/o colon CA on palliative chemo presents with severe abdominal pain, diffusely TTPNO_PO contrast// eval appy/diverticulitis, 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 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 10.4 mGy (Body) DLP = 536.2 mGy-cm. Total DLP (Body) = 545 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 2.2 cm hypoattenuating lesion at the posterior hepatic dome is unchanged (2:5) and likely represents a peritoneal implant. No new focal lesions are identified. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: As before, the patient is status post distal pancreatectomy. The remaining portions of the pancreas are unremarkable. As before, the distal remnant pancreas tail is encased by a large mass in the splenectomy bed. SPLEEN: The patient is status post splenectomy. Re-demonstrated is a large heterogeneous, predominantly hypodense mass in the surgical bed measuring approximately 6.7 x 5.3 x 7.1 cm (02:13, 601:33). As before, the mass closely abuts the greater curvature of the stomach and the adjacent jejunal loops. 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 persistent moderate to severe right-sided hydroureteronephrosis with a delayed right nephrogram secondary to right-sided pelvic soft tissue masses along the course of the distal right ureter measuring 3.6 cm and 3.1 cm, unchanged (02:58, 66). The left kidney is unremarkable without evidence of hydronephrosis. GASTROINTESTINAL: The patient is status post partial gastrectomy. There is a few dilated, fluid-filled loops of small bowel in the left hemiabdomen measuring up to 3.6 cm. There appears to be a transition point in the left mid abdomen near the known soft tissue mass in the left anterior abdomen, which measures approximately 3.2 cm (02:40). There is no evidence of perforation. There is an area of relatively hyperdense, asymmetric thickening of the bowel wall in the left mid abdomen, which may represent an additional submucosal metastatic lesion. The patient is status post partial colectomy. The remaining colon and rectum are within normal limits. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Findings concerning for small bowel obstruction secondary to a 3.2 cm omental implant in the left mid abdomen. No signs to suggest bowel ischemia. 2. Relatively hyperdense, asymmetric thickening of the bowel wall in the left mid abdomen (601:75, 2:48) likely represents an additional submucosal metastatic lesion. 3. Persistent moderate to severe right-sided hydroureteronephrosis with a delayed right nephrogram secondary to malignant obstruction of the right distal ureter, similar to prior. 4. Re-demonstration of the 3 previously noted omental implants in the abdomen/pelvis measuring up to 3.6 cm, similar to prior. 5. Re-demonstration of a large 7.1 cm mass in the splenectomy bed as well as a 2.2 cm omental implant fat in the liver dome. Gender: M Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Other intestnl obst unsp as to partial versus complete obst temperature: 97.5 heartrate: 55.0 resprate: 14.0 o2sat: 100.0 sbp: 157.0 dbp: 98.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, It was a privilege caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because of abdominal pain. WHAT HAPPENED TO ME IN THE HOSPITAL? - We performed imaging that showed that intestines were being compressed from your cancer, causing obstruction. - We gave you pain medication, and allow your intestines to rest. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Please ensure that you follow-up with the outpatient oncologist next ___. This is absolutely essential. We wish you the best! 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: ___ Major Surgical or Invasive Procedure: None. History of Present Illness: ___ year old gentleman with history of AAA s/p EVAR and fem-fem bypass, CAD s/p CABG (___) with bare metal stent placed in ___, severe AS with most recent echo showing AVR of 0.9 cm2 on echo ___, HFpEF with recent echo ___ EF >55%), COPD, CKD (baseline creatinine 2.0), afib (CHADS-VASC 5) on warfarin, who was noted to have elevated creatinine to 4.5 on outpatient laboratory evaluation. Patient was unable to void and presented to ___. At that time, creatinine was noted to be 4.6, with potassium of 6.1. For the hyperkalemia, received calcium gluconate, dextrose x 2, 2 units insulin. A foley catheter was palced and 750 cc urine was drained. CXR was performed "Cardiomegaly. Sternotomy. Blunted right costophrenic sulcus perhaps a tiny right pleural effusion." Of note, patient' most recent creatinine was 2.8 on ___. His diuretic regimen has been adjusted on ___ given fluctuations in his creaitnine. At his most recent nephrology appointment, decision was made to change diuretic regimen to 80 mg QAM, 40 mg QPM, reduce metolazone to 5 mg M, W, F. Patient recently had CTA chest with contrast on ___ for pre-eval for TAVR. Patient continued on the same diuretic regimen he had been on since ___ but began to gain approximately 12 pounds between ___, with bilateral lower extremity edema and shortness of breath. There were no dietary indiscretions. In the ED, initial vitals were: 96.6, HR 85, BP 116/61, RR 22, Pulse Ox 95% on nasal cannula. Labs were notable for WBC 11.8, H/H 7.6/23.5, platelets 101. proBNP elevated at 6,427. Chemistry notable for Na 131, K 5.3, Bun/Cr 88/4.8. Trop elevated at 0.07. Lactate 2.0. UA showed 77 WBC, few bacteria, >182 RBC. Patient received 40 mg IV furosemide x 1 and albuterol nebulizer x 1. Of note, during prior hospitalization in ___ patient was noted to be in heart failure after receiving blood for GI bleed (no active bleeding found but was noted to have AVM within the cecum on colonoscopy) During that hospitalization, he required IV Lasix 100-120 mg boluses and drip at ___ mg/hour. Diuresis was limited by orthostatic hypotension and patient was discharged hypervolemic with bibasilar crackles and pitting edema but diuresis was limited due to orthostatic hypotension and severe AS. On the floor, patient denies any fevers, chills, dysuria, chest pain, chest pressure, chest palpitations. He does note that his breathing has improved throughout the day. Denies any nausea or vomiting. Review of systems: Please see HPI. Past Medical History: 1. CAD s/p CABG ___ at ___ 2. NSTEMI ___ 3. Cerebral Amyloid angiopathy 4. Severe AS 5. Chronic diastolic heart failure 6. PVD s/p complex EVAR ___ at ___ and fem-fem bypass ___. Right Iliac is occluded. S/p bilateral prosthetic grafts in both groins. 7. HTN 8. Atrial Fibrillation 9. HLD 10. CKD stage 3 11. Orthostatic hypotension 13. COPD 14. Hypothyroidism 15. Carotid disease 16. Raynaud's 17. s/p bilateral knee replacement Social History: ___ Family History: Father with gastric cancer Otherwise noncontributory Physical Exam: ADMISION PHYSICAL EXAM: ========================= Vital Signs: 98.1, 124/65, 78, 22, 98% on 1L. Weight 108.3 kg. General: Alert but fatigued appearing, laying in bed on nasal cannula, breathing comfortably. HEENT: Sclerae anicteric, MMM, oropharynx clear, JVD to the jaw. CV: Irregularly irregular rhythm, S1 and S2 present, harsh systolic murmur at the right upper sternal border. Lungs Crackles approximately ___ up the lung fields. Abdomen: soft, non-tender, non-distended, no rebound or guarding. GU: Foley in place draining pink tinged urine. Ext: Warm, well perfused, 3+ pitting edema to the thighs. Neuro: CNII-XII intact, moves arms and legs without difficulty. DISCHARGE PHYSICAL EXAM: ========================== VS: T 98.1-98.6 BP 91/55 (80s-110s/50s), HR 70 (70-80), RR 18, SAT ___ RA I/Os: 8hr: 60|650, 24hr: 784|2950 (put out about 700 cc after Lasix) Weight: 90.8<-91.7<-94.0<-95.2<-95.2<-95.5 (accurate from now on) <-97.4<-109.8 <-108.3 <- 108.3 (note: bed weights) Admission weight: 108.3 kg GENERAL: Elderly male in no distress, sleeping flat, HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVD mid neck at 45 degrees. CARDIAC: Heart sounds regular, normal S1, S2, ___ systolic ejection murmur at the base. No S3 or S4. LUNGS: Respiration unlabored. No crackles, wheezing, or rhonchi. ABDOMEN: Soft, NT, ND. No HSM or tenderness. EXTREMITIES: WWP. 1+ pitting edema in in both legs up to ankles, R>L. 2+ radial/DP pulses bilaterally. SKIN: No significant skin lesions. Pertinent Results: ADMISSION LABS: ================================ ___ 08:30PM URINE HOURS-RANDOM UREA N-333 CREAT-37 SODIUM-37 ___ 08:30PM URINE OSMOLAL-335 ___ 08:30PM URINE UHOLD-HOLD ___ 08:30PM URINE COLOR-RED APPEAR-Hazy SP ___ ___ 08:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD ___ 08:30PM URINE RBC->182* WBC-77* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-2 ___ 07:58PM LACTATE-2.0 ___ 07:45PM GLUCOSE-93 UREA N-88* CREAT-4.8*# SODIUM-131* POTASSIUM-5.3* CHLORIDE-91* TOTAL CO2-24 ANION GAP-21* ___ 07:45PM estGFR-Using this ___ 07:45PM LD(LDH)-264* TOT BILI-0.5 ___ 07:45PM cTropnT-0.07* ___ 07:45PM proBNP-6427* ___ 07:45PM IRON-72 ___ 07:45PM IRON-72 ___ 07:45PM WBC-11.8*# RBC-2.61* HGB-7.6* HCT-23.5* MCV-90 MCH-29.1 MCHC-32.3 RDW-16.6* RDWSD-54.4* ___ 07:45PM NEUTS-85.2* LYMPHS-3.5* MONOS-10.5 EOS-0.0* BASOS-0.1 IM ___ AbsNeut-10.09* AbsLymp-0.41* AbsMono-1.24* AbsEos-0.00* AbsBaso-0.01 ___ 07:45PM PLT COUNT-101* ___ 07:45PM ___ PTT-31.7 ___ MICROBIOLOGY: ================================ Blood culture x2 (___): negative Urine culture (___): negative IMAGING: ================================ CXR Portable (___): FINDINGS: Cardiac silhouette is enlarged. Prior sternotomy. Increased interstitial as well as alveolar opacities most consistent with interstitial edema/ CHF. Findings are similar to the previous CXR from ___. Renal U/S (___): FINDINGS: The right kidney measures 10.3 cm. The left kidney measures 13.4.0 cm. There is no hydronephrosis, stones or masses bilaterally. There are multiple simple simple cysts in the bilateral kidneys, as seen on prior CT. The largest is noted in the left kidney lower pole measuring 6.7 x 5.2 cm. A Foley catheter is present. The bladder was not visualized. IMPRESSION: 1. No evidence of hydronephrosis, as clinically questioned. 2. The bladder was not visualized. A Foley catheter is present. CARDIAC STUDIES: ================================ EKG (___): HR 78. Sinus rhythm. Left bundle-branch block. Repolarization abnormalities consistent with left bundle-branch block. Compared to the previous tracing of ___ no significant change. EKG (___): HR 90. Probable sinus rhythm. Normal Axis. Prolonged P-R interval. Intermittent sinus tachycardia versus atrial tachycardia. Left bundle-branch block. Compared to the previous tracing of ___ the rate has increased. DISCHARGE AND PERTINENT LABS: ================================ ___ 06:25AM BLOOD ALT-17 AST-12 LD(LDH)-247 AlkPhos-68 TotBili-0.5 ___ 01:15AM BLOOD CK-MB-2 cTropnT-0.08* ___ 07:00AM BLOOD TSH-0.11* ___ 11:50AM BLOOD Free T4-1.6 ___ 05:30AM URINE Hours-RANDOM TotProt-22 ___ 05:30AM URINE U-PEP-NO PROTEIN ___ 06:10AM BLOOD WBC-6.8 RBC-3.30* Hgb-9.5* Hct-29.4* MCV-89 MCH-28.8 MCHC-32.3 RDW-17.0* RDWSD-55.1* Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-90 UreaN-50* Creat-2.3* Na-137 K-3.9 Cl-94* HCO3-29 AnGap-18 ___ 06:10AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Docusate Sodium 100 mg PO DAILY 5. Furosemide 40 mg PO QPM 6. Gabapentin 100 mg PO QHS 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Midodrine 10 mg PO TID 10. Ranexa (ranolazine) 500 mg oral BID 11. Tamsulosin 0.4 mg PO QHS 12. Tiotropium Bromide 1 CAP IH DAILY 13. Warfarin 2.5 mg PO DAILY16 14. Pantoprazole 40 mg PO Q12H 15. Finasteride 5 mg PO DAILY 16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN wheezing/shortness of breath 17. Lidocaine 5% Ointment 1 Appl TP QID 18. PredniSONE 10 mg PO DAILY 19. Metolazone 5 mg PO 3X/WEEK (___) 20. Potassium Chloride 40 mEq PO DAILY 21. Iron Polysaccharides Complex ___ mg PO DAILY 22. Lactulose 15 mL PO DAILY 23. Lidocaine 5% Patch 1 PTCH TD QAM 24. Furosemide 80 mg PO QAM 25. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of breath/wheezing 26. Milk of Magnesia 30 mL PO DAILY:PRN constipation 27. Fleet Enema ___AILY:PRN constipation 28. Bisacodyl 10 mg PR QHS:PRN constipation 29. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Furosemide 80 mg PO BID 2. Levothyroxine Sodium 125 mcg PO 6X/WEEK (___) 3. Levothyroxine Sodium 62.5 mcg PO 1X/WEEK (___) 4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of breath/wheezing 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Bisacodyl 10 mg PR QHS:PRN constipation 9. Docusate Sodium 100 mg PO DAILY 10. Finasteride 5 mg PO DAILY 11. Iron Polysaccharides Complex ___ mg PO DAILY 12. Lactulose 15 mL PO DAILY 13. Lidocaine 5% Ointment 1 Appl TP QID 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Lidocaine 5% Patch 1 PTCH TD QAM 16. Midodrine 10 mg PO TID 17. Milk of Magnesia 30 mL PO DAILY:PRN constipation 18. Pantoprazole 40 mg PO Q12H 19. Potassium Chloride 40 mEq PO DAILY 20. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN wheezing/shortness of breath 21. Tamsulosin 0.4 mg PO QHS 22. Tiotropium Bromide 1 CAP IH DAILY 23. Warfarin 2.5 mg PO DAILY16 24. HELD- Allopurinol ___ mg PO DAILY This medication was held. Do not restart Allopurinol until kidney function has normalized. 25. HELD- Gabapentin 100 mg PO QHS This medication was held. Do not restart Gabapentin until kidney function normalizes. 26. HELD- Ranexa (ranolazine) 500 mg oral BID This medication was held. Do not restart Ranexa until resolution of hypotension. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ========================= Acute exacerbation of Chronic Diastolic Heart Failure Acute kidney injury on chronic kidney disease Severe aortic stenosis Atrial fibrillation Anemia Hypothyroidism Coronary artery disease SECONDARY DIAGNOSES: ========================= COPD Peripheral neuropathy Benign prostatic hypertrophy Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old gentleman with history of AAA s/p EVAR and fem-fem bypass, CAD s/p CABG (___) with bare metal stent placed in ___, severe AS with most recent echo showing AVR of 0.9 cm2 on echo ___, HFpEF with recent echo ___ EF >55%), COPD, CKD (baseline creatinine 2.0), afib (CHADS-VASC 5) on warfarin, who was noted to have elevated creatinine to 4.5 on outpatient laboratory evaluation. Now with diffuse wheezing on exam and inspiratory crackles. // Assess for acute lung pathology, pulmonary edema? infection? FINDINGS: Cardiac silhouette is enlarged. Prior sternotomy. Increased interstitial as well as alveolar opacities most consistent with interstitial edema/ CHF. Findings are similar to the previous CXR from ___. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with urinary retention and ___. // Please evaluate for hydronephrosis/renal parenchymal disease. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CT ___. FINDINGS: The right kidney measures 10.3 cm. The left kidney measures 13.4.0 cm. There is no hydronephrosis, stones or masses bilaterally. There are multiple simple simple cysts in the bilateral kidneys, as seen on prior CT. The largest is noted in the left kidney lower pole measuring 6.7 x 5.2 cm. A Foley catheter is present. The bladder was not visualized. IMPRESSION: 1. No evidence of hydronephrosis, as clinically questioned. 2. The bladder was not visualized. A Foley catheter is present. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, Dyspnea Diagnosed with Heart failure, unspecified, Acute kidney failure, unspecified temperature: 96.6 heartrate: 85.0 resprate: 22.0 o2sat: 95.0 sbp: 116.0 dbp: 61.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you! You were admitted with shortness of breath and cough. We determined that you were in heart failure, a condition in which your heart does not pump effectively. As a result fluid builds up throughout your body, including in your lungs. We treated you with intravenous diuretics to eliminate this fluid, and you improved. Please take all medications as directed and try your best to keep all of your scheduled appointments. Please check your weights daily. If you gain greater than 3lbs in 24hrs or 5lbs in 48hrs, please contact your doctor. Your weight at discharge was 90.8 kg or 200 pounds. We wish you the best! Your ___ Cardiology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Voltaren Attending: ___. Chief Complaint: cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old ___ speaking woman, with history of dementia, recurrent UTIs, HTN, and hypothyroidism, who is presenting today with increased URI symptoms for the past 3 days. Patient's health aid had also noticed that for the past 3 days, she has had increased cough x 3 days, rhinorrhea, body aches, and subjective fevers with generalized malaise. She denies any chest pains, palpitations, shortness of breath, nausea/vomiting or diarrhea. Recently, she was seen by her PCP ___ ___ to have an e. coli UTI, and was started on a 5 day course of macrobid (last day ___. Of note, patient was seen by here PCP ___ ___ and was found to have poor appetite and knee pains. At that time, thought to be ___ to depression, as there was no evidence for GI etiology. Furthermore, thought to have a component of GERD. Patient also was complaining of left knee pain, and was given prescription for APAP TID. Moreover, her memory loss thought to be stable. Patient was treated with macrobid x 5 days starting on ___. In the ED, initial vital signs were: 97.9 83 144/72 18 98% Nasal Cannula. Exam was notable for bilateral wheezing. - Labs were notable for: BNP 1686, Trop x 1 negative, Chem panel with K 6 hemolyzed, BUN 27, Creatinine 1.0. WBC 10.6. Influenza Negative. Urinalysis showed trace protein, moderate leuk, few bacteria. Lactate 2.5. The patient was given: IH Albuterol 0.083% Neb Soln 1 NEB IH Ipratropium Bromide Neb 1 NEB IV CeftriaXONE 1 gm IV Azithromycin 500 mg Vitals prior to transfer were: 78 120/58 18 97% Nasal Cannula Upon arrival to the floor, patient was in no acute distress. She was ambulating around her hospital bed, drinking coffee and sitting up comfortably. She complains that she is very thirsty and very hungry. She says she doesn't know why her niece brought her in. She is denying having a home health aide, says only someone who cleans comes by a couple times per week. She reports that she would like to be DNR/DNI. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: 1. Hypothyroidism 2. Hypertension 3. Urinary Tract Infections 4. Bilateral Knee Arthritis 5. Dementia 6. Depression Social History: ___ Family History: Unknown. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS - 97.8, 117/48, 70, 20, 95% on RA Weight 73.7 kg GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, no thyromegaly, no JVP CARDIAC - regular rate & rhythm, normal S1/S2, I/VI systolic murmur PULMONARY - crackles on R mid and lower lung field. CTA on left side. No wheezes. ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. Gait assessment deferred PSYCHIATRIC - listen & responds to questions appropriately,pleasant DISCHARGE PHYSICAL EXAM: VITALS - 99.5 142/68 62 18 95RA Weight 74.7 kg GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, no thyromegaly, no JVP CARDIAC - regular rate & rhythm, normal S1/S2, II/VI systolic murmur PULMONARY - CTAB. No wheezes. ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. Gait assessment deferred PSYCHIATRIC - listen & responds to questions appropriately,pleasant Pertinent Results: ADMISSION LABS: ___ 02:10AM BLOOD WBC-10.6* RBC-4.29 Hgb-11.8 Hct-37.8 MCV-88 MCH-27.5 MCHC-31.2* RDW-14.5 RDWSD-46.5* Plt ___ ___ 02:10AM BLOOD Neuts-77* Bands-1 Lymphs-6* Monos-9 Eos-4 Baso-1 ___ Metas-2* Myelos-0 AbsNeut-8.27* AbsLymp-0.64* AbsMono-0.95* AbsEos-0.42 AbsBaso-0.11* ___ 02:10AM BLOOD Glucose-121* UreaN-27* Creat-1.0 Na-139 K-6.0* Cl-102 HCO3-23 AnGap-20 ___ 02:10AM BLOOD cTropnT-<0.01 proBNP-1686* ___ 03:11PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7 ___ 02:16AM BLOOD Lactate-2.5* PERTINENT LABS: ___ 10:00AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 02:10AM BLOOD cTropnT-<0.01 proBNP-___* ___ 07:51AM BLOOD Lactate-2.0 IMAGING: CXR: Interval development of diffuse bilateral interstitial opacities and small bilateral pleural effusions, consistent with mild pulmonary interstitial edema. DISCHARGE LABS: ___ 08:00AM BLOOD WBC-10.0 RBC-3.89* Hgb-10.5* Hct-33.9* MCV-87 MCH-27.0 MCHC-31.0* RDW-14.6 RDWSD-45.9 Plt ___ ___ 08:00AM BLOOD Glucose-109* UreaN-20 Creat-0.9 Na-141 K-4.6 Cl-104 HCO3-28 AnGap-14 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO BID 2. Donepezil 5 mg PO BID 3. iodoquinol-HC ___ % topical unknown 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN knee pain 6. Lorazepam 0.5 mg PO QHS:PRN insomnia 7. nystatin 100,000 unit/gram topical BID:PRN affected area 8. Patanol (olopatadine) 0.1 % ophthalmic BID 9. Omeprazole 20 mg PO DAILY 10. TraMADOL (Ultram) 50 mg PO BID:PRN knee pain 11. TraZODone 50 mg PO QHS:PRN insomnia 12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 13. Acetaminophen 1000 mg PO Q8H:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Atenolol 50 mg PO BID 3. Donepezil 5 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN knee pain 6. Lorazepam 0.5 mg PO QHS:PRN insomnia 7. Omeprazole 20 mg PO DAILY 8. TraMADOL (Ultram) 50 mg PO BID:PRN knee pain 9. TraZODone 50 mg PO QHS:PRN insomnia 10. Azithromycin 250 mg PO Q24H Duration: 2 Days RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 11. iodoquinol-HC ___ % topical unknown 12. nystatin 100,000 unit/gram topical BID:PRN affected area 13. Patanol (olopatadine) 0.1 % ophthalmic BID 14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 15. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days RX *cefpodoxime 200 mg 2 tablet(s) by mouth every 12 hours Disp #*16 Tablet Refills:*0 16. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Community Acquired Pneumonia Pulmonary Edema Acute exacerbation of Congestive Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with cough and fever // eval for pna TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Cardiomediastinal silhouette is stable. However, in comparison to the prior study there is interval development of diffuse bilateral interstitial opacities with perihilar predominance and small bilateral pleural effusions. There is an area of more confluent opacification at the right base. No pneumothorax. IMPRESSION: Interval development of diffuse bilateral interstitial opacities and small bilateral pleural effusions, consistent with mild pulmonary interstitial edema. Gender: F Race: HISPANIC/LATINO - COLUMBIAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Pneumonia, unspecified organism, Heart failure, unspecified, Dyspnea, unspecified temperature: 97.9 heartrate: 83.0 resprate: 18.0 o2sat: 98.0 sbp: 144.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It has been a pleasure taking care of you at ___. Why was I here? - You were admitted for with cough and found to have a pneumonia. - You also had some fluid in your lungs. What was done for me in the hospital? - You were started on antibiotics for your pneumonia. - You were given an IV medication to remove extra fluid from your lungs and make you urinate more frequently. You will take the same medication in a pill form when you go home. You will get a new prescription for this medication (furosemide). - You will have an ultrasound of your heart done on ___ at 10AM at ___ building. Please make sure you keep this appointment. What should I do when I leave the hospital? - You should take all of your medications. - You should attend your appointments. Please bring someone with you to your appointments who speaks both ___ and ___. - Please weigh yourself every morning. If you gain more than 3lbs from the previous day, please call your doctor. If you weigh more than 3lbs less than the previous day, do not take your Lasix. Please record the days when you do not take your Lasix. Sincerely, Your ___ Team Estimada Sra ___, Ha sido un placer cuidar de que en ___. ¿Por qué estaba aquí? - ___ fue admitido para ___. ¿Qué se hizo para mí ___ hospital? - ___ se iniciaron en los antibióticos para una pneumonía. - Se ___ una medicación IV para eliminar el exceso de líquido de ___ y te hacen orinar con más frecuencia. - Tendrá una ecografía del corazón hecho el jueves a las 10 am ¿Qué ___ cuando ___ hospital? - Debe tomar todos sus medicamentos. - ___ debe asistir a sus citas. Por favor, que alguien lo acompañe a sus citas que habla español e Inglés. - Por favor, ___ mañana. Si ___ más de 3 libras desde el día anterior, por favor ___ médico. Si ___ pesa más de 3 libras menos que el día anterior, no tome ___ Lasix. Por favor, ___ los días en ___ no ___ Lasix. Sinceramente, ___ ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Tetracycline Analogues / amoxicillin Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: -None History of Present Illness: Mr. ___ is a ___ male with HTN who presented with ___ weeks of cough and 6 hours of chest pain associated with post-tussive emesis and shortness of breath. He reports that a few days after ___, he developed nausea, chills, sweats, achiness, and heart palpitations. He has a history of chronic palpitations, but these were more severe than normal and were painful so he had his son bring him to the ED (this was in ___. He was told he had influenza and was started on Tamiflu, benzonatate, and an albuterol inhaler. He felt better within a few days, but he had a dry cough that persisted. He was in ___ and ___ for the following week and a half and they were quite active - walking around the cities, ___, ___, etc. He said with a few of the hills he felt slightly short of breath so he used the inhaler with improvement in his breathing. They came back from the ___ on ___ evening (___). He felt like his dry cough started to worsen again. He woke up ___ with shortness of breath and also noticed pain and swelling in his right shoulder. He went to ___ where they did a RUE US which was negative for DVT. He was discharged with an NSAIDs and plans for orthopedics follow up. His arm is still swollen but the pain is improved since he started taking naproxen. Early this morning (___) he woke up at 2am with substernal, non-radiating chest tightness associated with shortness of breath. The chest pain/shortness of breath lasted from 2am to 10am and resolved spontaneously. It was not associated with activity. He had been watching TV and was sleeping before it started. He has never had chest pain like this in the past - his previous episodes of chest pain were always associated with palpitations. Today in the ED, he was getting ready to go home, thinking that his cough and shortness of breath was likely due to a viral illness. However, he got up from bed, took 3 steps and acutely felt very short of breath and diaphoretic and called for help. He felt better after Duonebs. Throughout all of this (since ___), the dry cough has been persistent and bothersome. He notes that he does tend to have shortness of breath that improves with use of an albuterol MDI in the winter. He thinks he may have some post-nasal drip. His GERD has been well controlled. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: - Hypertension - Hyperlipidemia - Pre-diabetes; most recent Hgb A1c 6.6% (___) - Obesity - Onychomycosis - Possible cervical radiculopathy - GERD - H/o ___ tear Social History: ___ Family History: FAMILY HISTORY: MS - Mother COPD - Father CAD - maternal GF and paternal GF Asthma - paternal GM Physical Exam: Discharge Exam: VITALS: T 97.5, HR 116, BP 125/69, RR 20, SpO2 94% on RA GENERAL: NAD, appears well, breathing room air comfortable EYES: Anicteric, PERRL ENT: MMM, OP clear CV: Tachycardic, regular rhythm. No m/r/g. No JVD. RESP: scant expiratory wheezing with good air movement throughout anterior and posterior lung fields. GI: Abdomen soft, obese, protuberant, non-tender to palpation. Bowel sounds present. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: ___ 06:15AM BLOOD WBC-18.4* RBC-4.92 Hgb-12.6* Hct-40.3 MCV-82 MCH-25.6* MCHC-31.3* RDW-16.1* RDWSD-48.2* Plt ___ ___ 06:15AM BLOOD WBC-18.4* RBC-4.92 Hgb-12.6* Hct-40.3 MCV-82 MCH-25.6* MCHC-31.3* RDW-16.1* RDWSD-48.2* Plt ___ ___ 05:53AM BLOOD Glucose-161* UreaN-13 Creat-0.8 Na-143 K-4.7 Cl-105 HCO3-19* AnGap-19* ___ 12:56AM BLOOD cTropnT-<0.01 ___ 12:17PM BLOOD cTropnT-<0.01 ___ 06:25AM BLOOD cTropnT-<0.01 ___ 03:42PM BLOOD ___ pO2-40* pCO2-42 pH-7.39 calTCO2-26 Base XS-0 CXR ___: MPRESSION: 1. Mildly enlarged cardiomediastinal silhouette, which may represent cardiomegaly or pericardial effusion. 2. No focal consolidation. TTE ___ The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is grossly normal (apical image quality poor with limited views of the basal segments, but nu multisegment abnormalities seen). Overall left ventricular systolic function is normal (LVEF>55%). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal global biventricular systolic function. No regional dysfunction seen in the context of poor apical image quality. No pathologic valvular flow. Normal left atrial size. Normal diastolic function. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Atorvastatin 20 mg PO QPM 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 5. Benzonatate 100 mg PO TID cough Discharge Medications: 1. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 3. Atorvastatin 20 mg PO QPM 4. Benzonatate 100 mg PO TID cough 5. Lisinopril 10 mg PO DAILY 6. Omeprazole 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: -Acute Asthma Exacerbation -Acute Dyspnea -ACS r/o Discharge Condition: Good Alert and Oriented x3 Ambulatory without assistance Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with cough, sob// pna TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___. FINDINGS: There is no pleural effusion, pneumothorax or focal consolidation. Cardiomediastinal silhouette is mildly enlarged when compared to the st recent chest radiograph. However, there is no pulmonary vascular congestion. There are no acute osseous or soft tissue abnormalities. IMPRESSION: 1. Mildly enlarged cardiomediastinal silhouette, which may represent cardiomegaly or pericardial effusion. 2. No focal consolidation. Radiology Report EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL RIGHT INDICATION: ___ year old man with swelling and pain in the RUE// ?DVT in RUE 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 right subclavian vein. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Chest pain, Cough, Dyspnea Diagnosed with Chest pain, unspecified temperature: 96.9 heartrate: 83.0 resprate: 19.0 o2sat: 98.0 sbp: 117.0 dbp: 75.0 level of pain: 3 level of acuity: 3.0

Dear Mr. ___, You were admitted to the hospital with shortness of breath likely from an asthma flare. We treated you with nebulizers and steroids and you got better day by day. When you leave the hospital you should see Dr. ___ in clinic on ___ as planned. You should continue an additional 3 days of oral steroids upon discharge. You should have Pulmonary function tests (PFTS) to formally diagnose your likely asthma. You should continue to use your albuterol inhaler every 6 hours while you feel short of breath. Dr. ___ will go over your Echo results with you. It was a pleasure taking care of you. Best Regards, ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: vertigo and left leg weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ independently living woman with hx of BPPV, CABG in ___, hypothyroidism, hypertension and cervical stenosis who presents with unsteadiness and weakness/funny feeling in left leg. Last night, when she attempted to get out of bed to use the restroom, she was unsteady and unable to walk. Her unsteadiness symptoms have been persisting since that time, however she has not tried to walk since then. In the ED, initial vitals: 96.6 61 158/82 16 100% RA - Exam notable for: Unable to walk. No gaze deviation. Head impulse with corrective saccade. - Neurology was consulted and said- Neg ___. No dysmetria, rebound or overshoot. Nl proprioception. No skew, no nystagmus, +corrective saccade to L on turning head R on head impulse testing. - Labs notable for: INR: 1.0, Cr .8, TSH:2.5, Hgb 13.3, WBC 5.4, Trop-T: <0.01, K 4.0; trace leuks and blood on UA, neg nitrites - Imaging notable for: CTA H/N: No flow limiting stenosis, occlusion, dissection, or aneurysm of the bilateral internal carotid arteries, bilateral vertebral arteries, anterior circulation, posterior circulation, and circle of ___. 2. Mild atherosclerotic disease involving the aortic arch and the bilateral cavernous carotid arteries. - Vitals prior to transfer: 98.4 62 152/75 16 100% RA On arrival to the floor, pt denies any visual changes, headache, ringing in the ears, auditory changes, ear pain, chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea, dysuria. She denies any vertigo currently sitting in bed. She denies any symptoms currently. She has a cane at home and did not try to use it last night. She has had a few episodes of this exact same vertigo in the past, but denies the leg 'weakness', this is brand new and 'weakness' best approximates the funny feeling she endorses, but not exactly. Denies any falls. Past Medical History: PAST MEDICAL HISTORY: 1. Coronary artery disease, followed by Dr. ___. 2. Status post myocardial infarction. 3. Osteopenia. 4. Hyperlipidemia. 5. Insomnia. 6. Hypertension. 7. Uterovaginal prolapse 8. Hypothyroidism PAST SURGICAL HISTORY: 1. Coronary artery bypass graft ___. 2. Left eye cataract surgery. 3. Surgical removal of pessary ___. Social History: ___ Family History: Mother died age ___ following a hip fracture. Father died of colon cancer. Sister died age ___ of lung cancer. Other family history notable for heart disease, hypertension, arthritis, cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.1 PO 163 / 87 R Lying 65 18 97 Ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, nystagmus Neck: supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN2-12 intact, no focal deficits, strength is ___ in elbow, knee, hip, ankle flexors and extensors, sensation to light touch intact throughout, attempted to stand her up, her hesitated putting her toes on the ground, seemed a little wobbly initially, but stood without falling, then had her sit back down Extremities- varicose veins present, but no palpable cord or lesions, does have an open abrasionon her elbow, she says acquired from hospital DISCHARGE PHYSICAL EXAM: Vitals: 97.9, 156 / 81 lying, 174 / 103 standing, 58, 16, 100 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, nystagmus Neck: supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN2-___ intact. Strength is ___ with flexion and extension at elbow, knee, hip, ankle. Sensation to light touch intact on extremities. Briefly stood without falling but felt very unsteady, and sat back down. Extremities: varicose veins present, tenderness to palpation on R anterior leg. Pertinent Results: RELEVANT LABS: =============== ___ 01:47PM BLOOD WBC-5.4 RBC-4.48 Hgb-13.3 Hct-41.1 MCV-92 MCH-29.7 MCHC-32.4 RDW-12.2 RDWSD-40.9 Plt ___ ___ 01:47PM BLOOD ___ PTT-28.1 ___ ___ 01:47PM BLOOD Glucose-93 UreaN-16 Creat-0.8 Na-139 K-4.0 Cl-103 HCO3-24 AnGap-16 ___ 01:47PM BLOOD ALT-14 AST-23 AlkPhos-60 TotBili-0.5 ___ 01:47PM BLOOD Albumin-4.4 Calcium-9.6 Phos-4.1 Mg-2.3 ___ 06:40AM BLOOD VitB12-338 ___ 06:40AM BLOOD %HbA1c-5.7 eAG-117 ___ 01:47PM BLOOD TSH-2.5 IMAGING: ======== - ___ CXR No acute cardiopulmonary process. - ___ CTA NECK W/ & W/O CONTRAST and CTA HEAD W/ & W/O CONTRAST 1. There is no evidence of hemorrhage, edema, mass effect, or acute vascular territorial infarction. 2. Unremarkable head and neck MRA. 3. Right maxillary canine dental ___ and periapical lucency should be correlated with dental examination to exclude active infection. - ___ LLE DOPPLER ULTRASOUND No evidence of deep venous thrombosis in the left lower extremity veins. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Quinapril 10 mg PO BID 2. Simvastatin 40 mg PO QPM 3. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___) 4. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___) 5. Aspirin 81 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___) 3. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___) 4. Quinapril 10 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: benign positional paroxysmal vertigo Secondary diagnoses: hypertension, hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with dizziness// Evaluate for ACS TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: ___. FINDINGS: The lungs are clear. There is no focal consolidation, effusion, or edema. Cardiomediastinal silhouette is within normal limits. Median sternotomy wires and mediastinal clips are again noted. Additionally, surgical clips are noted in the upper abdomen. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD INDICATION: ___ woman with unsteadiness. Evaluate for aneurysm, posterior circulation flow defect TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 57.2 mGy (Head) DLP = 28.6 mGy-cm. 3) Spiral Acquisition 4.7 s, 37.3 cm; CTDIvol = 31.8 mGy (Head) DLP = 1,187.7 mGy-cm. Total DLP (Head) = 2,113 mGy-cm. COMPARISON: ___ noncontrast head CT FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of hemorrhage, edema, mass effect, or acute vascular territorial infarction. The ventricles and sulci are age-appropriate. Periventricular and scattered subcortical white matter hypodensities are nonspecific but likely sequelae of chronic microangiopathy in this age group. Aside from left cataract extraction, the orbits are unremarkable. The paranasal sinuses, mastoid air cells, middle ear cavities are clear. There is a carry an periapical lucency in the right maxillary canine. CTA HEAD: There is mild atherosclerotic disease in the cavernous portion of the carotid arteries bilaterally. The vessels of the circle of ___ and their principal intracranial branches otherwise appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: The carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the upper lungs is notable for mild centrilobular emphysema. The lungs are clear the visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. There is no evidence of hemorrhage, edema, mass effect, or acute vascular territorial infarction. 2. Unremarkable head and neck MRA. 3. Right maxillary canine dental ___ and periapical lucency should be correlated with dental examination to exclude active infection. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS INDICATION: ___ year old woman with funny feeling and unsteadiness of L leg // eval for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dizziness Diagnosed with Dizziness and giddiness temperature: 96.6 heartrate: 61.0 resprate: 16.0 o2sat: 100.0 sbp: 158.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to the hospital with dizziness. We got a CT scan of your head which did not show any stroke. Your dizziness was most likely from your vertigo. Physical therapy evaluated you and felt that you'd benefit from vestibular physical therapy (special therapy to help with your dizziness). If this does not help, please contact your doctor, as you might want to try meclizine. It was a pleasure caring for you! We wish you the very best. -- Your care team at ___

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: ___ with CAD w/ CABG, CKD, on coumadin for mechanical valve, IDDM, who presents with syncope. Was out with home health aid when she felt light-headed. Made it to passenger seat of car and lost consciousness. EMS arrived and she arose to sternal rub. Taken to ___. At ___ she awoke and by report was agitated and required Ativan & seroquel. CT head there was negative for acute stroke or bleed but did show subacute to chronic left parietal infarct. In the ___ ED intial vitals were: 97.9 75 21 159/53 95%RA. Labs showed a therapeutic INR and no abnormalities aside from baseline CKD Vitals on transfer: 98 73 19 129/37 100%2LNC On the floor VS 85kg, 98.4, 120/48, 73, 18, 100%2LNC. She is very sleepy but arousable and answering questions appropriately and following commands. She moves all4 extremities. Past Medical History: Past Medical History: 1. CAD, status post CABG in ___. 2. S/p mechanical aortic valve (St. ___, on Coumadin. 3. dCHF, last EF of 55%. 4. Insulin-dependent diabetes. 5. Hyperlipidemia. 6. Peripheral neuropathy. 7. History of toe ulceration, status post amputation in ___. 8. Depression. 9. Spinal stenosis 10. Atrial fibrillation 11. Colon adenocarcinoma ___ Past Surgical History: 1. CABG ___ 2. Mechanical valve (___ ___ 3. Caesarean section 4. Cholecystectomy 5. Right colectomy and VHR ___ (___) 6. Takeback exploratory laparotomy, washout, lysis of adhesions, ileocolectomy, small bowel resection, and ileostomy placement ___ (___) Social History: ___ Family History: Notable for a brother who died of lung cancer Physical Exam: ADMISSION PHYSICAL EXAM Vitals- 85kg, 98.4, 120/48, 73, 18, 100%2___ General- lethargic, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, ___ SEM, audible click from mechanical valve, no rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- foley in Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, moves all 4 extrmemities to command DISCHARGE PHYSICAL EXAM Vitals: T: 98.4 BP: 108/91 P: 75 R: 18 O2: 98%RA General: Awake, alert, conversant, very pleasant, wondering when she can go home, in 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, ___ SEM, audible click from mechanical valve, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes seen. Neuro: ___ (knows at Deaconess however does not know year or month, usually states ___, slight drooping of R eyelid, and R upper extremity slightly weaker compared to left, gross sensory intact bilaterally, no pronator drift, no asterexis. Pertinent Results: ADMISSION LABS ___ 09:45PM BLOOD WBC-8.0 RBC-3.12* Hgb-8.7* Hct-28.4* MCV-91 MCH-27.9 MCHC-30.6* RDW-16.2* Plt ___ ___ 09:45PM BLOOD Neuts-84.0* Lymphs-10.8* Monos-3.7 Eos-1.3 Baso-0.3 ___ 09:45PM BLOOD ___ PTT-45.0* ___ ___ 09:45PM BLOOD Glucose-306* UreaN-46* Creat-2.1* Na-139 K-4.7 Cl-109* HCO3-24 AnGap-11 ___ 07:25AM BLOOD CK-MB-5 cTropnT-0.04* ___ 07:30AM BLOOD CK-MB-4 cTropnT-0.03* ___ 09:45PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.7 ___ 09:58PM BLOOD Lactate-1.4 ___ 12:45AM URINE Blood-TR Nitrite-NEG Protein-300 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 12:45AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 INTERVAL LABS ___ 07:25AM BLOOD TSH-1.4 ___ 07:25AM BLOOD Free T4-0.75* DISCHARGE LABS ___ 06:55AM BLOOD WBC-5.6 RBC-3.14* Hgb-8.5* Hct-28.3* MCV-90 MCH-27.2 MCHC-30.1* RDW-15.9* Plt ___ ___ 06:55AM BLOOD ___ PTT-85.4* ___ ___ 06:55AM BLOOD Glucose-159* UreaN-47* Creat-2.3* Na-137 K-4.4 Cl-107 HCO3-24 AnGap-10 MICRO ___ blood culutre x1 No Growth ___ C. diff negative ___ stool culture negative IMAGING MRI/MRA Head and Neck ___ 1. No evidence of acute infarct. Chronic left parietal infarct. Right thalamic chronic lacunar infarct. 2. No new visualization of the left vertebral artery in the neck and in the head indicating occlusion. 3. Mild intracranial atherosclerotic disease involving the left middle cerebral artery and left posterior cerebral artery. TTE ___ IMPRESSION: Mild symmetric left ventricular hypertrophy with regional left ventricular systolic dysfunction c/w CAD. Bileaflet aortic valve prosthesis with higher than expected gradients and mild aortic regurgitation. Mild mitral regurgitation. Moderate tricuspid regurgitation. At least moderate pulmonary artery systolic hypertension. Portable CXR ___ IMPRESSION: Mild-to-moderate pulmonary edema with vascular congestion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. QUEtiapine Fumarate 12.5 mg PO QHS:PRN sleep 5. Warfarin 5 mg PO DAILY16 6. Calcium Carbonate 500 mg PO QHS 7. Vitamin D 1000 UNIT PO DAILY 8. Docusate Sodium 100 mg PO QAM 9. Senna 1 TAB PO HS 10. Lisinopril 5 mg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO DAILY 2. Calcium Carbonate 500 mg PO QHS 3. Docusate Sodium 100 mg PO QAM 4. Senna 1 TAB PO HS 5. Vitamin D 1000 UNIT PO DAILY 6. Warfarin 5 mg PO DAILY16 7. LeVETiracetam 250 mg PO BID RX *levetiracetam 250 mg Take 1 tablet by mouth twice daily Disp #*30 Tablet Refills:*0 8. Citalopram 20 mg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. QUEtiapine Fumarate 12.5 mg PO QHS:PRN sleep Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report PATIENT HISTORY: ___ years old woman with AMS and recent syncope, question congestive heart failure, question pneumonia. COMPARISON: Exam is compared to chest x-ray of ___. FINDINGS: Portable single view AP of the chest shows reduced lung volume with increased opacification due to mild-to-moderate pulmonary edema. Perihilar vascular markings are prominent for vascular congestion. Heart size is enlarged. No pleural effusion or pneumothorax. IMPRESSION: Mild-to-moderate pulmonary edema with vascular congestion. Radiology Report HISTORY: ___ year old woman with CAD, CKD, MVR, DM, L parietal lobe infarction presents with syncope with AMS: Eval for infarction, hemorrhage TECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility and diffusion axial images of the brain were acquired. 2D time-of-flight MRA of the neck vessels and 3D time-of-flight MRA of the circle of ___ were obtained. Gadolinium enhanced MRA was not performed given the patient's low GFR. COMPARISON: MRI of ___. FINDINGS: There is no acute infarct identified. There is no mass effect, midline shift or hydrocephalus. Chronic left parietal cortical subcortical infarct is again seen. The suprasellar and craniocervical regions are unremarkable on the sagittal images. No evidence of chronic micro hemorrhages. Chronic lacunar infarcts is Visualized in the right thalamus. MRA of the neck shows nonvisualization of the left vertebral artery. Evaluation for other vascular structure is somewhat limited due to motion but no evidence of high-grade stenosis or occlusion seen. MRI of cancellous nonvisualization of left distal vertebral artery due to occlusion in the neck. Mild atherosclerotic disease in irregularities are seen in the pelvis signal of both middle cerebral arteries. The distal right vertebral artery and basilar artery appear normal in appearance. Mild irregularity of the proximal left posterior cerebral artery is seen secondary to atherosclerotic disease. IMPRESSION: 1. No evidence of acute infarct. Chronic left parietal infarct. Right thalamic chronic lacunar infarct. 2. No new visualization of the left vertebral artery in the neck and in the head indicating occlusion. 3. Mild intracranial atherosclerotic disease involving the left middle cerebral artery and left posterior cerebral artery. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, Syncope Diagnosed with SYNCOPE AND COLLAPSE temperature: 97.6 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 122.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You were admitted to the hospital because you lost consciousness. We believe that you experienced a seizure causing you do pass out. We started you on an anti-seizure medication. Please go to all of your follow-up appointments. All the best, Your ___ Team - Atenolol was stopped during this hospitalization. Please discuss with PCP whether to restart this. (Blood pressure was low) - Take warfarin 3mg today ___, then restart 5mg on ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Keflex / Ciprofloxacin / Bactrim / Sulfa (Sulfonamide Antibiotics) / Prochlorperazine Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of UC s/p TAC and PSC complicated by chronic cholangitis and stricture, recently s/p exploratory laparotomy and lysis of adhesions for small bowel obstruction, now presents with abdominal pain. Reportedly, pain began ___ ago (localized to RUQ), although significantly worsened overnight (localized to lower abdomen) in association with nausea and 1 loose stool. Pain now localized to lower abdomen and reportedly feels similar to prior episode per patient. No emesis prior to presentation, has since vomited x3 in ED during/after contrast ingestion in preparation for the CT scan. Denies fever / chills, headache / dizziness, chest pain, shortness of breath, dysuria, and/or musculoskeletal pain. Past Medical History: PMH: UC, PSC, h/o acalculous cholecystitis, CBD stricture, SBO, polymyositis PSH: ex-lap/LOA ___ (Dr ___, lap cholecystectomy and liver bx ___ (Dr. ___, TAC with ileal pouch and diverting ileostomy ___ (Dr. ___, ileostomy take-down ___ (Dr. ___, C-section Social History: ___ Family History: Grandfather with colon cancer, cousin with celiac sprue, cousin with ___. No family history of UC. Breast cancer in maternal aunt, paternal aunt, grandmother; ovarian ___ paternal side. Physical Exam: On discharge (___) T 98.7, HR 75, BP 98/50, RR 18, O2 sat 100% RA Gen: NAD, A+Ox3 CV: RRR Lungs: nmL respiratory effort, clear to auscultation bilaterally Abd: healing midline incision with no erythema/drainage, abdomen soft, non-distended, minimal tenderness to palpation lower abdomen Ext: warm, well-perfused, no edema Pertinent Results: CT abdomen/pelvis (___): interval resolution of small bowel obstruction, s/p numerous bowel surgeries with multiple anastomoses and ileoanal J-pouch. No evidence of obstruction or abscess. Stable intra- and extra-hepatic bile duct dilatation, compatible with known history of primary sclerosing cholangitis. Medications on Admission: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Ursodiol 500 mg PO BID 3. Ondansetron 4 mg PO Q8H:PRN nausea 4. Docusate Sodium 100 mg PO BID:PRN constipation Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Ursodiol 500 mg PO BID 3. Ondansetron 4 mg PO Q8H:PRN nausea 4. Docusate Sodium 100 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Abdominal pain; suspected small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with history of ulcerative colitis, primary sclerosing cholangitis, and multiple abdominal surgeries, presenting with abdominal pain. Evaluate for abscess or small bowel obstruction. COMPARISONS: Multiple prior abdomen and pelvis CTs, most recently of ___. TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis with administration of 130 cc of Omnipaque contrast. Oral contrast was not administered. Axial images were interpreted in conjunction with coronal and sagittal reformats. FINDINGS: ABDOMEN: The visualized heart is unremarkable. The lung bases are clear. No pleural or pericardial effusion is visualized. The liver parenchyma is normal without focal or diffuse abnormality. The gallbladder has been removed. There is stable dilatation of the intra- and extra-hepatic bile ducts, with the common duct measuring up to 7 mm. The cystic duct stump remains dilated, suggestive of a mucocele. The pancreatic duct is slightly prominent, similar to prior, and the pancrease is otherwise unremarkable. The spleen and bilateral adrenal glands are normal. Bilateral kidneys enhance symmetrically and excrete contrast promptly. Bilateral ureters appear normal in course and caliber. The stomach is unremarkable. The patient is status post numerous abdominal procedures with multiple small bowel anastomoses seen. Suture lines are seen in the left lower quadrant and the right lower quadrant. Ileoanal J-pouch is seen in the pelvis. No dilated loops of small and large bowel are present. There is no evidence of pneumatosis or free air. The portal and intra-abdominal systemic vasculature are unremarkable. No retroperitoneal or mesenteric lymphadenopathy. No intra-abdominal fluid collection or abdominal wall hernia. PELVIS: The bladder is normal. The uterus and adnexa appear unremarkable. Trace free pelvic fluid. No pelvic or inguinal lymphadenopathy. No inguinal hernia. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Interval resolution of small bowel obstruction. Status post numerous bowel surgeries with multiple anastomoses and ileoanal J-pouch. No evidence of obstruction or abscess. 2. Stable intra- and extra-hepatic bile duct dilatation, compatible with known history of primary sclerosing cholangitis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ULCERATIVE COLITIS UNSPEC temperature: 98.8 heartrate: 95.0 resprate: 22.0 o2sat: 100.0 sbp: 114.0 dbp: 72.0 level of pain: 10 level of acuity: 3.0

Please call or come to the Emergency Room if you experience fever (>101.5F) or chills, recurrent or worsening abdominal pain, abdominal distension, bilious or bloody emesis, chest pain, shortness of breath, blood per rectum, or any other symptoms of acute concern.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Cymbalta / lisinopril / sulfasalazine Attending: ___. Chief Complaint: ___ edema and 10lb weight gain Major Surgical or Invasive Procedure: none History of Present Illness: ___ COPD on 2.5L of home 02, HTN, s/p brain surgery ___, fibroscan showing fibrosis of the liver who c/o 10lb weight gain over 10 days with increased leg swelling x7 days and sob x1 day. Currently without any symptoms of sob as she is on baseline 2.5L of oxyogen at home and was sating well in ED. She denies headache, cp, abd pain, leg pain. feels that she has left>right leg swelling and a rash over this site. She notes that at urgent care her fsbg 505, no prior diagnosis of diabetes. sent here for new onset DM and electolyte imbalance. In the ED, initial vitals were: 97.6 69 100/50 16 97% Nasal Cannula - Labs were significant for: H&H of 8.8/___, WBC 12, Cr of 1.4, positive UA, and K+ of 3.0 - Imaging revealed new pulmonary congestion, moderate cardiomegaly - The patient was given 20 IV lasix and 40 PO K+ Vitals prior to transfer were: Upon arrival to the floor, pt endorces feeling more confused the last few months, more fatigued, and has developed a new tremor that appears more intentional than resting; however, on exam appears to be consistent with asterixsis. She also endorces having darker than normal stools, but unsure if they are black. She denies BRBPR, hematemsis, N&V. She denies ABD pain, chest pain, diarrhea, but does state she has burning with urination and has more difficilty urinating. 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, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - HTN, - GERD, - hiatal hernia, - OSA on CPAP, - Morbid obesity, - Depression and anxiety, - CKD (?), - Spinal stenosis, - EtOh Cirrhosis Social History: ___ Family History: Bone cancer, heart disease, thyroid disease Physical Exam: EXAM ON ADMISSION: Vitals: 97.9 128/57 70 18 38 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: Supple, JVP difficult to assess, no LAD CV: Distant heart sounds, but Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breath sounds bilaterally with ocassional fine crackles otherwise Clear to auscultation bilaterally, no wheezes, Abdomen: Obese, Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: Warm, well perfused, 2+ edema on the Right 3+ on Left. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. EXAM ON DISCHARGE: Vitals: T 97.8 BP 120-130s/60-70s HR 80-90s O2 94% on 2.5L I/O 340/700 I/O (24HR) ___ BMx1 wt 118.2 (120.4 on admission) ___ 138, 235 Exam: GENERAL - alert, obese woman sitting up in bed, in NAD HEENT - PERRLA, sclerae anicteric, MMM HEART - Distant heart sounds, RRR, nl S1-S2, no MRG LUNGS - CTAB ABDOMEN - Normal BS, distended, but soft and nontender, not able to assess for hepatomegaly due to increased abdominal girth, no ascites EXTREMITIES - WWP, clubbing of fingernails b/l, 1+ ___ edema up to mid-calf NEURO - awake, A&Ox3 SKIN - palmar erythema and spider angiomas on chest, not jaundiced Pertinent Results: =====================LABS ON ADMISSION============================ ___ 05:00PM BLOOD WBC-12.1* RBC-3.73* Hgb-8.8*# Hct-28.4*# MCV-76*# MCH-23.6*# MCHC-31.0* RDW-18.8* RDWSD-51.0* Plt ___ ___ 05:00PM BLOOD Neuts-82.2* Lymphs-11.3* Monos-5.7 Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.91* AbsLymp-1.36 AbsMono-0.69 AbsEos-0.00* AbsBaso-0.02 ___ 06:20AM BLOOD ___ PTT-31.6 ___ ___ 05:00PM BLOOD Ret Aut-1.9 Abs Ret-0.07 ___ 05:00PM BLOOD Glucose-352* UreaN-34* Creat-1.4* Na-136 K-3.0* Cl-91* HCO3-31 AnGap-17 ___ 05:00PM BLOOD ALT-26 AST-31 LD(LDH)-458* AlkPhos-51 TotBili-0.4 ___ 05:00PM BLOOD proBNP-352* ___ 05:00PM BLOOD Albumin-3.8 Calcium-9.5 Phos-3.2 Mg-2.2 Iron-24* ___ 05:00PM BLOOD calTIBC-472* ___ Ferritn-13 TRF-363* ___ 11:20PM BLOOD %HbA1c-7.8* eAG-177* ___ 05:10PM BLOOD ___ pO2-56* pCO2-51* pH-7.47* calTCO2-38* Base XS-11 ___ 08:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG ___ 08:00PM URINE RBC-1 WBC-20* Bacteri-FEW Yeast-NONE Epi-0 RenalEp-<1 ___ 08:00PM URINE Hours-RANDOM Creat-13 Na-68 K-7 Cl-51 ___ 08:00PM URINE Osmolal-215 ===========================LABS ON DISCHARGE===================== ___ 06:55AM BLOOD WBC-7.7 RBC-3.94 Hgb-9.4* Hct-30.7* MCV-78* MCH-23.9* MCHC-30.6* RDW-19.9* RDWSD-54.9* Plt ___ ___ 06:55AM BLOOD Glucose-90 UreaN-32* Creat-1.3* Na-137 K-3.7 Cl-96 HCO3-30 AnGap-15 ___ 06:55AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.9 = ==========================IMAGING=============================== ___ CXR: IMPRESSION: Moderate cardiomegaly and mild pulmonary vascular congestion without frank pulmonary edema. ___ ECHO: IMPRESSION: Biatrial enlargement. Normal left ventricular wall thickness, cavity size and global systolic function with high cardiac output. Grade II diastolic dysfunction with increased PCWP. Normal RA pressure by noninvasive assessment with moderate pulmonary hypertension. ___ RUQ US: IMPRESSION: Patent hepatic vasculature. No ascites. Splenomegaly. ========================MICRO======================== URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. BuPROPion (Sustained Release) 100 mg PO Q12H 3. eszopiclone 1.5 mg oral QHS 4. Naltrexone 50 mg PO QHS 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB 6. estradiol-levonorgestrel 0.045-0.015 mg/24 hr transdermal QWeekly 7. Amlodipine 5 mg PO DAILY 8. Torsemide 20 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 11. Cyanocobalamin 1000 mcg PO DAILY 12. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 13. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. BuPROPion (Sustained Release) 100 mg PO Q12H 2. Gabapentin 800 mg PO TID 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 4. Ferrous Sulfate 325 mg PO TID This medication can cause constipation. You can take a laxative if this occurs. RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 6. Amlodipine 5 mg PO DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. estradiol-levonorgestrel 0.045-0.015 mg/24 hr transdermal QWeekly 9. eszopiclone 1.5 mg oral QHS 10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Naltrexone 50 mg PO QHS 13. Pantoprazole 40 mg PO Q24H 14. Amoxicillin-Clavulanic Acid ___ mg PO Q12H END ___ RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*5 Tablet Refills:*0 15. Torsemide 30 mg PO DAILY 16. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY Do Not Crush RX *metformin 1,000 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 17. TraZODone 50 mg PO QHS:PRN insomnia RX *trazodone 50 mg 1 tablet(s) by mouth QHS:prn Disp #*15 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Acute diastolic congestive heart failure Urinary tract infection Diabetes Mellitus type 2 Anemia Secondary: Hypertension COPD (on home O2 2.5L) Fibrotic liver Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ with chest pain, dyspnea // eval heart and lungs TECHNIQUE: Chest PA and lateral COMPARISON: None FINDINGS: Cervical fusion hardware projects over the cervical spine. The heart is moderately enlarged. The hilar contours are within normal limits. There is mild pulmonary vascular congestion without frank pulmonary edema. There is no focal consolidation, pleural effusion or pneumothorax. Minimal bibasilar atelectasis. IMPRESSION: Moderate cardiomegaly and mild pulmonary vascular congestion without frank pulmonary edema. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: R/o for PVT and ascites. Please conduct with dopplers. Asses TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen was performed. COMPARISON: CT colonography ___. FINDINGS: Liver: The hepatic parenchyma is within normal limits. Nofocal liver lesions are identified. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct measures up to 7 mm. Gallbladder: Post cholecystectomy. Pancreas: Imaged portion of the pancreas appears within normal limits, with portions of the pancreatic tail obscured by overlying bowel gas. Spleen: The spleen demonstrates normal echotexture, and measures 14 cm. Kidneys: The right kidney measures 13 cm. The left kidney measures 10 cm. No stones, masses or hydronephrosis are identified in either kidney. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is approximately 18 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: Patent hepatic vasculature. No ascites. Splenomegaly. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, L Leg swelling, Hyperglycemia Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, ANEMIA NOS, DIABETES UNCOMPL ADULT temperature: 97.6 heartrate: 69.0 resprate: 16.0 o2sat: 97.0 sbp: 100.0 dbp: 50.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ for lower leg swelling and 10 pound weight gain over the past couple of weeks. You were found to have decompensated heart failure, which caused fluid to back up and accumulate in your legs. We gave you furosemide and then torsemide, which were effective in getting rid of that extra fluid. In the hospital, your lab tests showed that you have high glucose levels, and they've been high for some time. You were diagnosed with diabetes type 2 and given insulin here. When you go home, you can take metformin for your diabetes. With metformin, you do not need to monitor your blood glucose levels daily. If you would like to learn more about your diagnosis, there are also many helpful resources at ___ (___). In addition, we found that you had a urinary tract infection, which we treated with antibiotics. You also had low iron levels, which caused anemia, and we gave you iron supplements. When you go home, you will be started on several medications: torsemide 30mg once a day for your heart (increased from your original dose), metformin 1000mg once a day for diabetes, Augmentin 875mg twice a day for the urinary tract infection (last day ___, and iron supplements. All of your medications are detailed in your discharge medication list. You should review this carefully and take it with you to any follow up appointments. The details of your follow up appointments are given below. It was a pleasure taking care of you. Sincerely, Your ___ Cardiology and Medicine Teams

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L elbow ORIF Major Surgical or Invasive Procedure: s/p ulna ORIF ___, ___. History of Present Illness: HPI: ___ w/ no PMH s/p fall off bicycle while riding in JP. Pt lost control of his bicycle and fell onto his left elbow resulting in a comminuted proximal ulna/radius fx w/ ?radial head disloc. The pt had experienced a similar injury ___ years prior and underwent ORIF L elbow by Dr. ___. Past Medical History: none Social History: ___ Family History: n/ Physical Exam: Vitals: VSS General: A&0x3, NAD, Pleasant Left upper extremity: Splint intact and in proper position - Left upper extremity compartments soft to palpation - Able to hold wrist in extension/flexion against gravity, unable for further motion ___ to pain - Full, painless ROM at shoulder and digits - Fires EPL/FPL/DIO - SILT axillary/radial/ulnar nerve distributions, median nerve sensation intact to light touch but slightly diminished. - 2+ radial pulse, WWP Radiology Report INDICATION: History: ___ with fall left elbow deformity// ? dislocation TECHNIQUE: Left elbow, three views COMPARISON: Left elbow radiographs ___ FINDINGS: Comminuted fracture of the proximal ulna and olecranon with intra-articular extension is demonstrated with distraction of fracture fragments including proximal displacement of the dominant proximal fracture fragment by approximately 7 mm. Impacted comminuted fracture of the radial head is demonstrated with the radial head dorsally and laterally dislocated relative to the capitellum. There is marked associated soft tissue swelling as well as a joint effusion. 2 screws are noted within the distal humerus, unchanged. IMPRESSION: 1. Comminuted intra-articular distracted fracture of the proximal ulna and olecranon. 2. Impacted comminuted fracture of the radial head with the radial head appearing dislocated dorsally and laterally relative to the capitellum. 3. Associated joint effusion and extensive surrounding soft tissue swelling. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with fall, headstrike// eval for 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 16.0 s, 17.0 cm; CTDIvol = 47.3 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute infarction,hemorrhage,edema, or mass. The ventricles and sulci are normal in size and configuration. There is no evidence of acute fracture. There is minimal mucosal thickening of the ethmoid air cells. 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 abnormalities. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with fall, headstrike// eval for fracture TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.2 s, 20.5 cm; CTDIvol = 22.6 mGy (Body) DLP = 463.1 mGy-cm. Total DLP (Body) = 463 mGy-cm. COMPARISON: None. FINDINGS: Alignment is normal. Fusion of C3 and C4 vertebral bodies and posterior elements is likely congenital. There is mild loss of disc space at C4-5 and C6-7 with small disc bulges resulting in mild central canal narrowing at these levels. No acute fractures are identified. There is no evidence of severe spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. The thyroid gland is homogeneous in attenuation. The imaged lung apices are grossly unremarkable. IMPRESSION: 1. No traumatic malalignment or acute fracture. 2. Likely congenital fusion of C3 and C4 vertebral bodies. Radiology Report INDICATION: ___ year old man with left elbow fx, pre-op planning// eval intraartic extension fx TECHNIQUE: Imaging was performed through the left elbow without contrast. Coronal and sagittal reformats were produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.5 s, 18.0 cm; CTDIvol = 23.1 mGy (Body) DLP = 415.2 mGy-cm. Total DLP (Body) = 415 mGy-cm. COMPARISON: Left elbow radiographs ___ and CT left elbow ___ FINDINGS: Patient has had prior surgery with internal fixation of a comminuted distal humeral fracture. Two surgical screws transfix the prior fracture site without evidence of a hardware complication. There is a new comminuted transverse fracture through the olecranon with distraction measuring approximately 1 cm (401:31). There is longitudinal extension along the proximal ulnar metaphysis which is minimally displaced (401:37). There is a fracture of the coronoid process with multiple displaced bony fragments measuring up to 1.7 cm (401:33). The ulnar trochlear articulation is congruent. There is dislocation of the radiocapitellar articulation with a comminuted fracture of the radial head (401:43). Intra-articular fragment of the radial head measures approximately 9 mm (401:43). No humeral fracture seen. There is a moderately large joint effusion, presumed hemarthrosis. There is extensive soft tissue edema overlying the olecranon. IMPRESSION: 1. Comminuted intra-articular fracture of the radial head with a displaced intra-articular fragment measuring 9 mm. 2. Dislocation of the radiocapitellar articulation. 3. Comminuted displaced fracture of the olecranon. 4. Coronoid fracture with intra-articular fragments measuring up to 1.7 cm. 5. Large hemarthrosis. NOTIFICATION: At the time of dictation, the patient had been admitted and is scheduled to go to the OR today (___). Radiology Report EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT INDICATION: Left elbow fracture, ORIF TECHNIQUE: 10 spot fluoroscopic images obtained in the OR without radiologist present Fluoroscopy time: 186.2 seconds COMPARISON: CT left upper extremity ___ FINDINGS: The available images show steps related to open reduction internal fixation of an olecranon fracture. In addition, there has been apparent reduction of the previously seen radiocapitellar dislocation/subluxation. There is persistent visualization of a comminuted fracture through the radial head and coronoid process. Pre-existing hardware in the distal humerus is unchanged in appearance. Please see the operative report for further details. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Bicycle accident Diagnosed with Unsp fracture of lower end of left humerus, init for clos fx, Pedl cyclst (driver) injured in oth transport acc, init temperature: 98.0 heartrate: 71.0 resprate: 20.0 o2sat: 100.0 sbp: 134.0 dbp: 80.0 level of pain: 7 level of acuity: 2.0

Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Non weight bearing 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: - No pharmacologic DVT prophylaxis necessary. Please ambulate as much as possible to prevent blood clots WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin Attending: ___. Chief Complaint: Asthma exacerbation Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male severe asthma on Xolair presented to the ED with dyspnea. Patient reports being in another ED three days ago with an asthma exacerbation and being treated with nebulizers and steroids. Unfortunately, his symptoms worsened today, prompting him to call EMS who found him in respiratory distress. He was given nebulizers, solumedrol 125mg, magnesium 2g, and brought to the ED for further evaluation. In the ED, patient was noted to have significant prolonged expiratory phase with mildly increased respiratory effort and diffuse wheezes. CXR was unremarkable. Labs were notable for WBC 11.3 and VBG 7.38/44. Patient received albuterol neb, budesonide neb, and duoneb. He was then admitted to medicine for further evaluation. On arrival to the floor, patient confirms the above history. He reports feeling a little better since arrival. Of note, review of the OMR shows that patient has been having trouble obtaining his meds. He was seen by his PCP ___ ___ for an asthma exacerbation that improved with two duoneb treatments. He was also prescribed PO prednisone 50mg daily x5 days and azithromycin x5 days. REVIEW OF SYSTEMS: A 10-point ROS was taken and is negative except otherwise stated in the HPI. Past Medical History: - Asthma - Phimosis - Seasonal allergies - Depression - GERD Social History: ___ Family History: Denies known FH of asthma, allergies, ezcema. Physical Exam: ADMISSION PHYSICAL EXAM: ============================ VITALS: 142 / 90 ___ NC General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse expiratory wheezes throughout. Adequate air movement. No rales or rhonchi. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, ___ strength upper/lower extremities DISCHARGE PHYSICAL EXAM: ============================ Vitals: 98.4 118 / 69 91 18 95 Ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Wheeze substantially improved. Adequate air movement. No rales or rhonchi. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, ___ strength upper/lower extremities Pertinent Results: ADMISSION LABS: ================== ___ 12:00AM BLOOD WBC-11.3* RBC-4.95 Hgb-15.1 Hct-46.7 MCV-94 MCH-30.5 MCHC-32.3 RDW-12.7 RDWSD-43.8 Plt ___ ___ 12:00AM BLOOD Neuts-50.9 ___ Monos-7.8 Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.76 AbsLymp-4.58* AbsMono-0.88* AbsEos-0.00* AbsBaso-0.03 ___ 06:55AM BLOOD ___ PTT-26.1 ___ ___ 12:00AM BLOOD Glucose-131* UreaN-17 Creat-1.2 Na-140 K-4.4 Cl-106 HCO3-22 AnGap-12 ___ 12:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-3.6* DISCHARGE LABS: =================== ___ 07:07AM BLOOD WBC-9.5 RBC-4.67 Hgb-13.8 Hct-43.2 MCV-93 MCH-29.6 MCHC-31.9* RDW-12.8 RDWSD-43.3 Plt ___ ___ 07:07AM BLOOD Glucose-86 UreaN-16 Creat-1.0 Na-140 K-3.6 Cl-102 HCO3-27 AnGap-11 ___ 07:07AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.2 IMAGING/RESULTS: =================== CXR ___: In comparison with the earlier study of this date, the patient has taken a better inspiration. The area of increased opacification at the right base is much less prominent and probably merely represents mild elevation of pulmonary venous pressure and crowding of pulmonary vessels at the cardiophrenic angle. No evidence of acute pneumonia at this time. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with asthma exacerbation, ? overlaying PNA.// ? PNA overlaying asthma exacerbation? IMPRESSION: In comparison with the earlier study of this date, the patient has taken a better inspiration. The area of increased opacification at the right base is much less prominent and probably merely represents mild elevation of pulmonary venous pressure and crowding of pulmonary vessels at the cardiophrenic angle. No evidence of acute pneumonia at this time. Gender: M Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Asthma exacerbation Diagnosed with Unspecified asthma with (acute) exacerbation temperature: 97.7 heartrate: 98.0 resprate: 18.0 o2sat: 98.0 sbp: 171.0 dbp: 114.0 level of pain: 0 level of acuity: 2.0

====================== DISCHARGE INSTRUCTIONS ====================== Dear ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You had an asthma exacerbation causing you to have difficulty breathing. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received multiple medications to treat the exacerbation and make sure that your body was receiving adequate oxygen and that your lungs improved so that it is safe for you to be at home. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Followup with your outpatient doctor in order to make sure you are able to get all of your prescriptions and take them faithfully. You are in the process of getting extra health insurance that will cover more of your costs, and in the meantime we have given you enough prescriptions to cover you until then. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: amlodipine Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: CC: ___ pain HPI: ___ yo man w h/o HTN, BPH, MGUS p/w acute RUQ pain. Pain woke him up from sleep at 2AM on ___ and was sharp, constant, non-radiating, non-positional. No ameliorating factors. He has never had pain like this before. No N/V, fever, chills, diarrhea, hematochezia, dysuria, hematuria. He had a ___ cheese steak for dinner ~5 hrs prior to onset of pain. In the ED, initial vs were: 97.9 61 160/61 18 98% RA. Troponins were negative and EKG did not show ischemic changes. UA did not appear infected. CT A/P was notable for R kidney mass in upper pole and possible GB edema. RUQ US showed GB sludge but no signs of acute cholecystitis. Pt received IV zofran and morphine with subsequent pain control. He was admitted for further workup of his kidney mass. Past Medical History: HTN BPH ELEVATED TSH MONOCLONAL GAMMOPATHY - IgG of 1690 in ___, 1625 in ___, 1738 in ___, 1771 in ___ NECK PAIN - c-spine films show DJD OSTEOARTHRITIS TINEA VERSICOLOR CATARACT SURGERY EDEMA ___ - mild edema of feet bilat. HEARING LOSS Social History: ___ Family History: Mother died of MI at age ___ 2 siblings with DM No known h/o cancer or kidney disease Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 98.6, 134/49, 62, 18, 97% on RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-distended. tender with deep palpation of RUQ, negative ___ sign. bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley. No CVA tenderness. Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: VS: 98.5 145/54 68 18 99% on RA Gen: AOx3, NAD Head/neck: 5cm mass on posterior right neck, non-tender to palpation. Otherwise supple, no JVD CV: RRR, nl S1S2 Resp: CTAB, breathing comfortably Abd: Obese, soft, slightly larger on right than left. Non-tender to deep palpation throughout. No palpable masses. GU: No CVAT Ext: WWP, 2+ pulses, no edema Neuro: CN II-XII grossly intact, motor function normal Pertinent Results: PERTINENT BLOOD: ___ 06:00AM BLOOD WBC-8.9 RBC-4.32* Hgb-13.5* Hct-40.1 MCV-93 MCH-31.3 MCHC-33.8 RDW-12.7 Plt ___ ___ 02:30PM BLOOD WBC-9.4# RBC-4.38* Hgb-13.8* Hct-40.4 MCV-92 MCH-31.4 MCHC-34.1 RDW-12.6 Plt ___ ___ 02:30PM BLOOD Neuts-83.5* Lymphs-11.5* Monos-4.9 Eos-0 Baso-0.2 ___ 02:30PM BLOOD Glucose-139* UreaN-19 Creat-0.9 Na-137 K-4.2 Cl-100 HCO3-28 AnGap-13 ___ 02:30PM BLOOD ALT-28 AST-25 AlkPhos-43 TotBili-0.5 ___ 02:30PM BLOOD Lipase-55 ___ 02:30PM BLOOD cTropnT-<0.01 ___ 02:30PM BLOOD Albumin-4.6 Calcium-9.6 Phos-2.6* Mg-1.9 PERTINENT URINE: ___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD ___ 04:00PM URINE RBC-2 WBC-10* Bacteri-NONE Yeast-NONE Epi-1 ___ 04:00PM URINE Mucous-RARE PERTINENT IMAGING: CT Abd and Pelvis wwo Contrast (___): IMPRESSION: 1. Low level enhancing lesion in the upper pole of the left kidney, highly suggestive of a renal cell carcinoma and does not appear to represent a hyperdense cyst. Suggest Urology evaluation or further characterized by nonemergent MRI if clinically indicated. 2. Mild gallbladder distention and surrounding stranding without gallbladder wall edema or pericholecystic fluid, correlate clinically with symptoms. CT Abd and Pelvis with contrast (___): IMPRESSION: 1. Distended gallbladder with possible edema of the gallbladder wall. Recommend clinical correlation and possible right upper quadrant ultrasound if indicated. 2. Lobulated contour at the upper pole of the left kidney concerning for enhancing mass, likely renal cell carcinoma. MR evaluation ___ multiphasic CT if patient not ammenable) is recommended. 3. Normal appendix. No fluid collection or abscess. Liver/Gallbladder U/S (___): IMPRESSION: Distended gallbladder with dependent sludge and possible tiny stone. No other findings to suggest acute cholecystitis. Radiology Report HISTORY: Periumbilical pain. TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous contrast was performed. Multiplanar reformats were prepared and reviewed. COMPARISON: None. FINDINGS: ABDOMEN: The visualized lungs are clear. The liver is homogeneous without focal lesions. There is no biliary ductal dilatation. The gallbladder is distended with possible wall thickening but no surrounding fat stranding. The spleen, pancreas, and adrenal glands are normal. There is a 2.8 x 1.7 x 1.7 cm lobulated mass in the upper pole of the left kidney which is hypoenhancing compared with renal parenchyma and is concerning for malignancy. Multiple hypodensities are seen in the bilateral kidneys. The large hypodensities in the left kidney are consistent with simple cysts and the smaller lesions bilaterally are too small to characterize but likely represent cysts. There is no evidence of hydronephrosis. The stomach, duodenum, and intra-abdominal loops of bowel are normal in caliber and unremarkable. The appendix is normal. There is no retroperitoneal or mesenteric lymphadenopathy. The intra-abdominal aorta is normal in appearance. PELVIS: The sigmoid colon and rectum are normal in appearance. There is a bladder diverticulum. The prostate is slightly enlarged. There is no pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for infection or malignancy is seen. Degenerative changes are noted throughout the visualized spine and hips. IMPRESSION: 1. Distended gallbladder with possible edema of the gallbladder wall. Recommend clinical correlation and possible right upper quadrant ultrasound if indicated. 2. Lobulated contour at the upper pole of the left kidney concerning for enhancing mass, likely renal cell carcinoma. MR evaluation ___ multiphasic CT if patient not ammenable) is recommended. 3. Normal appendix. No fluid collection or abscess. Updated impression from wet read communicated to Dr. ___ at 7:22 p.m. on ___ by phone. Radiology Report HISTORY: Right upper quadrant abdominal pain, concerning for cholecystitis and cholelithiasis. TECHNIQUE: Grayscale and color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Comparison is made with CT abdomen pelvis from the same day, ___. FINDINGS: The liver shows no evidence of focal lesions or textural abnormality. Doppler assessment of the main portal vein shows patency and hepatopetal flow. There is no ascites. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The CBD measures 6 mm. The gallbladder is distended with dependent sludge and possible tiny stone. No other findings to suggest acute cholecystitis. The tail of the pancreas is not well visualized due to overlying bowel gas, but the visualized portions of the pancreas are unremarkable. The spleen measures 10.5 cm and has a homogeneous echotexture. Limited views of the bilateral kidneys are unremarkable. IMPRESSION: Distended gallbladder with dependent sludge and possible tiny stone. No other findings to suggest acute cholecystitis. Radiology Report INDICATION: Right lobulated kidney mass suspicious for malignancy. Further evaluation requested. COMPARISON: CT abdomen and pelvis from ___. TECHNIQUE: Axial helical MDCT images were obtained through the abdomen and pelvis before and after the administration of intravenous contrast. Multiplanar reformatted images in coronal and sagittal axes were generated. DLP: 833 mGy-cm. FINDINGS: The bases of the lungs are clear. The visualized heart and pericardium are unremarkable. CT ABDOMEN: The liver is hypoattenuating consistent with steatosis. There are no focal lesions or intrahepatic biliary dilatation. The portal vein is patent. The gallbladder is mildly distended with some adjacent fat stranding; however, there is no gallbladder wall edema or pericholecystic fluid. The pancreas, spleen and adrenal glands are unremarkable. The right kidney enhances without focal lesions or hydronephrosis. In the left kidney in the upper pole, there is a partially exophytic lobulated mass measuring 2.4 x 2.4 x 2 cm, demonstrates low-level enhancement. Multiple other hypodense lesions within the left kidney are consistent with cysts; the largest of which measures 5.1 cm. Stomach, duodenum and small bowel are unremarkable. The colon demonstrates scattered diverticulosis without evidence of diverticulitis. The appendix is visualized and there is no evidence of appendicitis. There is no retroperitoneal or mesenteric lymph node enlargement by CT size criteria. There is no ascites, free air or abdominal wall hernias. The intra-abdominal vasculature demonstrates scattered atherosclerotic calcifications. CT PELVIS: The prostate is enlarged. There is a bladder diverticulum at the right side of the bladder. There is no pelvic free fluid. No inguinal or pelvic lymphadenopathy. OSSEOUS STRUCTURES: No lytic or sclerotic lesion suspicious for malignancy is present. Multilevel degenerative changes of the thoracolumbar spine are noted. IMPRESSION: 1. Low level enhancing lesion in the upper pole of the left kidney, highly suggestive of a renal cell carcinoma and does not appear to represent a hyperdense cyst. Suggest Urology evaluation or further characterized by nonemergent MRI if clinically indicated. 2. Mild gallbladder distention and surrounding stranding without gallbladder wall edema or pericholecystic fluid, correlate clinically with symptoms. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED, RENAL & URETERAL DIS NOS, HYPERTENSION NOS temperature: 97.9 heartrate: 61.0 resprate: 18.0 o2sat: 98.0 sbp: 160.0 dbp: 61.0 level of pain: 8 level of acuity: 3.0

You were seen in the hospital for new abdominal pain. Imaging of your abdomen was performed and showed a mass in the upper portion of your left kidney. The shape of this mass is concerning for kidney cancer. Following discharge, it is important that you follow up in ___ clinic to discuss treatment options for this mass. You may need further testing and possibly surgery. The urologists are in the process of arranging an appointment for you in the ___. Someone should be in touch with you soon about a date and time. IMPORTANT: If you have not heard from someone in ___ by ___ at noon, please call the clinic at ___ and ask about the status of your appointment. It is important that you be seen in clinic within ___ weeks of discharge. It is possible the pain you experienced was due to a gallbladder problem. If you experience recurrence of this pain, or have nausea/vomiting or fevers/chills, we encourage you to call your primary care doctor or proceed to the Emergency Room.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Influenza Virus Vaccine / Atenolol / lactose Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: none History of Present Illness: ___ female fwith history of breast cancer, GERD, HTN who presents from her assisted living facility ___) after being found unconscious sitting up on her porch. Patient was lowered to the ground by staff member and regained consciousness, but was reportedly confused. She was brought to the emergency department by EMS. Currently, patient has no complaints. She states that she was just sleeping on her porch. She is not sure why she was brought to the hospital. She does say that she felt a little bit lightheaded when she was woken up by the staff member at her assisted living facility. She denies any chest pain, palpitations, shortness of breath, abdominal pain, nausea, or vomiting, dysuria, fevers or chills. She states that she did eat breakfast this morning and has been drinking adequate amounts of water. In the ED, initial VS were: T 96.7, HR 61, BP 108/72, RR 10, RA 95% on RA Exam notable for: Head: AT/NC Eyes: PERRL, EOMi Heart: RRR, no murmur Lungs CTAB Abd: soft, tenderness to palpation Extremities: no edema ECG: SR @ 62 bpm, nl axis, nl intervals, no ST-T wave changes Labs showed: - UA with mod leuks, 47 WBCs, 5 RBC - Lactate 2.1 - Trop 0.01 - AST, ALT WNL, AP 114 - CBC 10.4/11.1/34.7/254 - Coags ___ Patient received: - 500 cc NS - ceftriaxone 1g On arrival to the floor, patient reports that she is feeling well and does not have any complaints. Past Medical History: BREAST CANCER ___ COLONIC POLYPS EGD HYPERGLYCEMIA HYPERTENSION IRRITABLE BOWEL SYNDROME OSTEOPOROSIS RIGHT UPPER QUADRANT PAIN SCOLIOSIS COSTOCHONDRITIS HERPES ZOSTER Social History: ___ Family History: No family history of breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.2, BP 184/73, HR 79, RR 18, O2 sat 95% on room air GENERAL: pleasant elderly female in no acute distress HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: RRR, S1/S2, ___ systolic ejection murmur heard over right upper sternal border, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, no suprapubic pain EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose SKIN: Venous stasis in bilateral lower extremities, otherwise warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: 24 HR Data (last updated ___ @ 759) Temp: 98.3 (Tm 98.3), BP: 142/92(manual) (111-166/67-96), HR: 73 (71-75), RR: 18 (___), O2 sat: 95%, O2 delivery: Ra General: Alert, not in acute distress Lungs: mild crackles at base, otherwise good airflow throughout without wheeze or rales CV: Normal sinus rhythm, +S1+S2, no murmur/rub/gallop Abdomen: soft, non-tender to palpation throughout, no rebound tenderness, no guarding, +BS Back: No CVAT Ext: Warm, well perfused, no edema Pertinent Results: ADMISSION LABS: ___ 01:25PM BLOOD WBC-10.4* RBC-3.83* Hgb-11.1* Hct-34.7 MCV-91 MCH-29.0 MCHC-32.0 RDW-14.5 RDWSD-47.8* Plt ___ ___ 01:25PM BLOOD Neuts-78.4* Lymphs-13.7* Monos-5.6 Eos-1.4 Baso-0.3 Im ___ AbsNeut-8.13* AbsLymp-1.42 AbsMono-0.58 AbsEos-0.15 AbsBaso-0.03 ___ 01:25PM BLOOD ___ PTT-27.1 ___ ___ 01:25PM BLOOD Plt ___ ___ 01:25PM BLOOD Glucose-122* UreaN-20 Creat-0.7 Na-135 K-4.8 Cl-98 HCO3-23 AnGap-14 ___ 01:25PM BLOOD ALT-10 AST-17 AlkPhos-114* TotBili-0.6 ___ 01:25PM BLOOD Lipase-33 ___ 01:25PM BLOOD cTropnT-<0.01 ___ 01:25PM BLOOD Albumin-3.9 ___ 01:36PM BLOOD Lactate-2.1* ___ 02:25PM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:25PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD* ___ 02:25PM URINE RBC-5* WBC-47* Bacteri-FEW* Yeast-NONE Epi-<1 ___ 02:25PM URINE CastHy-25* INTERVAL LABS: ___ 06:00AM BLOOD WBC-9.2 RBC-3.90 Hgb-11.0* Hct-34.8 MCV-89 MCH-28.2 MCHC-31.6* RDW-14.6 RDWSD-47.5* Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-139 K-4.5 Cl-101 HCO3-23 AnGap-15 ___ 06:00AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.9 DISCHARGE LABS: ___ 04:30AM BLOOD WBC-8.4 RBC-3.98 Hgb-11.4 Hct-35.8 MCV-90 MCH-28.6 MCHC-31.8* RDW-14.4 RDWSD-47.4* Plt ___ ___ 04:30AM BLOOD Plt ___ ___ 04:30AM BLOOD Glucose-90 UreaN-18 Creat-0.6 Na-140 K-4.9 Cl-101 HCO3-28 AnGap-11 ___ 04:30AM BLOOD Calcium-9.6 Phos-4.3 Mg-1.9 MICROBIOLOGY: ___ 1:25 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 2:25 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S ___ 6:10 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. IMAGING: ___ CT ABD & PELVIS WITH CO IMPRESSION: 1. No acute findings to account for hypotension and abdominal pain. 2. Incidental findings as detailed above. ___ CXR IMPRESSION: Compared to chest radiographs since ___ most recently ___. No pneumonia. Mild interstitial abnormality, probably chronic. Heart size top-normal. No pleural effusion. Chronic right apical scarring unchanged since at least ___ due to prior infection or radiation therapy. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with hypotention, hypothermia, syncope// eval for poss infection eval for poss infection IMPRESSION: Compared to chest radiographs since ___ most recently ___. No pneumonia. Mild interstitial abnormality, probably chronic. Heart size top-normal. No pleural effusion. Chronic right apical scarring unchanged since at least ___ due to prior infection or radiation therapy. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ female with hypotension and abd tenderness. TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed without contrast. Multiplanar reformations were provided. DOSE: Total DLP (Body) = 541 mGy-cm. COMPARISON: Prior CT abdomen pelvis from ___ FINDINGS: Lung Bases: At the imaged lung bases, there is mild dependent atelectasis with a trace right pleural effusion. The heart appears top-normal in size with partially visualized mitral annular dense calcifications. Abdomen: The liver enhances normally and contains no worrisome focal lesion. Main portal vein is patent. Mild prominence of the central biliary tree is similar to prior and of doubtful clinical significance in the absence of associated right upper quadrant pain. Cholelithiasis without evidence of cholecystitis with complete decompression of the gallbladder. CBD is normal in size. The spleen is normal. Slight thickening of the adrenal glands is unchanged without discrete nodule. 2 adjacent right renal upper pole cysts are noted, the larger positioned superiorly measuring 4.7 x 3.6 x 4.3 cm. A third simple appearing renal cyst is seen arising from the midpole right kidney. No concerning renal lesion. No hydronephrosis. The abdominal aorta is densely calcified and there is no aneurysm. No retroperitoneal or mesenteric adenopathy. The stomach appears normal. The duodenum appears normal. Pelvis: Loops of small and large bowel demonstrate no signs of ileus or obstruction. The appendix is normal. There is a normal appearance of the appendix. The colon notable for diverticulosis and no diverticulitis. A uterine calcification likely represents a small fibroid. The urinary bladder is partially distended appearing normal. No pelvic free fluid. No pelvic sidewall or inguinal adenopathy. No adnexal masses. Bones: No worrisome lytic or blastic osseous lesion is seen. IMPRESSION: 1. No acute findings to account for hypotension and abdominal pain. 2. Incidental findings as detailed above. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, Syncope Diagnosed with Syncope and collapse, Urinary tract infection, site not specified, Lower abdominal pain, unspecified temperature: 96.7 heartrate: 61.0 resprate: 10.0 o2sat: 95.0 sbp: 108.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure to care for you at the ___ ___. Why did you ___ to the hospital? - You were found unconscious by staff at your assisted living facility ___). Upon waking up, you were confused and brought to the hospital for further evaluation. What did you receive in the hospital? - On presentation you were found to have a possible urinary tract infection, and you were started on an IV antibiotic. - Because you did not have any symptoms, we decided to stop the antibiotic after 1 day. - To make sure your heart didn't cause you to go unconscious, we monitored your heart rhythm. - Our physical therapists recommended that you go to rehab to get stronger. What should you do once you leave the hospital? - You should follow up with your primary care provider which will be arranged by the rehabilitation facility. - If you notice any pain on urination, lightheadedness or dizziness please return to the emergency department. We wish you the ___! Your ___ treatment team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Claritin Attending: ___. Chief Complaint: Abdominal/ chest pain Major Surgical or Invasive Procedure: ___: Laparascopic cholecystectomy History of Present Illness: ___ year old female pt presents with epigastric and RUQ pain associated with N/V since 3 am. She reports the pain was about ___ radiating to the back but that now she has ___ pain and no nausea. She reports having previous intermittent episodes of RUQ pain since ___. She reports that the pain is aggravated with fatty foods. She also reports acid reflux especially at night after eating late. Past Medical History: Past Medical History: 1. Asthma. 2. Depression. 3. Hypothyroidism. 4. Mitral valve prolapse. Past Surgical History: 1. Ventral and inguinal hernia repair. 2. Uterus surgery. 3. Knee surgery. 4. Appendectomy. 5. T&A. 6. Turbinectomy. Social History: ___ Family History: Mother: ___, Lung resection. Father: CAD, ___ valve prolapse. Physical Exam: VS: 98.8 63 110/58 18 93% RA Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: RRR, NL S1,S2, No MRG Lungs: CTA B Abd: Soft, appropriate ___ tenderness, no rebound tenderness/guarding Wounds: Abd lap sites with primary dsg, CDI Ext: No edema Pertinent Results: ___ 06:48AM BLOOD WBC-9.0 RBC-4.64 Hgb-13.1 Hct-40.9 MCV-88 MCH-28.3 MCHC-32.1 RDW-12.9 Plt ___ Neuts-73.5* Lymphs-19.1 Monos-4.5 Eos-2.2 Baso-0.6 ___ PTT-28.2 ___ Glucose-180* UreaN-17 Creat-0.7 Na-140 K-3.9 Cl-107 HCO3-22 AnGap-15 ALT-11 AST-15 AlkPhos-68 TotBili-0.2 cTropnT-<0.01 Albumin-3.9 Calcium-8.7 Phos-3.4 Mg-2. ___ 01:20PM BLOOD cTropnT-<0.01 ___: ABDOMEN U.S. (COMPLETE STUDY): IMPRESSION: Preliminary Report: Distended gallbladder with wall thickening and multiple gallstones consistent with acute cholecystitis. No evidence of intrahepatic biliary ductal dilatation ___: CTA CHEST W&W/O C&RECONS, NON-CORONARY: IMPRESSION: 1. No pulmonary embolism or evidence of acute aortic pathology. 2. Left basal opacity is most compatible with atelectasis or scarring. ___ CHEST (PORTABLE AP): IMPRESSION: No acute intrathoracic process. Medications on Admission: Wellbutrin XL 300', Levoxyl 50', Singulair 10', Sertraline 100', Ambien 10' Discharge Medications: 1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. Disp:*25 Tablet(s)* Refills:*0* 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain: Do not exceed 4000 mg per 24 hour period. 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for Insomnia. 7. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Take while requiring pain medication; discontinue with loose bowel movements. Disp:*60 Capsule(s)* Refills:*0* 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute cholecytitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ woman with chest pain, assess for pneumonia or other acute process. COMPARISONS: ___. TECHNIQUE: Portable AP upright radiograph of the chest. FINDINGS: Lungs are low in volume but clear. The heart is mildly enlarged. There is no pleural effusion or pneumothorax. IMPRESSION: No acute intrathoracic process. Radiology Report INDICATION: ___ female with chest pain radiating to the back, assess for dissection. COMPARISONS: Chest radiograph from earlier the same date. TECHNIQUE: MDCT-acquired axial images were obtained through the lungs prior to and in arterial phase after the uneventful administration of 100 cc of Omnipaque contrast medium. Coronal and sagittal and bilateral oblique reformations were prepared. FINDINGS: There is no evidence of pulmonary embolism with symmetric and complete opacification of the pulmonary vessels to the segmental and subsegmental level. The aorta and major branches are patent with normal three-vessel arch and no evidence of acute aortic pathology. The heart is moderately enlarged with prominent left atrium. No pericardial effusion is seen. Within the lungs, there is patchy opacification of the left base which is likely atelectasis or scarring. No focal consolidation is seen. There is no pleural effusion or pneumothorax. The trachea and central airways are patent to the segmental level. The esophagus is normal with a small hiatal hernia. There is no axillary, mediastinal, hilar, or supraclavicular pathologic adenopathy, though scattered nonenlarged nodes are seen. Though this study is not tailored for subdiaphragmatic evaluation, imaged upper abdomen is unremarkable. OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion concerning for osseous malignant process. IMPRESSION: 1. No pulmonary embolism or evidence of acute aortic pathology. 2. Left basal opacity is most compatible with atelectasis or scarring. Changes from the initial interpretation were discussed with Dr. ___ by Dr. ___ at 1110 on ___ by phone. Radiology Report INDICATION: Epigastric pain radiating to the back, evaluate for cholecystitis. COMPARISON: Concurrent CTA chest, ___, 07:30 hours. FINDINGS: The liver is normal in echotexture without focal lesions identified. The gallbladder wall is thickened, measuring 5.5 mm and contains numerous gallstones. There is no intrahepatic biliary ductal dilatation and the common bile duct is normal, measuring 6 mm. There is normal hepatopetal flow seen in the main portal vein. Right kidney measures 10.5 cm and the left kidney measures 9.5 cm. There are no renal masses or nephrolithiasis identified. The spleen is normal. IMPRESSION: Distended gallbladder with wall thickening and multiple gallstones concerning for acute cholecystitis. No evidence of intrahepatic biliary ductal dilatation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CP Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ACUTE CHOLECYSTITIS, CHEST PAIN NOS temperature: nan heartrate: 53.0 resprate: nan o2sat: 100.0 sbp: 102.0 dbp: 66.0 level of pain: 9 level of acuity: 2.0

You were admitted to the hospital with chest and abdominal pain attributable to acute cholecytitis. 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: clindamycin / Cephalosporins / lisinopril / Penicillins / Iodine and Iodide Containing Products / herbal drugs / fish derived / most nuts Attending: ___ ___ Complaint: Hodgkins Lymphoma Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ yr old female on ___ s/p a BEAM auto-HSCT for Hodgkin lymphoma. She was treated with ABVD for six cycles, which completed in ___. In ___, she was noted for an enlarged submandibular lymph node and unfortunately, PET imaging showed multistation FDG-avid lymphadenopathy within the neck, mediastinum, and retroperitoneum. Left neck biopsy on ___ showed recurrence of her classical Hodgkin's lymphoma. She subsequently was treated with ICE for three cycles from ___ to ___ and then received high-dose Cytoxan for stem cell mobilization followed by autologous transplantation with the BEAM regimen. Day 0 was on ___. She is currently undergoing brentuximab maintenance (last ___ dose on ___ now presenting with a few day history of occipital HAs now with two days of fevers and a progressively developing papular rash of the face and anterior chest with a patchy rash on the RLE. Past Medical History: PAST ONCOLOGIC HISTORY (updated from most recent outpatient oncology note on ___: Pt was diagnosed with stage IIIB nodular sclerosing Hodgkin's disease in ___. At that time, she was noted for large necrotic splenic mass with 4 cm retroperitoneal adenopathy. She had fevers, night sweats and a 20-pound weight loss at that time. Chest CT showed a small left pleural effusion. PET scan was positive in the left supraclavicular and internal mammary nodes, spleen, retroperitoneum and upper abdominal nodes as well as the left lung base. Bone marrow biopsy was negative. She underwent FNA of lymph nodes as well as core biopsy, which showed the diagnosis of nodular sclerosing Hodgkin's lymphoma. She received ABVD chemotherapy for six cycles from ___ to ___. Followup imaging remained negative. Over the past ___, Ms. ___ reports having issues with a tooth infection around the same time she had also travel to ___ and developed a rash, which was initially felt to be scabies or other parasites and then was identified as a folliculitis. The tooth infection was on her right side, but she also was noting an enlarged left-sided cervical lymph node. She lost 40 pounds over the summer months and was not feeling well, but when she finally was able to have her tooth pulled, her feelings of malaise improved and she was back eating without issues. She denied any specific fevers or chills. She had no night sweats. She did have itching from her rash, but she always has some itching. She has had a sense of allergic history. In ___, Ms. ___ was due for her usual followup and was noted for an enlarged submandibular lymph node on the left. She underwent PET imaging on ___ which showed multistation FDG-avid lymphadenopathy within the left neck, mediastinum and retroperitoneum, SUV max of 8.3 and the higest in the neck, 7.2-7.3 in the mediastinum and 5.1 in the abdomen. There was noted macronodular contour of the liver which may represent cirrhosis. On ___, Ms. ___ underwent a left neck mass biopsy, which showed recurrence of her classical Hodgkin's lymphoma, nodular sclerosing type, ___ is negative. Also, noted on the PET scan was no splenomegaly and most of these nodes were under 3 cm. Ms. ___ subsequently started chemotherapy with ICE. Her first cycle was on ___, although day 3 was not given due to poor access. She had a Port-A-Cath placed in the interim and received cycle 2 on ___. She was treated with prednisone for a rash on ___. She has had similar rashes in the past, felt to be allergic and possibly contact dermatitis. She received most recent cycle 3 of ICE chemotherapy on ___ and then underwent restaging PET scan on ___. Results showed a significant interval decrease in the size and FDG avidity of the left cervical chain lymphadenopathy with now mild residual FDG uptake in the left level II lymph node with maximum SUV of 3.2. This was previously 6.1 and 7. Mediastinal lymph nodes have also decreased in size and FDG uptake with a subcarinal lymph node showing a maximal SUV of 3.3, previously 7.3 and another was noted at 15. The abdominal lymph nodes are also markedly decreased in size and FDG avidity with no FDG-avid lymphadenopathy within the abdomen or pelvis. PAST MEDICAL HISTORY: 1. Recurrent Hodgkin's lymphoma (see above) 2. Intraductal breast ca s/p lt radical mastectomy w/ TRAM flap reconstruction 3. Hypertension 4. Diabetes, on oral meds 5. Cataracts s/p lt cataract surgery (needs rt cataract surgery) 6. Left-sided sciatica 7. Spinal stenosis 8. Hypercholesterolemia 9. Colonic adenoma 10. GERD Social History: ___ Family History: No known family history of lymphomas. Brother is ___, Father ___ at ___ had Hypertension and Stroke, Mother ___ at ___ and had Cancer, twin Sister Alive with ___ and Thyroid Disorder Pertinent Results: ___ 04:04AM BLOOD WBC-2.9* RBC-2.85* Hgb-9.2* Hct-26.9* MCV-94 MCH-32.3* MCHC-34.2 RDW-12.1 RDWSD-41.8 Plt Ct-54* ___ 05:30PM BLOOD WBC-4.6 RBC-3.81* Hgb-12.4 Hct-35.7 MCV-94 MCH-32.5* MCHC-34.7 RDW-12.2 RDWSD-42.2 Plt Ct-58* ___ 04:04AM BLOOD Neuts-56.1 ___ Monos-9.8 Eos-2.8 Baso-0.7 Im ___ AbsNeut-1.61 AbsLymp-0.87* AbsMono-0.28 AbsEos-0.08 AbsBaso-0.02 ___ 05:30PM BLOOD Neuts-74.0* Lymphs-13.8* Monos-11.0 Eos-0.6* Baso-0.4 Im ___ AbsNeut-3.42 AbsLymp-0.64* AbsMono-0.51 AbsEos-0.03* AbsBaso-0.02 ___ 06:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ ___ 04:04AM BLOOD Plt Ct-54* ___ 05:30PM BLOOD Plt Ct-58* ___ 04:04AM BLOOD Glucose-123* UreaN-6 Creat-0.6 Na-140 K-3.6 Cl-105 HCO3-29 AnGap-10 ___ 05:30PM BLOOD Glucose-180* UreaN-14 Creat-1.0 Na-136 K-3.3 Cl-97 HCO3-27 AnGap-15 ___ 04:04AM BLOOD ALT-22 AST-23 LD(LDH)-166 AlkPhos-92 TotBili-0.7 ___ 05:30PM BLOOD ALT-29 AST-30 AlkPhos-107* TotBili-0.9 ___ 04:04AM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.5* Mg-2.1 ___ 05:30PM BLOOD Albumin-4.5 ___ 06:10AM BLOOD IgG-408* ___ 04:04AM BLOOD HERPES SIMPLEX VIRUS, TYPE 1 & 2 DNA, QUANTITATIVE REAL TIME PCR-PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Lorazepam 0.5 mg PO BID:PRN nausea 3. Omeprazole 40 mg PO DAILY 4. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 5. Multivitamins W/minerals 1 TAB PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Potassium Chloride 10 mEq PO DAILY 11. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 12. ValACYclovir 1000 mg PO Q8H 13. Acetaminophen 500 mg PO Q8H:PRN pain 14. Vitamin D 1000 UNIT PO DAILY 15. Magnesium Oxide 280 mg PO BID 16. Fexofenadine 120 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q8H:PRN pain 2. Atenolol 50 mg PO DAILY RX *atenolol 50 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 3. FoLIC Acid 1 mg PO DAILY 4. Lorazepam 0.5 mg PO BID:PRN nausea 5. Omeprazole 40 mg PO DAILY 6. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 7. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) 8. Vitamin D 1000 UNIT PO DAILY 9. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Duration: 1 Dose 10. Magnesium Oxide 280 mg PO BID 11. MetFORMIN (Glucophage) 500 mg PO BID 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. Potassium Chloride 10 mEq PO DAILY 15. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache/ pain RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every 6hrs Disp #*30 Tablet Refills:*0 16. Fexofenadine 120 mg PO DAILY 17. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth every 8 hrs Disp #*60 Tablet Refills:*2 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hodgkins Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: Status post bone marrow transplant for Hodgkin's lymphoma, presenting with fever. TECHNIQUE: Chest, PA and lateral P COMPARISON: Chest CT dated ___. FINDINGS: Port-A-Cath terminates in lower superior vena cava. The cardiac, mediastinal and hilar contours appear stable. The right hemidiaphragm is again elevated. There is no pleural effusion or pneumothorax. The lungs appear clear. There has been no significant change. IMPRESSION: No evidence of acute cardiopulmonary disease. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECKMRI of the head with and without contrast.MRI AND MRA BRAIN AND MRA NECK INDICATION: ___ year old woman with hodgkins // eval for etiology left occiptal neuralgia 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. The T1 weighted images were repeated after the administration of intravenous gadolinium contrast, sagittal MPRAGE and multiplanar reconstructions were also obtained. MRA of the head. 3D time arteriography of the head vessels was obtained, axial source images and maximal intensity projection images were reviewed. COMPARISON: No prior examinations of the head are available. FINDINGS: There is no evidence of intracranial hemorrhage, mass, mass effect or shifting of the normally midline structures. The ventricles and sulci are slightly prominent, suggesting cortical volume loss, probably age related and involutional in nature. Multiple scattered foci of high signal intensity are identified on T2 and FLAIR sequences, distributed in the pons, subcortical and periventricular white matter, which are nonspecific and may reflect changes due to small vessel disease. No diffusion abnormalities are detected. There is no evidence of abnormal enhancement to suggest leptomeningeal disease. The major vascular flow voids are present and demonstrate normal distribution. The orbits are unremarkable, the paranasal sinuses are clear, minimal mucosal thickening is noted at the tip of the mastoid air cells bilaterally. MRI Brain: There is no evidence of acute intracranial hemorrhage or mass effect. The ventricles and basal cisterns appear normal. There is no evidence of acute infarct based on diffusion-weighted imaging. There are normal vascular flow voids. There is diffuse brain parenchymal volume loss. There are punctate and confluent areas of subcortical T2/FLAIR signal hyperintensity which are nonspecific though presumably relate to sequelae of chronic small vessel ischemic disease. There is no abnormal brain parenchymal or leptomeningeal enhancement. The orbits and mastoid air cells are unremarkable. There is a right maxillary sinus mucosal retention cyst. MRA neck: The common, internal and external carotid arteries appear normal. There is no evidence of internal carotid artery stenosis by NASCET criteria. The subclavian arteries in the origins of the common carotid arteries appear normal. The origin of the right vertebral artery is not well seen which is commonly artifact although stenosis is not excluded IMPRESSION: There is no evidence of acute intracranial process. Scattered foci of high signal intensity detected on FLAIR and T2 weighted images, distributed in the subcortical and periventricular white matter, are nonspecific and may reflect changes due to small vessel disease.There is no evidence of abnormal enhancement. 1. No evidence of acute intracranial hemorrhage, mass effect, or acute infarct. 2. Brain parenchymal volume loss and probable sequelae of chronic microangiopathy. 3. No evidence of stenosis, dissection, or occlusion within the vasculature of the neck. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever, Nausea Diagnosed with FEVER, UNSPECIFIED, DIARRHEA, URIN TRACT INFECTION NOS temperature: 98.6 heartrate: 82.0 resprate: 18.0 o2sat: 97.0 sbp: 134.0 dbp: 65.0 level of pain: 8 level of acuity: 2.0

Ms. ___, You were admitted because you had left side pain in the back of your head and thighs. We were concerned about shingles due to the type of pain you were having and the appearance of some rashes on those regions. We did further biospy of the rash and found out that this pain may be related to your chemotherapy brentuximab. We were also concerned about the diarrhea you had during your admission but this has seemed to resolve. We also thought that the diarrhea may be related to your chemotherapy in concert with other medications you are taking. We consulted with neurology about your symptoms and it would be best if you follow up with an outpatient neurology provider for further assessment and management of this pain. We discussed with you taking neurontin, lyrica or receiving injections to help alleviate your pain and you did not want to do this at this time. We completed further imaging of your head and neck today and your outpatient provider, Dr. ___ follow up with you regarding the results. It was a pleasure taking care of you. Do not hesistate to contact us if you have any questions or concerns about your care. Please refer to below for follow up appointments with your outpatient provider.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Amoxicillin Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o F with h/o alcoholic cirrhosis complicated by hepatic encephalopathy, coagulopathy, pancytopenia, SBP and ascites presenting with fever and altered mental status. Patient was last seen normal at noon ___. Later this afternoon, her daughter found her minimally responsive and lethargic. Finger stick for EMS was 199. She has had mild fatigue for the past few days. She reports 1 week of R leg swelling, pain, warmth and erythema, on top of chronic leg swelling bilaterally. Pt denies trauma to the area. She denies F/C, N/V, diarrhea, abdominal pain. She has been taking lactulose regularly, and has no recent changes to her medications. In the ED, initial vitals were notable for T 103.4(rectal), HR 116, RR 18, BP 118/43 (dropped to 96/47, but was fluid responsive), sat: 99% on RA. Exam was notable for confusion initially, which cleared over several hours with IV fluids. She had an erythematous, swollen RLE. Lactate was 4.5. UA, CXR, Abd u/s showed no other source of infection. She received 4L IVF and vanc/cefipime was started for sepsis thought ___ cellulitis. On arrival to the MICU, her mental status had cleared and she was fully alert and oriented and appropriately conversant. She complained of thirst and her chronic back pain. Past Medical History: Alcoholic cirrhosis c/b hepatic encephalopathy, coagulopathy and pancytopenia, SBP, ascites/lower extremity edema Nutritional deficiency/Hypooalbuminemia UTI - VRE & Carbapenem resistent Hx of adrenal insufficiency (on midodrine) Vertebral fractures Afib during recent ICU admission ___ Past Surgical History: 4 C-sections, open appendectomy Social History: ___ Family History: Alcoholism Physical Exam: Admission Physical Exam ======================== Vitals- T:98.7 BP:100/39 P:101 R:22 O2:100 RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Obese, mildly distended, mildly tender to palpation throughout, bowel sounds present, no HSM appreciated EXT: Edema to thighs bilaterally, R > L. SKIN: Warm, erythematous rash without clear borders on R inner thigh that appears to extende to the labia bilaterally. (Marked with marker) NEURO: No focal deficits, no asterixis. Discharge Physical Exam ========================= GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Obese, mildly distended, mildly tender to palpation throughout (chronic per patient), bowel sounds present EXT: Evidence of chronic venous stasis in ___ bilaterally, RLE acute swelling nearly resolved SKIN: Warm, erythematous rash without clear borders on R shin, nearly resolved NEURO: No focal deficits, no asterixis, alert and oriented x3 PSYCH: Appropriate, euthymic Pertinent Results: Admission Labs ============================== ___ 04:46PM BLOOD WBC-5.7# RBC-4.63 Hgb-14.2 Hct-45.2 MCV-98 MCH-30.8 MCHC-31.5 RDW-14.8 Plt Ct-53* ___ 04:46PM BLOOD Neuts-93* Bands-4 Lymphs-3* Monos-0 Eos-0 Baso-0 ___ Myelos-0 ___ 04:46PM BLOOD Plt Smr-VERY LOW Plt Ct-53* ___ 04:46PM BLOOD Glucose-188* UreaN-12 Creat-1.1 Na-136 K-4.0 Cl-96 HCO3-25 AnGap-19 ___ 04:46PM BLOOD ALT-31 AST-93* AlkPhos-91 TotBili-3.1* ___ 04:46PM BLOOD Albumin-3.6 Calcium-9.5 Phos-3.5 Mg-1.1* ___ 05:00PM BLOOD Lactate-4.5* ___ 06:16AM BLOOD freeCa-1.09* Pertinent Interval =============================== ___ 04:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:00PM BLOOD Lactate-4.5* ___ 07:35PM BLOOD Lactate-4.8* ___ 12:18AM BLOOD Glucose-202* Lactate-5.1* K-3.9 ___ 06:16AM BLOOD Lactate-5.2* ___ 08:09AM BLOOD Lactate-2.8* Discharge Labs =============================== ___ 06:45AM BLOOD WBC-4.7 RBC-3.87* Hgb-12.2 Hct-38.7 MCV-100* MCH-31.4 MCHC-31.4 RDW-14.8 Plt Ct-82* ___ 06:45AM BLOOD ___ ___ 06:45AM BLOOD Glucose-119* UreaN-8 Creat-0.7 Na-138 K-3.7 Cl-105 HCO3-27 AnGap-10 ___ 06:45AM BLOOD TotBili-2.7* ___ 06:45AM BLOOD Albumin-2.8* Calcium-8.5 Phos-3.0 Mg-1.8 Imaging =============================== ___ AP Chest PORTABLE FRONTAL VIEW OF THE CHEST: The examination is limited. There is motion artifact and low volumes are low. Within this limitation, an opacity in the lingula appears likely similar since recent prior studies. For further evaluation a repeat chest radiograph could be obtained. ___ CT Head W/O Contrast 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. The basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. The globes appear normal. IMPRESSION: No evidence of acute intracranial process ___ CXR SINGLE FRONTAL VIEW OF THE CHEST: Linear opacities in the lingula are present over multiple prior studies and appear relatively unchanged. There is no focal consolidation, pleural effusion, or pneumothorax. Mild cardiomegaly is unchanged. The mediastinal contours are normal. There is no free air beneath the hemidiaphragms. IMPRESSION: No evidence of pneumonia. Unchanged mild cardiomegaly. ___ ___ FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral, proximal femoral, mid femoral, distal femoral and popliteal veins. There is normal color flow and compressibility in the right posterior tibial veins. The right peroneal veins are not visualized. IMPRESSION: No deep venous thrombosis within the right lower extremity. Non-visualized left peroneal veins. ___ RUQ US IMPRESSION: 1. Bidirectional portal vein flow is unchanged since ___. 2. Coarsened liver echotexture consistent with the provided diagnosis of cirrhosis. 3. A small amount of perihepatic ascites is new since ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. Citalopram 20 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Lactulose 15 mL PO BID 6. lidocaine 5 %(700 mg/patch) topical ONCE 7. Midodrine 15 mg PO TID 8. Multivitamins 1 TAB PO DAILY 9. OLANZapine 5 mg PO QAM 10. OLANZapine 10 mg PO HS 11. Rifaximin 550 mg PO BID 12. Simethicone 40-80 mg PO QID:PRN gas 13. Spironolactone 50 mg PO QAM 14. Thiamine 100 mg PO DAILY 15. Zinc Sulfate 220 mg PO DAILY 16. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral BID 17. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 0.08-1.80 gram-kcal/mL oral daily Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Lactulose 15 mL PO TID 5. Midodrine 15 mg PO TID 6. Multivitamins 1 TAB PO DAILY 7. OLANZapine 5 mg PO QAM 8. OLANZapine 10 mg PO HS 9. Rifaximin 550 mg PO BID 10. Simethicone 40-80 mg PO QID:PRN gas 11. Spironolactone 50 mg PO QAM 12. Thiamine 100 mg PO DAILY 13. Zinc Sulfate 220 mg PO DAILY 14. Clindamycin 450 mg PO Q8H RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 8hours Disp #*57 Capsule Refills:*0 15. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral BID 16. Ciprofloxacin HCl 500 mg PO Q24H 17. lidocaine 5 %(700 mg/patch) topical ONCE 18. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 0.08-1.80 gram-kcal/mL oral daily 19. HumaLOG Mix ___ (insulin lispro protam-lispro) 100 unit/mL (75-25) SUBCUTANEOUS DAILY 45 units with breakfast 30 units with dinner Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL INDICATION: Fever and altered mental status. Evaluate for pneumonia. COMPARISON: Multiple prior chest radiographs, the most recent of ___. PORTABLE FRONTAL VIEW OF THE CHEST: The examination is limited. There is motion artifact and low volumes are low. Within this limitation, an opacity in the lingula appears likely similar since recent prior studies. For further evaluation a repeat chest radiograph could be obtained. Radiology Report CLINICAL INDICATION: Altered mental status. Evaluate for intracranial hemorrhage. TECHNIQUE: Multidetector CT scan of the head was performed without IV contrast. Reformatted images are provided. DLP: 891.93 mGy-cm. COMPARISON: CT head ___. 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. The basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. The globes appear normal. IMPRESSION: No evidence of acute intracranial process. Radiology Report CLINICAL INDICATION: Fever and altered mental status. Repeat chest radiograph due to artifact. COMPARISON: Multiple prior chest radiographs, the most recent of ___. SINGLE FRONTAL VIEW OF THE CHEST: Linear opacities in the lingula are present over multiple prior studies and appear relatively unchanged. There is no focal consolidation, pleural effusion, or pneumothorax. Mild cardiomegaly is unchanged. The mediastinal contours are normal. There is no free air beneath the hemidiaphragms. IMPRESSION: No evidence of pneumonia. Unchanged mild cardiomegaly. Radiology Report CLINICAL INDICATION: Right lower extremity redness and swelling. Evaluate for DVT. TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation of the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral, proximal femoral, mid femoral, distal femoral and popliteal veins. There is normal color flow and compressibility in the right posterior tibial veins. The right peroneal veins are not visualized. IMPRESSION: No deep venous thrombosis within the right lower extremity. Non-visualized left peroneal veins. Radiology Report CLINICAL INDICATION: Cirrhosis and fever. Evaluate for thrombus. TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation of the abdomen. COMPARISON: Abdominal ultrasound ___. CT abdomen and pelvis ___. FINDINGS: The liver is coarse in echotexture consistent with the provided diagnosis of cirrhosis. The contour of the liver is smooth and no focal liver lesions are identified. Bidirectional flow within the main portal vein is unchanged compared to the prior ultrasound. Normal color flow and a venous waveform are seen within the main portal veins There is no intrahepatic biliary duct dilation. The common bile duct measures 5 mm. The gallbladder wall is slightly thickened, likely due to underlying liver disease. No gallstones are identified. New trace perihepatic ascites is identified. The visualized portions of the pancreas, aorta and IVC appear normal. IMPRESSION: 1. Bidirectional portal vein flow is unchanged since ___. 2. Coarsened liver echotexture consistent with the provided diagnosis of cirrhosis. 3. A small amount of perihepatic ascites is new since ___. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Altered mental status Diagnosed with HEPATIC ENCEPHALOPATHY, OTHER MALAISE AND FATIGUE, CELLULITIS OF LEG, ALCOHOL CIRRHOSIS LIVER temperature: nan heartrate: 131.0 resprate: nan o2sat: 92.0 sbp: 80.0 dbp: 46.0 level of pain: nan level of acuity: 1.0

Dear Ms. ___, You were admitted to the hospital because you were confused and having fevers. You were first admitted to the ICU because your blood pressure was very low. The cause of your symptoms was a skin infection of your right leg. You were started on antibiotics and your symptoms revolved. We will send you home with a antibiotics to take through ___. It is very important that you follow up on the appointments listed below. It was a pleasure to be a part of your care! Your ___ treatment team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / IV Dye, Iodine Containing Contrast Media / Shellfish / ibuprofen / Peanut / Latex / Penicillins / ZOFRAN ODT / metronidazole / vancomycin Attending: ___ Chief Complaint: Polymicrobrial bacteremia Major Surgical or Invasive Procedure: ___ transesophageal echocardiogram History of Present Illness: ___ w/ hx of asthma, bipolar, IBS, PCOS, chronic abd pain who was recently treated for presumed endocarditis due to blood cultures growing strep viridans from a left maxillary dental abscess- from ___ cultures d/c on ___ on ___ wks iv vanc with a picc line. She was at home on ___ was having F/C, N/v and feeling weak called the ambulance at they brought her to ___. She dislikes that hospital and asked to be sent to ___. ___ hospital course: ___ ICU for fever 103.9 hypotension, tachycardia to 140s. Cr 1.7. Had n/v/diarrhea. Was given 6 L IVF, had 4 bottles grow gram negative species in blood. PICC line was thought to be source and it was removed. She was given aztreonam and vancomycin. She was transfered to the floor today. Pt wanted to leave for ___ and left ___ AMA. She had her last vanc dose this afternoon at 1pm, getting 1 g BID vanco and 1 g daily of aztreonam. For workup of GN bacteremia, she had CT abd (non contrast since she had ARF) that was overall unremarkable. She currently says she feels sick/tired, denies n/v/f/c currenlty since the am, some mild abd pains similar to her chronic. She also has a gradual onset HA from last night, thobbing, at her vertex to the back of her head. Her abdomen hurts similar to her chronic pain. Denies any sob, visual chnages, cp, leg pain or swelling. She denies any ivda. 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: # Hepatitis C. Genotype 1b. -- Denies hx of IVDU, believes it was contracted sexually # Polycystic Ovary Syndrome: with hx of cyst rupture # Anxiety # Asthma # EtOH abuse # Multiple allergies # s/p gallbladder removal ___ years ago for ?cholecystitis vs choledocholithiasis # S viridens bacteremia, admission ___, given ___ntibiotics for presumed endocarditis even though TTE and TEE negative. Had pulled maxillary tooth, had small abscses. Dental did not think necessary to drain abscess. Has been supposedly poorly compliant with vanco at home, subtherapeutic levels, threatnening to pull out own picc line. #Chronic abd pain: several admission for this in the past. Unreavaeling workup. Has sibling with IBD. OSH CT showed ?terminal ileitis in ___ admission but subsequent MR enterography unremarkable. ___ endo and ___ negative. Social History: ___ Family History: Sister has ___ Disease Atopy No known hx of malignancy Physical Exam: Upon Admission: =============================== VS - 98.0 122/81 79 20 95%RA GENERAL - well-appearing woman in NAD, HEENT - NC/AT, PERRLA, EOMI, left eye strabismus. sclerae anicteric, MMM, OP clear. Poor dentition. NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, ___ systolic murmur heard best over left ___ intercostal. ABDOMEN - NABS, soft, TTP in RUQ and RLQ, no rebound or guarding, no HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions. site of removed left PICC line not erythematous or TTP. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Upon Discharge: =============================== afebrile >48 hours before discharge VS - Tm=Tm 97.9 120/80 79 18 94%RA GENERAL - well-appearing woman in NAD, HEENT - NC/AT, left eye strabismus. sclerae anicteric NECK - supple, no lymphadenopathy LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, ___ systolic murmur heard best over left ___ intercostal. ABDOMEN - NABS, soft, mild TTP in RUQ and RLQ, no rebound tenderness or guarding EXTREMITIES - WWP, no c/c/e SKIN - no rashes or lesions. NEURO - no focal deficits Pertinent Results: Upon Admission: ============================= ___ 06:25PM BLOOD WBC-6.7 RBC-2.87* Hgb-8.8* Hct-27.1* MCV-94 MCH-30.6 MCHC-32.5 RDW-16.1* Plt ___ ___ 06:25PM BLOOD Glucose-97 UreaN-7 Creat-0.9 Na-144 K-3.8 Cl-111* HCO3-20* AnGap-17 ___ 06:47AM BLOOD ALT-40 AST-38 LD(LDH)-249 AlkPhos-123* TotBili-0.4 ___ 06:25PM BLOOD calTIBC-263 ___ Ferritn-49 TRF-202 ___ 06:26PM BLOOD Lactate-2.1* Upon Discharge: ============================== ___ 06:20AM BLOOD WBC-5.4 RBC-3.26* Hgb-9.8* Hct-30.9* MCV-95 MCH-30.1 MCHC-31.8 RDW-16.1* Plt ___ ___ 06:20AM BLOOD Glucose-91 UreaN-6 Creat-0.7 Na-142 K-3.8 Cl-107 HCO3-24 AnGap-15 Imaging: ============================== ___ CXR: minimal bibasilar atelectasis without evidence for consolidation ___ TEE: EF>55% No vegetations or clinically-significant valvular disease seen. Patent foramen ovale. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 2. Lorazepam 2 mg PO Q8H:PRN anxiety 3. Sertraline 50 mg PO BID 4. traZODONE 100 mg PO HS 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID Discharge Medications: 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Lorazepam 2 mg PO Q8H:PRN anxiety 3. Sertraline 50 mg PO BID 4. traZODONE 100 mg PO HS 5. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 6. DiphenhydrAMINE 50 mg PO Q8H Please give dose 30 minutes prior to vancomycin doses to prevent allergic reaction. RX *diphenhydramine HCl [Allergy Medicine] 25 mg 2 tablet(s) by mouth TID PRN itching Disp #*30 Tablet Refills:*0 7. Nicotine Patch 14 mg TD DAILY RX *nicotine [Nicoderm CQ] 14 mg/24 hour 1 patch daily Disp #*28 Each Refills:*0 8. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*22 Tablet Refills:*0 9. Linezolid ___ mg PO Q12H RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day Disp #*23 Tablet Refills:*0 10. Voriconazole 200 mg PO Q12H Duration: 12 Doses RX *voriconazole 200 mg 1 tablet(s) by mouth twice a day Disp #*22 Tablet Refills:*0 11. Outpatient Lab Work CBC, Chem10, AST/ALT/Alk phos/T.bili twice a week PLEASE FAX RESULTS TO ___ ID department at ___ Discharge Disposition: Home Discharge Diagnosis: Severe Sepsis Polymicrobial bacteremia Fungemia Discharge Condition: mental status: alert, oriented, coherent, clear ambulatory status: ambulates independently Followup Instructions: ___ Radiology Report EXAM: Chest, frontal and lateral views. CLINICAL INFORMATION: Bacteremia. ___ as well ___. FINDINGS: Frontal and lateral views of the chest were obtained. There is minimal bibasilar atelectasis. Slight increase in the interstitial markings, more so at the lung bases could be artifactual, although atypical infection cannot be excluded. No lobar consolidation is seen. No large pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes are stable and unremarkable. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess line. Right PICC is malpositioned. The tip is going up in the right internal jugular vein. Cardiomediastinal contours are normal. The lungs are clear. There is no pneumothorax or pleural effusion. Findings were discussed with IV nurse, ___, by phone on ___ at 8:40 a.m. Radiology Report INDICATION: Repositioning of right PICC. COMPARISON: Comparison is made to radiograph of the chest from one hour prior at 8:17 on ___. FINDINGS: Frontal radiograph of the chest demonstrates repositioning of right PICC which is now in standard position with distal tip terminating in the mid-to-low SVC. There is no pneumothorax. The lungs are well expanded and clear. The cardiomediastinal silhouette is unremarkable. There is no evidence of pleural effusion. CONCLUSION: Right PICC is now in standard position with distal tip in the mid-to-low SVC. Otherwise, unchanged since the prior study. The above findings were communicated to IV nurse, ___, by Dr. ___ telephone at 10:06, 5 minutes after discovery was made. Radiology Report CHEST RADIOGRAPH INDICATION: Bacteremia and sepsis, spiking fevers, questionable pneumonia. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. No evidence of pneumonia on the frontal and lateral radiograph. No other lung parenchymal changes. Normal size of the cardiac silhouette. Unchanged position of the right-sided PICC line. No pleural effusions. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: BACTEREMIA Diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS temperature: 98.2 heartrate: 86.0 resprate: 16.0 o2sat: 98.0 sbp: 133.0 dbp: 89.0 level of pain: 6 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking part in your care at ___ ___. You were admitted for a an infection in your blood. There were multiple different types of bacteria growing in your blood. It is likely that the cause of this serious infection was contamination of your PICC line. There was no evidence of any abdominal infection, urinary tract infection, pneumonia, or any other source of infection. Also, there is no evidence of infection spreading to the heart based on the ultrasound of your heart that you had performed while you were in the hospital. You are being treated with three oral antibiotics, ciprofloxacin, linezolid, and voriconazole. Your infection has improved significantly during your admission and the oral antibiotics have been working well. You should take these antibiotics until ___. It is important that you go to a lab to have your blood drawn twice a week. For your information, the results should be faxed to the infectious disease department at ___ ___. I wish you all the best in the future, and a speedy recovery!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / morphine / Tetracyclines / meperidine / metoprolol / amitriptyline / doxycycline / Sulfa (Sulfonamide Antibiotics) / Tegretol / trazodone / Zoloft / WelChol Attending: ___ Chief Complaint: palpitations, weight gain Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ female w/ history of VF arrest in the setting of inferolateral STEMI, status post DES to LCx ___ who presents with dizziness and dyspnea, reported 4 lb weight gain, admitted for management of suspected volume overload. Cardiac arrest was 6 weeks ago. Patient just woke up this morning and ___ took her blood pressure and heart rate and reported them as being low. Patient also complains of shortness of breath, palpitations and lightheadedness over the past 2 days. She reported 4 pound weight gain since yesterday. Patient denies chest pain, fever, cough. She was discharged from the hospital 3 days ago for an NSTEMI. Cath was performed showing elevated left heart filling pressures, otherwise no interventions performed. She was discharged with a change of her diuretics from furosemide to torsemide. Patient has not urinated as much as she expected. In the ED: Initial VS: T: 98.9, HR: 80, BP: 128/69, RR 19, O2Sat: 100% on RA Physical exam: unremarkable Labs remarkable for: leukocytosis but downtrending from recent admission. Anemia stable from recent admission. Stable Creatinine at baseline. Negative troponins. ECG: NSR, HR 76, normal axis, normal intervals, no ST elevations or depressions, inferolateral T wave inversions, similar from prior Studies notable for: normal CXR Consults: at___ cardiology Patient was given: nothing Vitals on transfer: T: 98.1, HR: 64, BP: 92/60, RR: 12, O2Sat: 96% on RA On arrival to the cardiology service, the patient endorses the above history. She states that she experiences SOB and dizziness when going up the stairs but denies feeling them at rest. At rest her main complain are intermittent palpitations. She endorses chest pain but mostly mechanical from rib fracture and denies any similarities with previous episodes of ACS. Denies lower extremity edema REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope, or presyncope. On further review of systems, denies fevers or chills. 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 exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: -HTN -HLD -CAD Other PMH: -hypothyroidism -pulmonary nodule -anxiety -lumbosacral radiculopathy s/p spinal fusion on opioids Social History: ___ Family History: Family passed away from MI in late ______ Physical Exam: ADMISSION PHYSICAL EXAM ========================= 24 HR Data (last updated ___ @ 1725) Temp: 98.0 (Tm 98.0), BP: 113/78, HR: 66, RR: 16, O2 sat: 98%, O2 delivery: ra, Wt: 168.87 lb/76.6 kg GENERAL: Well developed, well nourished woman 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. NECK: JVP flat at 45 degrees. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM ======================== GENERAL: Well developed, well nourished woman 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. NECK: JVP flat at 45 degrees. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS ================ ___ 04:50PM cTropnT-0.01 ___ 11:04AM GLUCOSE-116* UREA N-13 CREAT-0.7 SODIUM-146 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14 ___ 11:04AM cTropnT-0.01 ___ 11:04AM proBNP-1115* ___ 11:04AM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-1.8 ___ 11:04AM WBC-12.6* RBC-3.25* HGB-11.0* HCT-35.5 MCV-109* MCH-33.8* MCHC-31.0* RDW-14.6 RDWSD-58.9* ___ 11:04AM NEUTS-61.6 ___ MONOS-11.1 EOS-3.7 BASOS-0.7 IM ___ AbsNeut-7.76* AbsLymp-2.79 AbsMono-1.40* AbsEos-0.46 AbsBaso-0.09* ___ 11:04AM PLT COUNT-457* DISCHARGE LABS =============== ___ 06:07AM BLOOD Glucose-110* UreaN-15 Creat-0.8 Na-139 K-5.2 Cl-99 HCO3-26 AnGap-14 ___ 06:07AM BLOOD Calcium-10.2 Phos-5.6* Mg-2.2 REPORTS / IMAGING ================== Cest XR ___ Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. No evidence of pneumonia Cath ___ The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 20% stenosis in the distal segment. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. There is a stent in the proximal and mid segments that is widely patent The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 30% stenosis in the mid segment. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. TTE ___ The left atrial volume index is normal. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild regional left ventricular systolic dysfunction with inferior and basal inferolateral hypokinesis (see schematic) and preserved/normal contractility of the remaining segments. Quantitative biplane left ventricular ejection fraction is 62 % (normal 54-73%). The visually estimated left ventricular ejection fraction is 45%. 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 with a normal descending aorta diameter. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate to severe [3+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing, dyspnea 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. BuPROPion XL (Once Daily) 300 mg PO DAILY 5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheezing, dyspnea 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Lidocaine 5% Patch 3 PTCH TD QAM 9. Omeprazole 20 mg PO BID GERD 10. TiCAGRELOR 90 mg PO BID prevent stent thrombosis 11. Atenolol 12.5 mg PO DAILY 12. Torsemide 10 mg PO DAILY 13. Bisacodyl 10 mg PO/PR DAILY 14. ALPRAZolam 1 mg PO QHS Discharge Medications: 1. Atenolol 25 mg PO DAILY RX *atenolol 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 2. Torsemide 10 mg PO DAILY 3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing, dyspnea 4. ALPRAZolam 1 mg PO QHS 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Bisacodyl 10 mg PO/PR DAILY 8. BuPROPion XL (Once Daily) 300 mg PO DAILY 9. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate 10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheezing, dyspnea 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch 3 PTCH TD QAM 13. Omeprazole 20 mg PO BID GERD 14. TiCAGRELOR 90 mg PO BID prevent stent thrombosis Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: # Palpitations - frequent premature ventricular contractions # Heart failure with recovered ejection fraction Secondary diagnoses: # Depression / anxiety # Rib fracture secondary to CPR # Hypertension # Anemia # Hypothyroidism 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 previous V. fib arrest here with shortness of breath, weight gain// Fluid status, infection TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. No evidence of pneumonia Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dizziness, Dyspnea Diagnosed with Shortness of breath, Palpitations, Dizziness and giddiness temperature: 98.9 heartrate: 80.0 resprate: 19.0 o2sat: 100.0 sbp: 128.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Dear ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had palpitations and a 4 pound weight increase. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were monitored and found to have frequent extra beats. Electrophysiology recommended increasing your beta-blocker medication to better control your palpitations and continue to use your heart monitor. - You were initially started on a medication called spironolactone for your heart failure, but this was stopped after we increased your atenolol WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. Please take 2 of your atenolol tablets (25mg total) until you run out, and then use new prescription - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor, or the Heartline 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: 79.2kg. 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: F Service: SURGERY Allergies: latex / bee venom (honey bee) Attending: ___. Chief Complaint: Motor Vehicle Collision Major Surgical or Invasive Procedure: - R Posterior Wall Acetabulum ORIF ___ (Dr. ___ - Closed reduction and percutaneous pinning of left distal radius fracture (Dr. ___ History of Present Illness: ___ F s/p MVC, unrestrained driver in head-on collision. Taken to ___, where she was found to have left 6th rib fracture, small pneumothorax, left wrist fracture, right acetabular fracture, and 6 cm facial lac. At OSH, she was noted to have seizure-like activity and was intubated. Left chest tube and foley were placed. She appears to have received a bolus of fosphenytoin between ___ and MedFlight. She was transferred via MedFlight to ___ for further evaluation and management. Past Medical History: PMH: seizures PSH: gastric bypass Social History: ___ Family History: non-contributory Physical Exam: ___ EXAM: - Vitals: 100.3 97 107/86 100% - ___: eyes open - HEENT: sutured head laceration, C collar - Pulmonary: upper airway sounds - Cardiac: pulses x 4 palpated - Abdomen: soft, nontender, distended secondary to obesity Discharge Physical Exam: Gen: NAD HEENT: well healing head laceration CV: RRR no M/G/R P: CTAB no W/R/R Abd: S/NT/ND Ext: cont. RLE numbness and weakness on dorsiflexion, eversion. TLD: none. Pertinent Results: ___ 11:39PM GLUCOSE-122* UREA N-8 CREAT-0.4 SODIUM-140 POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-20* ANION GAP-14 ___ 11:39PM ALBUMIN-3.4* CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-1.7 ___ 11:39PM PHENYTOIN-6.9* VALPROATE-<3* ___ 11:39PM WBC-8.5# RBC-3.38* HGB-10.1* HCT-30.3* MCV-90 MCH-29.9 MCHC-33.3 RDW-14.0 RDWSD-45.3 ___ 11:39PM NEUTS-82.9* LYMPHS-7.1* MONOS-8.9 EOS-0.5* BASOS-0.2 IM ___ AbsNeut-7.08* AbsLymp-0.61* AbsMono-0.76 AbsEos-0.04 AbsBaso-0.02 ___ 11:39PM PLT COUNT-219 ___ 11:39PM ___ PTT-32.8 ___ ___ 07:51PM ___ PO2-32* PCO2-52* PH-7.27* TOTAL CO2-25 BASE XS--4 INTUBATED-INTUBATED ___ 07:51PM O2 SAT-52 ___ 04:30PM PH-7.32* INTUBATED-INTUBATED ___ 04:30PM GLUCOSE-96 LACTATE-1.8 NA+-140 K+-4.2 CL--110* TCO2-18* ___ 04:30PM freeCa-1.03* ___ 04:23PM UREA N-12 CREAT-0.6 ___ 04:23PM LIPASE-48 ___ 04:23PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:23PM URINE HOURS-RANDOM ___ 04:23PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 04:23PM WBC-18.3* RBC-3.96 HGB-11.8 HCT-35.8 MCV-90 MCH-29.8 MCHC-33.0 RDW-13.8 RDWSD-45.4 ___ 04:23PM PLT COUNT-266 ___ 04:23PM ___ PTT-29.6 ___ ___ 04:23PM ___ 04:23PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:23PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 04:23PM URINE RBC-24* WBC-6* BACTERIA-NONE YEAST-NONE EPI-1 ___ 04:23PM URINE CA OXAL-RARE ___ 04:23PM URINE MUCOUS-RARE Imaging: ___: CXR: Left sixth rib fracture, minimally displaced. Additional fractures better seen on outside CT examinations performed earlier today. Low lung volumes with a left basilar consolidation, may reflect aspiration and/or atelectasis. Blunting of the left costophrenic angle may reflect small pleural effusion. ___: CT Head: No acute intracranial abnormality. Subgaleal hematomas involving the right frontal subcutaneous tissues as well as left vertex with associated cutaneous staples noted. ___: R femur fx No femoral fracture. Right acetabular fracture better characterized on same day CT performed at outside facility. FOREARM (AP & LAT) LEFT; WRIST(3 + VIEWS) LEFT; HAND (PA,LAT & OBLIQUE) LEFT: Impacted, comminuted, and slightly displaced distal radial fracture. No definite intra-articular component, this is difficult to entirely exclude. Best appreciated on the lateral views, there is uplifting of the dorsal cortex. ___ Pelvis with Judet Views: Fracture through the posterior aspect of the right acetabulum is better evaluated on same day CT performed at an outside facility. No evidence of dislocation. The proximal right femur appears intact. ___: MR ___ Spine 1. No evidence of fracture or intrinsic spinal cord signal abnormality. 2. Multilevel degenerative changes, with disc bulges at L3-4 and L4-5 causing mild spinal canal and bilateral neural foraminal narrowing, as described above ___: MR Head: 1. No acute intracranial pathology. 2. Sphenoid and bilateral maxillary sinus air-fluid levels are likely due to intubation. ___: EEG: This is an abnormal continuous ICU EEG monitoring study due to a background characterized by diffuse alpha/beta activity consistent with propofol effects, alternating with periods of generalized delta slowing consistent with a severe encephalopathy, non-specific with regards to etiology. There are no epileptiform discharges or electrographic seizures. Two pushbutton activations, presumably for patient movements, are without EEG correlate. In comparison to the prior day's recording, no seizures are present on today's study. ___: CXR: As compared to previous radiograph of 1 day earlier, a bilateral and asymmetrically distributed pattern of pulmonary edema has shifted in distribution and overall slightly worsened in severity. No other relevant changes. Medications on Admission: Unknown. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID please hold for loose stool 3. Enoxaparin Sodium 30 mg SC Q12H Duration: 3 Weeks Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 30 mg/0.3 mL 30 mg SC every twelve (12) hours Disp #*56 Syringe Refills:*0 4. LeVETiracetam 1500 mg PO BID RX *levetiracetam 1,000 mg 1.5 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do NOT drink alcohol or drive while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 6. Senna 8.6 mg PO BID:PRN constipation 7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing Discharge Disposition: Home Discharge Diagnosis: Motor Vehicle Collision Left 6th rib fracture Left pneumothorax Right acetabular fracture Left impacted/comminuted distal radial fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: ___ female status post trauma. INDICATION: ___ female status post trauma. COMPARISON: None available. FINDINGS: Supine portable AP chest radiograph demonstrates an endotracheal tube which terminates approximately 3 cm above the level of the carina. An enteric tube descends the thorax an uncomplicated course, its tip which projects over the left upper quadrant within the proximal gastric lumen. Lung volumes are low. A chest tube traverses the left hemithorax. Note is made of blunting of the left costophrenic angle which may reflect a small pleural effusion. Consolidation at the left lung base may reflect combination of aspiration and atelectasis There is no large pneumothorax. There is a fracture through the lateral sixth left rib. Imaged upper abdomen is unremarkable. Heart and hilar borders appear within normal limits. IMPRESSION: Left sixth rib fracture, minimally displaced. Additional fractures better seen on outside CT examinations performed earlier today. Low lung volumes with a left basilar consolidation, may reflect aspiration and/or atelectasis. Blunting of the left costophrenic angle may reflect small pleural effusion. Radiology Report EXAMINATION: DX HAND, WRIST AND FOREARM INDICATION: History: ___ with MVC, intubated*** COMPARISON: None available. FINDINGS: Four views of the left wrist and three views of the left forearm are provided. There is is an impacted and comminuted fracture involving the distal left radius. The distal fracture fragment appears laterally displaced. Carpals appear in anatomic alignment and without a fracture identified. The ulna is unremarkable. Soft tissue swelling about the distal left forearm is noted. There is no radiopaque foreign body. Best appreciated on the lateral view, the dorsal cortex of the distal radius is uplifted. IMPRESSION: Impacted, comminuted, and slightly displaced distal radial fracture. No definite intra-articular component, this is difficult to entirely exclude. Best appreciated on the lateral views, there is uplifting of the dorsal cortex. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ female status post motor vehicle accident. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations were generated and reviewed. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: None available. FINDINGS: There is no acute hemorrhage, infarction, mass effect, or edema identified. There is no shift of normally midline structures. Ventricles and sulci are age appropriate in size. Basal cisterns are patent. No extra-axial fluid collection is identified. A subgaleal hematoma involving the right frontal subcutaneous tissues is noted without underlying bony abnormality. Additionally a smaller left vertex scalp hematoma is noted. Mild mucosal thickening involving the ethmoidal air cells, sphenoid sinuses, and a mucous retention cyst within the right maxillary sinus are noted. Mastoid air cells and middle ear cavities are clear. IMPRESSION: No acute intracranial abnormality. Subgaleal hematomas involving the right frontal subcutaneous tissues as well as left vertex with associated cutaneous staples noted. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT INDICATION: History: ___ with MVC, intubated*** WARNING *** Multiple patients with same last name! // eval for traumatic process eval for traumatic process COMPARISON: None available. FINDINGS: AP, AP internal rotation, and lateral views of the left knee were provided. There is no fracture or dislocation identified. Joint space appears preserved. No suspicious lytic or blastic lesion is identified. There is no large joint effusion. Note is made of soft tissue swelling and fat stranding within the prepatellar region and projecting over the lateral aspect of the knee on the AP view. . IMPRESSION: No fracture. Soft tissue fat stranding and edema noted projecting over the prepatellar soft tissues and lateral knee on the AP view. Radiology Report EXAMINATION: FEMUR (AP AND LAT) RIGHT INDICATION: History: ___ with polytrauma, R acetabular fx.*** WARNING *** Multiple patients with same last name! // Please obtain AP PELVIS WITH JUDET VIEWS to characterize acetabular fracture. Please obtain AP PELVIS WITH JUDET VIEWS to characterize acetabular fracture. COMPARISON: CT abdomen performed at outside facility on the same date, ___. FINDINGS: AP and cross-table lateral views of the right pelvis were provided. Again identified and better characterized on same day CT performed at outside facility is a posterior acetabular fracture. The proximal femur is without a fracture. Femoral head appears seated in the acetabulum. The mid to distal femur appears intact without a fracture. Subcutaneous tissues are without a radiopaque foreign body or abnormal soft tissue calcification. Limited images of the right knee are grossly normal. No suspicious lytic or blastic lesion is seen. IMPRESSION: No femoral fracture. Right acetabular fracture better characterized on same day CT performed at outside facility. Radiology Report EXAMINATION: PELVIS W/JUDET VIEWS (3V) INDICATION: ___ female with pelvic, and right acetabular fracture. COMPARISON: Abdominal CT performed at an outside facility on the same date, ___. FINDINGS: Four views of the right hip were provided. There is a fracture through the posterior wall of the acetabular roof. The femoral head appears seated in the acetabulum. No fracture is identified involving the proximal right femur. There is no evidence of dislocation. The left hip joint is unremarkable. A Foley catheter is noted within the bladder. Contrast from prior examination is identified within the bladder lumen. IMPRESSION: Fracture through the posterior aspect of the right acetabulum is better evaluated on same day CT performed at an outside facility. No evidence of dislocation. The proximal right femur appears intact. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with same last name! // ?facial ?mandibular fxs 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) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 2.7 s, 21.1 cm; CTDIvol = 25.9 mGy (Head) DLP = 546.9 mGy-cm. Total DLP (Head) = 547 mGy-cm. COMPARISON: None. FINDINGS: SOFT TISSUES: There is a small right frontal scalp hematoma, partially imaged. MAXILLOFACIAL BONES: The maxillofacial bones are intact, without fracture. The zygomatico-maxillary complex is intact. The lateral pterygoid plates are intact. MANDIBLE: The mandible is without fracture or temporomandibular joint dislocation. The temporomandibular joints are symmetric, without significant degenerative change. SINUSES: Minimal mucosal thickening in the bilateral maxillary sinuses. There are small mucous retention cyst in the inferior maxillary sinuses. Minimal mucosal thickening of bilateral ethmoid air cells. There slice secretions are seen in the bilateral sphenoid sinuses. The mastoid air cells and middle ear cavities are clear. NOSE: There is no nasal bone fracture.The patient is intubated; fluid within the nasopharynx likely relates to intubation. ORBITS: The orbits, including the laminae papyracea, are intact. The globes are intact with non-displaced lenses and no intraocular hematoma. There is no preseptal soft tissue edema. There is no retrobulbar hematoma or fat stranding. IMPRESSION: 1. No acute fracture. Small right frontal scalp hematoma not fully imaged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with L chest tube // F/U Chest tube insertion F/U Chest tube insertion IMPRESSION: In comparison with the study of ___, there is little change in the appearance of the minimally displaced fracture of the sixth rib on the left. Chest tube is in place and there is no evidence of pneumothorax. Additional fractures were better seen on the outside CT examinations. There are are continued low lung volumes with opacification at the left base that could reflect areas of atelectasis or superimposed pneumonia. Monitoring and support devices are unchanged. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman s/p MVC, new onset seizures // new seizures with prior negative head CT TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CTA head and neck obtained earlier today. FINDINGS: Susceptibility artifact related to skin staples along the vertex of the scalp (09:24), limits evaluation of the vertex. Within these confines: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. A single tiny non-specific FLAIR signal hyperintensity is noted in the right frontal white matter, which may represent sequela of prior infection or trauma. There is no associated gradient echo susceptibility to suggest diffuse axonal injury or hemorrhages. Air-fluid levels are noted in the sphenoid and bilateral maxillary sinuses, likely related to intubation. IMPRESSION: 1. No acute intracranial pathology. 2. Sphenoid and bilateral maxillary sinus air-fluid levels are likely due to intubation. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: ___ year old woman s/p MVC, with new onset seizures, concern for new acute hemorrhage, dissection. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 1,009.3 mGy-cm. 4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7 mGy-cm. 5) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 38.1 mGy (Head) DLP = 19.1 mGy-cm. 6) Spiral Acquisition 5.4 s, 42.1 cm; CTDIvol = 32.1 mGy (Head) DLP = 1,352.0 mGy-cm. Total DLP (Head) = 2,383 mGy-cm. COMPARISON: CT head ___ at 17:37. Also CT facial bones, CT cervical spine and CT chest from ___ FINDINGS: CT HEAD WITHOUT CONTRAST: Streak artifact from EEG leads limits evaluation. There is no evidence of no evidence of acute hemorrhage, edema, mass effect, or loss of gray/white matter differentiation. Basal cisterns, cerebral sulci, and ventricles are normal in size. No interval change is seen compared to approximately 11 hr earlier. Skin staples are again seen at the vertex. No calvarial fracture is seen. Right frontal subgaleal hematoma has slightly decreased in size, but left parietal/occipital hypodense subgaleal fluid collection has increased. There is moderate mucosal thickening in the ethmoid air cells with opacification of the frontoethmoidal recesses. There is small amount of fluid, mild mucosal thickening, and small mucous retention cysts in bilateral maxillary sinuses. There is also fluid an mild mucosal thickening in the sphenoid sinuses with aerosolized secretions in the left sphenoid sinus. These findings may be secondary to endotracheal and orogastric intubation. Mastoid air cells are well aerated. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without evidence for dissection, flow-limiting stenosis, or aneurysm formation. The major dural venous sinuses are patent. CTA NECK: The aortic arch demonstrates a normal 3 vessel branching pattern. The carotid and vertebral arteries appear normal with no evidence of dissection or flow-limiting stenosis. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: The comminuted, displaced fracture of the right anterior first rib and is again seen. No other fractures are identified. There is no pneumothorax in the visualized upper lungs. There are partially visualized small bilateral pleural effusions with mild dependent atelectasis. The visualized portion of the thyroid gland is within normal limits. An endotracheal tube terminates at the level of the clavicles. An enteric tube is partially visualized. IMPRESSION: 1. Allowing for streak artifact from the EEG leads, the noncontrast head CT demonstrates no evidence for acute intracranial abnormalities. 2. Slightly decreased right frontal subgaleal hematoma. Slightly increased left parietal/occipital hypodense subgaleal fluid collection. No evidence for a calvarial fracture. 3. Normal CTA of the head and neck without evidence for dissection or stenosis. 4. Comminuted fracture of the right anterior first rib is again demonstrated. Small bilateral pleural effusions with adjacent atelectasis are again partially visualized. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: ___ year old woman intubated in TICU // ? change in pulmonary status TECHNIQUE: Portable chest COMPARISON: Portable chest radiograph dated ___ FINDINGS: In comparison with chest radiograph obtained 1 day prior, there are increased, left greater than right basilar opacities, likely atelectasis. The lungs are otherwise clear without focal consolidation. Pleural effusions small, if any. A left-sided chest tube is unchanged in position with a side-port very near to the intercostal plane. No pneumothorax. An ET tube terminates 4.5 cm above the carina. The side port of an NG tube terminates in the mid stomach. IMPRESSION: Increased bibasilar atelectasis, less likely developing pneumonia. The side port of the left chest tube very near to the intercostal plane. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 11:42 AM, approximately 30 minutes after discovery of the findings. Radiology Report EXAMINATION: PELVIS (AP ONLY) INDICATION: ___ year old woman s/p multi trauma with right acetabular fracture // portable OK. TECHNIQUE: Portable supine view of the pelvis. COMPARISON: CT abdomen ___ FINDINGS: There is a minimally displaced predominately transverse fracture through the right acetabulum. This is better delineated on the prior CT but does not appear to have displaced significantly in the interval. No definite involvement of the superior inferior pubic rami is seen. There is a large displaced fragments laterally. Degenerative changes noted at symphysis pubis. Minimal irregularity at the bilateral sacroiliac joints may reflect sacroiliitis, but correlation with the patient's Clinical history is recommended. A sclerotic focus in the left inferior pubic ramus is nonspecific in appearance but likely represents a bone island. IMPRESSION: No appreciable interval displacement of the known right acetabular fracture. Findings suggestive of sacroiliitis, correlation with the patient's clinical history recommended. Radiology Report EXAMINATION: DX HAND AND WRIST INDICATION: ___ year old woman with fracture s/p reduction // ? improved alignment TECHNIQUE: Three views left wrist, three views left hand COMPARISON: Left wrist and forearm radiographs ___ FINDINGS: Fine bony detail is obscured by the overlying back slab. There is a transverse fractures through the distal radius with mild radial displacement and no significant angulation. No intra-articular extension seen. No additional fractures are seen. No destructive lytic or sclerotic bone lesions. IMPRESSION: Minimally displaced fracture through the distal radius. Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST T___ MR SPINE INDICATION: ___ year old woman with decreased RLE movement // ? spinal cord abnormality ? spinal cord abnormality TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. COMPARISON: No prior imaging of the spine is available for comparison. FINDINGS: Alignment is normal. Vertebral body heights are maintained. The conus terminates at the L1 level. No intrinsic cord signal abnormality is detected. There is no evidence of infection or neoplasm. A T2 hyperintense perineural cyst is noted in the left T10-11 neural foramen (02:15, 6:2). No significant spinal canal or neural foraminal narrowing is noted from T11-12 through L2-3. At L1-2, there is a Schmorl node, with inferior endplate irregularity of the L1 level (04:11), ___ chronic. There is a L1 vertebral body hemangioma. At L3-4, there is a diffuse disc bulge, with a small superimposed extrusion inferiorly, which mildly narrows the spinal canal, as well as causes bilateral mild neural foraminal narrowing. At L4-5, there is disc height loss and diffuse disc bulge, with superimposed central shallow protrusion with tiny annular fissure. There is mild spinal canal narrowing and crowding of the subarticular zones, with mild bilateral neural foraminal narrowing. At L5-S1, there is no significant neural foraminal or spinal canal narrowing. IMPRESSION: 1. No evidence of fracture or intrinsic spinal cord signal abnormality. 2. Multilevel degenerative changes, with disc bulges at L3-4 and L4-5 causing mild spinal canal and bilateral neural foraminal narrowing, as described above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p MVC with elevated temps/rigors eval for source // eval for PNA eval for PNA COMPARISON: ___ IMPRESSION: ET tube tip is 6 cm above the carinal. NG tube tip is in the stomach. Left chest tube is in place. Right basal consolidations are new and are concerning for interval progression of pneumonia or aspiration. RECOMMENDATION(S): Followup of right basal consolidations which are concerning for aspiration or developing infectious process. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: ___ year old woman with s/p MVC with chest tube clog, increased O2 requirement // eval for interval change TECHNIQUE: Portable chest COMPARISON: Portable chest radiograph dated ___ FINDINGS: In comparison to chest radiograph obtained 1 day prior, there appears to be a left basilar pneumothorax, either enlarged or not appreciated on prior studies due to patient positioning. The side-port of the left-sided chest tube projects over the right lateral ribs and is not likely in the pleural space. Additionally, there are increased right perihilar and retrocardiac consolidations concerning for infectious processes. An ETT tip is 3 cm above the carina. An enteric tube side port projects over the proximal stomach. IMPRESSION: New left basilar pneumothorax. Chest tube side port projecting over the lateral chest wall, position likely inadequate. Increased right perihilar and retrocardiac consolidations concerning for pneumonia. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 1:17 ___, approximately 160 minutes after discovery of the findings - initially paged resident approximately 15 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p MVC, now w/pneumothorax, ETT // lines/tubes lines/tubes COMPARISON: ___ IMPRESSION: ET tube tip is 4 cm above the carinal. NG tube tip is in the stomach. Heart size and mediastinum are stable. Bibasal consolidations appear to be unchanged involving the vast majority of the mid lung and lower lobes. The findings might representing combination of pulmonary edema and widespread infectious process, especially giving the lack of the findings back on the CT from ___ does pulmonary hemorrhage or lung contusion are not there reliably etiology. No definitive pneumothorax is seen. Small amount of bilateral pleural effusion cannot be excluded. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ y.o. F s/p unrestrained head-on MVC, now w/ left PTX + rib fx, right acetabular fx, R 1st rib frx, with episodes concerning for seizure activity with negative EEG // ?interval change s/p CT removal ?interval change s/p CT removal IMPRESSION: As compared to ___, the left chest tube was removed. Better visualized than on the previous image is a slightly displaced left rib fracture. No pneumonia, mild pulmonary edema. Borderline size of the cardiac silhouette. Moderate retrocardiac atelectasis. No pneumothorax is identified. Radiology Report EXAMINATION: PELVIS (AP, INLET AND OUTLET) IN O.R. INDICATION: RT ACETABULAR FX.ORIF TECHNIQUE: Screening provided in the operating room without a radiologist present. COMPARISON: ___. FINDINGS: Total fluoroscopy time was 2.9 seconds. Images demonstrate fixation of right acetabular fracture with plates and screws. For details of the procedure, please consult the procedure report IMPRESSION: Screening for procedure guidance. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with s/p MVC // serial CXR IMPRESSION: As compared to previous radiograph of 1 day earlier, a bilateral and asymmetrically distributed pattern of pulmonary edema has shifted in distribution and overall slightly worsened in severity. No other relevant changes. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with desatting s/p OR // ? acute cardiopulm process ? acute cardiopulm process COMPARISON: Prior chest radiographs ___ through ___ at 05:15. IMPRESSION: Severe pulmonary edema has improved slightly on the right common not on the left. Heart remains moderately enlarged and mediastinal veins are engorged. Left pleural effusion is not large, right pleural effusion small if any. ET tube an transesophageal drainage tube are in standard placements. Gender: F Race: UNKNOWN Arrive by AMBULANCE Chief complaint: MVC Diagnosed with Disp fx of posterior wall of right acetabulum, init, Laceration w/o foreign body of oth part of head, init encntr, Driver injured in collision w unsp mv in traf, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Ms. ___, You presented to ___ on ___ after suffering a motor vehicle collision. You were found to have a rib fracture, left lung puncture, a right hip fracture and a left radius fracture. You were admitted to the Trauma/Acute Care Surgery team for further medical treatment. On admission, you were noted to have seizure activity and Neurology was consulted. You were started on Keppra and it is recommended you continue to take this medication for at least the next 6 (six) months. Please do NOT drive for six months. You have a follow-up appointment scheduled with the outpatient Neurology clinic. You were evaluated by the Orthopaedics and Plastics teams. On ___, you were taken to the Operating Room and underwent surgery for your right hip fracture. On ___, you had surgery to repair your left radius fracture. You tolerated these procedures well. You have worked with Physical and Occupational Therapy who recommend your discharge to rehab. You are tolerating a regular diet and your pain is controlled. You are now medically cleared to be discharged to rehab to continue your recovery. Please note the following discharge instructions: * Your injury caused a left rib fracture which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). 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: M Service: MEDICINE Allergies: Ampicillin Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of CAD with 3v CABG (___), HFpEF (TTE ___- LVEF of 50%, with grade 1 diastolic dysfunction, HTN, HLD, colon cancer, s/p resection, asthma/COPD (obstructive dz dx on last admission ___, arthritis, and GERD, who was referred to ___ ___ by his nursing home for evaluation of shortness of breath. The patient is ___ and is alert and oriented to his name only in the ___. He is unable to provide any meaningful history, stating "bien" when asked in ___ if he has any symptoms. He is denying shortness of breath or any pain at this time. He was put on a nonrebreather by EMS for appearing dyspneic, unknown sat at that time, at the time of my encounter he is on room air. Of note, patient was just discharged on ___ following an admission for HFpEF exacerbation and obstructive lung disease exacerbation. He was started on furosemide 40mg daily, Fluticasone-Salmeterol BID, and duonebs prn, which were continued for discharge. In the ___, initial vital signs were: 97.4, 81, 134/84, 24, 99% Nasal Cannula - Exam notable for: Expiratory wheezes on exam - Labs were notable for Cr 1.9, K 4.3 - CXR showed somewhat low lung volumes. Mild vascular congestion. No pneumonia or pneumothorax. - Patient was given: ___ 03:30 IH Albuterol 0.083% Neb Soln 1 NEB ___ 03:30 IH Ipratropium Bromide Neb 1 NEB ___ 09:20 PO Azithromycin 500 mg ___ 09:20 IH Albuterol 0.083% Neb Soln 1 Neb ___ 09:20 IH Ipratropium Bromide Neb 1 Neb ___ 09:20 PO PredniSONE 60 mg ___ 09:20 PO/NG amLODIPine 2.5 mg ___ 09:20 PO/NG Aspirin 81 mg ___ 09:20 PO/NG Losartan Potassium 100 mg ___ 09:20 PO Metoprolol Succinate XL 50 mg ___ 09:20 PO Omeprazole 20 mg - Vitals on transfer: 97.7, 85, 172/82, 20, 97% RA Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -Coronary artery disease: CABG in ___. Had 4 vessel disease (LIMA to LAD, SVG to PDA, SVG to Y graft to om-ramus). -Chronic back pain -Insomnia -ADHD -Anxiety disorder -Arthritis -Asthma -Dementia -Depression -GERD -Hypertension -Colon cancer status post partial resection -Polymyalgia rheumatica -Chronic kidney disease stage III: His creatinine level was 1.4 PCPs notes in ___. -Acute right-sided congestive heart failure: The patient was treated with triamterene/HCTZ however given his creatinine elevation his PCP wanted to change his diuretic to torsemide. The ejection fraction is unknown. -diverticulosis Social History: ___ Family History: the patient has significant family history of heart failure. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= Vitals- 98.2 179/91 80 18 92% RA Discharge weight on ___: 88.2kg Discharge weight on ___: 87.2 kg/192 lbs GEN: Alert, lying in bed watching tv, no acute distress HEENT: PERRLA. EOMI. Moist MM, oropharynx clear, anicteric sclerae, no conjunctival pallor. NECK: Supple without LAD. No JVD. PULM: full air entry bilaterally, diffuse wheezes throughout, no crackles. no rales. HEART: RRR (+)S1/S2, no MRG. midline scar noted from prior CABG. ABD: ABDOMEN: Soft, obese, non-tender. No rebound/guarding. NABS+. Scar from prior colon resection noted. EXTREM: Warm, well-perfused. No peripheral edema. NEURO: CN II-XII grossly intact. Sensation intact to light touch throughout. Strength ___ throughout. Gait deferred. MENTAL STATUS: A&Ox3 (knows full name, ___, ___, but not ___. Poor historian- feels that he was brought here b/c of pneumonia. During interview with phone interpreter, kept repeating questions that were asked of him back. DISCHARGE PHYSICAL EXAM: ======================== Vitals- 98.2 143/65 (143-179/65-91) 95 (80-95) 18 92-94% RA Discharge weight on ___: 87.2 kg/192 lbs Admission weight ___: 89.9kg GEN: Alert, lying in bed watching tv, no acute distress HEENT: PERRLA. EOMI. Moist MM, oropharynx clear, anicteric sclerae, no conjunctival pallor. NECK: Supple without LAD. No JVD. PULM: full air entry bilaterally, expiratory wheezes L>R, no crackles. no rales. HEART: RRR (+)S1/S2, no MRG. midline scar noted from prior CABG. ABD: ABDOMEN: Soft, obese, non-tender. No rebound/guarding. NABS+. Scar from prior colon resection noted. EXTREM: Warm, well-perfused. No peripheral edema. NEURO: CN II-XII grossly intact. Sensation intact to light touch throughout. Strength ___ throughout. Gait deferred. MENTAL STATUS: A&Ox3 (knows full name, ___, ___, but not ___. Poor historian- feels that he was brought here b/c of pneumonia. During interview with phone interpreter, kept repeating questions that were asked of him back. Pertinent Results: ADMISSION LABS: =============== ___ 01:40AM BLOOD Neuts-67.5 Lymphs-18.4* Monos-8.6 Eos-3.5 Baso-0.3 Im ___ AbsNeut-5.89 AbsLymp-1.61 AbsMono-0.75 AbsEos-0.31 AbsBaso-0.03 ___ 01:40AM BLOOD WBC-8.7 RBC-3.51* Hgb-11.0* Hct-32.2* MCV-92 MCH-31.3 MCHC-34.2 RDW-13.8 RDWSD-45.9 Plt ___ ___ 01:40AM BLOOD Plt ___ ___ 01:40AM BLOOD Glucose-145* UreaN-35* Creat-1.9* Na-137 K-5.6* Cl-101 HCO3-22 AnGap-20 ___ 01:40AM BLOOD proBNP-503 ___ 01:40AM BLOOD cTropnT-0.01 ___ 01:40AM BLOOD Calcium-8.8 Mg-1.8 ___ 02:02AM BLOOD Lactate-1.8 K-4.3 MICROBIOLOGY: ============= ___ BLOOD CULTURE: PENDING IMAGING: ======== CXR (___): FINDINGS: Lung volumes are somewhat low. The cardiac silhouette is stable from the recent prior chest radiograph. Sternotomy wires are intact. The aorta is tortuous and calcified as before. There is mild pulmonary vascular engorgement. No pleural effusion is identified. No focal consolidation or pneumothorax is seen. IMPRESSION: Somewhat low lung volumes. Mild vascular congestion. No pneumonia or pneumothorax. DISCHARGE AND PERTINENT LABS: ============================ ___ 06:05AM BLOOD Calcium-9.0 Phos-4.1 ___ 06:05AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:05AM BLOOD Glucose-116* UreaN-34* Creat-1.5* Na-142 K-3.6 Cl-101 HCO3-22 AnGap-23* ___ 06:05AM BLOOD ___ PTT-26.9 ___ ___ 06:05AM BLOOD Plt ___ ___ 06:05AM BLOOD WBC-13.4*# RBC-3.59* Hgb-11.2* Hct-32.7* MCV-91 MCH-31.2 MCHC-34.3 RDW-13.6 RDWSD-44.3 Plt ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Metoprolol Succinate XL 75 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. amLODIPine 2.5 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. Furosemide 40 mg PO DAILY 10. alfuzosin 10 mg oral DAILY 11. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1 INH IH twice a day Disp #*1 Disk Refills:*0 3. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 capsule IH daily Disp #*30 Capsule Refills:*0 4. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 5. alfuzosin 10 mg oral DAILY 6. amLODIPine 2.5 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Furosemide 40 mg PO DAILY 10. Losartan Potassium 100 mg PO DAILY 11. Metoprolol Succinate XL 75 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Asthma COPD exacerbation Heart failure with preserved ejection fraction Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with dyspnea, hypoxia// Eval for acute process, attn. to CHF TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiographs from ___ through ___ FINDINGS: Lung volumes are somewhat low. The cardiac silhouette is stable from the recent prior chest radiograph. Sternotomy wires are intact. The aorta is tortuous and calcified as before. There is mild pulmonary vascular engorgement. No pleural effusion is identified. No focal consolidation or pneumothorax is seen. IMPRESSION: Somewhat low lung volumes. Mild vascular congestion. No pneumonia or pneumothorax. Gender: M Race: HISPANIC/LATINO - COLUMBIAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Other forms of dyspnea, Hypoxemia temperature: 97.4 heartrate: 81.0 resprate: 24.0 o2sat: 99.0 sbp: 134.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you! Why you were admitted: -you had worsening shortness of breath and an exacerbation of your chronic lung disease What we did for you: -We changed some of your medications to better treat your lung disease. Your next steps: - Please complete your course of azithromycin antibiotics. It is scheduled to end on ___. - Please take all of your medications as prescribed. - Please attend your scheduled follow-up appointments - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you the best! Your ___ Medicine Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reglan / Methotrexate / Dronabinol / chlorhexidine / vancomycin / levofloxacin / Betadine / Feraheme Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: Removal of ___ catheter with replacement by silicone catheter under general anesthesia (___). Replacement of J tube with GJ tube (___). Removal of left catheter and insertion of new tunneled catheter on the right (___) Replacement of GJ tube with J tube (___) History of Present Illness: Ms. ___ is a ___ year old woman with a history of left Hickman for home TPN, eosinophilic gastrointestinal disease, gastroperesis, and postural orthostatic tachycardic syndrome who presents with a 7 day history of headache and malaise and a one day history of fevers to Tmax 101. The patient has a ___ line and is on 12 hour home TPN at baseline. She has not had any significant PO intake since ___, and has failed multiple feeding trials over the last ___ years. She suffers from frequent bacteremia, reportedly every ___ months in the past ___ years, requiring frequent changes of her central access and courses of IV antibiotics. She has also had ___ fungemia in the past. She was bacteremic with a reported pseudomonas infection earlier this year, and had her central line replaced in ___ by ___ at ___. Over the last week the patient has felt increasingly fatigued, with a headache, nausea, and abdominal pain above her baseline. She monitored her temperature frequently, and was not febrile until today, with a fever of 101. Last night she awoke with chills, and her headache was worse this morning. She presented to the ___ ED. In the ED, initial vitals were: T 98.3, HR 145, BP 125/78, RR 18, O2 100%RA. Spiked fever to 102.6 in the ED. Labs notable for WBC 9.6, 93.3% SNs, lactate 2.4. Blood cultures x3 were drawn. Imaging notable for chest-xray without infiltrate. Patient was given 3L NS, zosyn and clindamycin, Tylenol 1g, and promethazine. Decision was made to admit for possible systemic infection. On the floor, she complains of mild abdominal pain, nausea, and headache. Past Medical History: --Eosinophilic gastrointestinal disease - with involvement of esophagus, stomach and small intestine --Has ___ cath for TPN, G-J tube --Peptic ulcer disease --Postural orthostatic tachycardia syndrome --Iron deficiency anemia Social History: ___ Family History: --No known FHx of GI malignancy or autoimmune processes. Has an identical twin sister who is healthy. Physical Exam: ADMISSION PHYSICAL EXAM VS: T: 98.3 BP: 143/93 P: 93 RR: 18 SPO2: 98 RA Gen: awake, alert, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no meningeal signs Neck: supple, JVP not elevated Chest: Hickman catheter in left chest, with no redness or pus around the insertion site. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, with mild epigastric tenderness. Bowel sounds present, no rebound tenderness or guarding. G and J tubes present, fentanyl patch in the LLQ. No erythema surrounding ports. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes noted. DISCHARGE PHYSICAL EXAM VS: P: 98.3 BP: 104/60 P: 94 RR: 20 SPO2: 99%RA GENERAL: alert, interactive, no acute distress HEENT: sclerae anicteric, MMM. Neck supple CHEST: tunneled line on right upper chest. No erythema or pus surrounding insertion site. Bandage on left upper chest covering site of previous tunneled line, without erythema or pus. LUNGS: Clear to auscultation bilaterally HEART: Normal S1, S2 no murmurs/rubs/gallops Abdomen: soft, non-distended, mild epigastric tenderness. Bowel sounds present, no epigastric rebound tenderness no guarding. G and J tubes present without surrounding erythema. J tube surrounded by a bandage. Fentanyl patch in the RUQ. Ext: Warm, well perfused, no clubbing, cyanosis or edema Pertinent Results: LABORATORY STUDIES ON ADMISSION ============================================== ___ 03:38PM BLOOD WBC-9.6 RBC-4.82 Hgb-14.0 Hct-39.1 MCV-81* MCH-29.0 MCHC-35.8 RDW-13.6 RDWSD-39.6 Plt ___ ___ 03:38PM BLOOD Neuts-93.3* Lymphs-2.4* Monos-3.1* Eos-0.3* Baso-0.5 Im ___ AbsNeut-8.92*# AbsLymp-0.23* AbsMono-0.30 AbsEos-0.03* AbsBaso-0.05 ___ 03:38PM BLOOD Glucose-117* UreaN-12 Creat-0.8 Na-138 K-4.3 Cl-104 HCO3-19* AnGap-19 ___ 03:38PM BLOOD ALT-19 AST-35 AlkPhos-78 TotBili-0.5 ___ 03:38PM BLOOD Lipase-24 ___ 03:38PM BLOOD Albumin-4.3 Calcium-9.4 Phos-2.8 Mg-1.6 ___ 05:50AM BLOOD 25VitD-21* ___ 03:54PM BLOOD Lactate-2.4* ___ 10:32AM URINE Color-Straw Appear-Clear Sp ___ ___ 10:32AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 10:32AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-3 IMAGING ================================================ CXR (___): No evidence pneumonia. Abdominal X-Ray (___): The tip of the JG tube terminates in the jejunum. MICROBIOLOGY ================================================ ENTEROBACTER ASBURIAE. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections,repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER ASBURIAE | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S LABORATORY STUDIES ON DISCHARGE ================================================ ___ 05:40AM BLOOD WBC-5.0 RBC-3.61* Hgb-10.3* Hct-30.8* MCV-85 MCH-28.5 MCHC-33.4 RDW-14.4 RDWSD-43.2 Plt ___ ___ 05:40AM BLOOD Glucose-140* UreaN-17 Creat-0.4 Na-135 K-3.9 Cl-103 HCO3-26 AnGap-10 ___ 04:57AM BLOOD Triglyc-250* Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fentanyl Patch 25 mcg/h TD Q72H 2. Lidocaine 5% Patch 2 PTCH TD QAM 3. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 4. mucositis & stomatitis combo 1 10 ml oral QID:PRN mucosities 5. vedolizumab 300 mg injection EVERY 2 WEEKS 6. Methylnaltrexone 12 mg SUBCUT EVERY OTHER DAY 7. BusPIRone 15 mg PO BID 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Memantine 10 mg PO BID 10. Pantoprazole 40 mg PO Q12H 11. Vivonex RTF (nut.tx.impaired digest fxn,soy) ___ gram-kcal/mL oral OTHER 12. Pyridostigmine Bromide Syrup 30 mg PO TID Discharge Medications: 1. Ertapenem Sodium 1 g IV DAILY Duration: 8 Days RX *ertapenem [Invanz] 1 gram 1 g IV daily Disp #*8 Vial Refills:*0 2. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL DAILY 3. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL DAILY Not for IV use. To be instilled into central catheter port for local dwell 4. Ethanol Lock Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL DAILY for 2 hours max per line 5. Ethanol Lock Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL DAILY for 2 hours max per line 6. Fluconazole 400 mg IV Q24H RX *fluconazole in NaCl (iso-osm) 400 mg/200 mL 400 mg IV once a day Disp #*8 Intravenous Bag Refills:*0 7. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush RX *sodium chloride 0.9 % 0.9 % 10 mL IV Daily Disp #*30 Syringe Refills:*0 8. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL 2 mL IV Daily Disp #*30 Syringe Refills:*0 9. BusPIRone 15 mg PO BID 10. Fentanyl Patch 25 mcg/h TD Q72H RX *fentanyl 25 mcg/hour apply to skin one patch for 72 hours Q72H Disp #*10 Patch Refills:*0 11. Lidocaine 5% Patch 2 PTCH TD QAM 12. Memantine 10 mg PO BID 13. Methylnaltrexone 12 mg SUBCUT EVERY OTHER DAY 14. Pyridostigmine Bromide Syrup 30 mg PO TID 15. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain RX *hydromorphone 2 mg 1 tablet(s) by mouth Q6H:PRN Disp #*80 Tablet Refills:*0 16. Metoprolol Succinate XL 100 mg PO DAILY 17. mucositis & stomatitis combo 1 10 ml oral QID:PRN mucosities 18. Pantoprazole 40 mg PO Q12H 19. vedolizumab 300 mg injection EVERY 2 WEEKS 20. Vivonex RTF (nut.tx.impaired digest fxn,soy) ___ gram-kcal/mL oral OTHER Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ================ Bacteremia Fungemia Secondary Diagnosis: ==================== Eosinophilic gastrointestinal disease Peptic ulcer disease Postural orthostatic tachycardia syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ with fever // PNA? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: The cardiomediastinal silhouette is within normal limits. A left central venous line terminates in the mid SVC. The lung fields are clear. The visualized upper abdomen appears within normal limits. There is no free air below the diaphragm. There is no pneumothorax or pleural effusion. IMPRESSION: No evidence of pneumonia. Radiology Report INDICATION: Please place silicone double lumen non-power tunneled line. Do not exchange over wire. Discussed with ___. Pt has CHG and betadine allergy. Please coordinate to have J-tube done at the same time. Will need general anesthesia due to poor reaction to moderate sedation in the past. // CVL replacement COMPARISON: Chest radiograph ___. 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: General anesthesia was administered by the anesthesiology department. Please refer to anesthesiology notes for details. MEDICATIONS: 1% lidocaine CONTRAST: 20 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 3 min 20 seconds, 9 mGy PROCEDURE: 1. Placement of a left internal jugular tunneled catheter, ___ ___ dual lumen. 2. Removal of the existing left internal jugular tunneled line. 3. Exchange of jejunal tube. PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The left chest and left abdomen were prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 54 cm tip-to-cuff length ___ dual lumen catheter was selected and trimmed to the appropriate length. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures and a Stay Fix device. Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The existing tunneled left IJ central catheter was removed. The existing jejunostomy tube (the tube that is inferior to the gastric tube), was injected with contrast to confirm intraluminal position. A stiff Glidewire was then advanced through the tube. The tube was removed over the stiff Glidewire. A new 18 ___ MIC tube was then advanced over the stiff glide wire. The wire was removed. The tube was injected with contrast to confirm appropriate positioning. The tube was then flushed and the balloon was inflated. The patient tolerated the procedure well. FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing ___ dual lumen ___ catheter with tip terminating in the right atrium. Intraluminal position of the existing J-tube. Successful exchange for a new 18 ___ MIC J-tube. IMPRESSION: Successful placement of a tunneled dual lumen ___ line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Successful removal of the existing left IJ tunneled catheter. Successful exchange for a new 18 ___ MIC J-tube. Radiology Report INDICATION: ___ year old woman with GJ tube acting as J tube only // eval for tube position TECHNIQUE: Supine portable radiograph of the abdomen. COMPARISON: ___ FINDINGS: The balloon portion of the GJ tube projects over the expected location of the stomach. There is a tube coiled over the left lower quadrant. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: GJ tube projects over expected area, however, if exact tube location needs to be identified, repeat imaging with a small amount of enteric contrast administered through the GJ tube is recommended. Radiology Report EXAMINATION: J tube check INDICATION: ___ year old woman with eosinophilic GI disease and recent placement of GJ tube by ___ now reporting abdominal burning and discomfort. // ?J tube positioning. Per ___ fellow recs, need to inject 10cc of contrast into the J tube port of the patient's GJ tube (the inferior tube in her abdomen) then obtain KUB to confirm appropriate placement in the bowel. TECHNIQUE: Single contrast upper GI. COMPARISON: None FINDINGS: Water-soluble contrast (Optiray) was administered through the J tube, opacifying loops of jejunum, confirming appropriate positioning. There is no leak or obstruction. IMPRESSION: The tip of the JG tube terminates in the jejunum. Radiology Report INDICATION: ___ year old woman with GJ tube, now with worsening distention and abdominal pain, evaluate for interval change. TECHNIQUE: Supine view of the abdomen. COMPARISON: Same-day G/J tube check. FINDINGS: A gastrojejunostomy tube projects over the left upper quadrant, unchanged in position from prior. Bowel gas pattern is nonobstructive with residual contrast seen primarily in the colon. There are no large pockets of free air on this supine only radiograph. There is no pneumatosis. Views of the osseous structures are unremarkable. IMPRESSION: No significant interval change. Nonobstructive bowel gas pattern. Radiology Report INDICATION: ___ year old woman with eosinophilic gastroenteritis and gastroparesis and multiple line infections. // please replace double lumen non-power tunneled access line. Cuff exposed on recently placed line. ? replace on right with long tunnel. Patient requires general anesthesia and is also planned for replacement of J tube under anesthesia. ___ aware. Call with questions. COMPARISON: ___. TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow 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: General anesthesia. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. FLUOROSCOPY TIME AND DOSE: 1.9 min, 3 mGy PROCEDURE: 1. Tunneled non-dialysis line placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The access site was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 10 ___ ___ double lumen catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and each lumen was capped. The catheter was sutured in place with 0 silk sutures. ___ subcuticular Vicryl sutures and Steri-strips were used to close the venotomy incision site. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing right IJ approach 10 ___ ___ double lumen catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 10 ___ ___ double lumen tunneled line via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology Report INDICATION: ___ year old woman with gastroparesis and long term G and J tubes. // please replace J tube with a NEW single lumen J tube, low profile COMPARISON: ___. TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: General anesthesia. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. CONTRAST: 20 ml of Optiray FLUOROSCOPY TIME AND DOSE: 3.3 min, 10 mGy PROCEDURE: Jejunostomy tube exchange. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. The existing tube was injected with contrast and showed opacification of small bowel. The stay sutures were cut and ___ wire was introduced into the stomach. The existing feeding tube was then removed. A MIC-KEY ___ Fr 2.5 cm stoma jejunostomy catheter was advanced over the wire into position. The sheath was then peeled away. The catheters balloon was inflated with 5 ml of contrast contrast diluted in sterile waterand locked in the small bowel after confirming the position of the catheter with a contrast injection. The catheter was then flushed and capped. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Appropriately positioned new MIC-KEY ___ Fr 2.5 cm stoma jejunostomy tube. IMPRESSION: Successful exchange of a junostomy tube for a new MIC-KEY ___ Fr 2.5 cm stoma jejunostomy tube. The tube is ready to use. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with Fever, unspecified temperature: 98.3 heartrate: 145.0 resprate: 18.0 o2sat: 100.0 sbp: 125.0 dbp: 78.0 level of pain: 5 level of acuity: 1.0

Dear Ms. ___, It was a pleasure treating you. You were admitted for a fever and chills, and were found to have bacteria and fungus in your blood stream. You were treated with antibiotics and antifungal medications and your condition improved. Additionally, we removed your Hickman line and replaced it with a new silicone catheter on the right. We have also replaced your J tube. You have been discharged with continued IV antibiotics, which you must take until ___. It is imperative that you continue to take these antibiotics, and that you followup with your GI team and you PCP. Thank you for allowing us to participate in your care. 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: dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterizaion ___ - No stents placed History of Present Illness: In the ED, initial vitals were: 97 ___ 34 96% NEB FSBG 122 ___ yo female with pmhx of COPD who presents with nausea and chest pain. Pt presented on RA and in extremis. Pt put on non-rebreather and given duonebs then transitioned to bipap. She appeared clinically overloaded with elevated JVP. EKG looks like rate related changes in lateral leads. Bedside echo with lateral wall motion abnormalities although also noted on TTE in past. D-dimer elevated but given CXR with volume overloaded, felt PE less likely. Didn't tolerate going off bipap for CTA. Gave 10 IV Lasix with 400 cc output. Improving with diuresis but still in respiratory distress, variable NC. On heparin gtt for NSTEMI. Covered empirically for pna. Peripherals for access. Labs: VBG pH 7.27 pCO2 53 HCO3 25 DDimer 1791 Trop 0.77 --6 hrs later -> 0.51 Na 141 K 4.7 Cl 105 Bicarb 23 BUN 27 Cr 1.3 Ca 9.5 Mg 2.3 P4.0 WBC 13.3 Hgb 10.6 Hct 34.9 Plt 338 81%N BNP 2881 PTT 25.7 INR 1.0 Imaging: CXR portable AP ___ Central pulmonary vascular engorgement and mild cardiomegaly. Increased opacity projecting over the right mid to lower lung is concerning for pneumonia and/or aspiration. Consults: Cardiology Patient was given: 125mg methylprednisolone, duoneb x3, heparin bolus and drip, ceftriaxone 1g @1836, azithromycin 500mg, aspirin 324mg, furosemide 10mg IV, acetaminophen 650mg PO Decision was made to admit to CCU for respiratory distress, variable need for BIPAP. Vitals on transfer were: 98.0 119/71 116 20 100%NC On the floor, patient reports months of progress dyspnea on exertion in addition to 3-pillow orthopnea and PND. She reports consistently worsening DOE, now out of breath when walking up 1 flight of stairs or 10 feet (bedroom to bathroom). Endorses 3 days of nausea and 1 episode of post-prandial emesis of food. No headache, cough, sputum changes, chest pain, jaw discomfort, numbness/tingling, abd pain, dysuria, frequency, or sick contacts. She reports severe dyspnea both at rest and exertion prior to presentation. She reports much relief after initial treatment in the ED and now feels ___aughter endorses patient's symptoms of worsening dyspnea over the past several weeks/months and has noticed her struggling with stairs. Past Medical History: COPD asthma htn hld ___ rectosigmoid polypoid mass (invasive moderately differentiated adenocarcinoma) s/p resection no residual carcinoma. ___ LN positive. No chemotherapy. osteoarthritis Chronic lower back pain Anxiety Depression Cataract Glaucoma GERD Venous stasis PSH: Bowel resection ___ Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================ VS: 98.2 109/63 109 25 100%3LNC GEN: Pleasant, calm, no acute distress HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Poor dentition. NECK: Supple, No LAD. JVP to ear. Normal carotid upstroke without bruits. No thyromegaly. CV: PMI in ___ intercostal space, mid clavicular line. RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops LUNGS: Tight diminished breath sounds throughout worse at bases ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by palpation. No abdominal bruits. EXT: WWP, NO CCE. Dopplerable pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. Normal coordination. Gait assessment deferred DISCHARGE PHYSICAL EXAMINATION: ================================ Vitals: 98.6 114/65-122/76 ___ 99% GEN: Pleasant, calm, no acute distress HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Poor dentition. NECK: Supple, No LAD. JVP to ear. Normal carotid upstroke without bruits. No thyromegaly. CV: PMI in ___ intercostal space, mid clavicular line. RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops LUNGS: mild end expiratory wheezing, diffuse ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by palpation. No abdominal bruits. EXT: WWP, NO CCE. Dopplerable pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. Normal coordination. Gait assessment deferred Pertinent Results: ADMISSION LABS: ============== ___ 04:10PM BLOOD WBC-13.3*# RBC-3.74* Hgb-10.6* Hct-34.9 MCV-93 MCH-28.3 MCHC-30.4* RDW-15.8* RDWSD-53.3* Plt ___ ___ 04:10PM BLOOD Neuts-81.3* Lymphs-12.2* Monos-5.6 Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.82*# AbsLymp-1.62 AbsMono-0.75 AbsEos-0.00* AbsBaso-0.01 ___ 04:10PM BLOOD ___ PTT-25.7 ___ ___ 04:10PM BLOOD Glucose-129* UreaN-27* Creat-1.3* Na-141 K-4.7 Cl-105 HCO3-23 AnGap-18 ___ 04:10PM BLOOD cTropnT-0.77* proBNP-2881* ___ 10:28PM BLOOD cTropnT-0.51* ___ 04:10PM BLOOD Calcium-9.5 Phos-4.0 Mg-2.3 ___ 04:10PM BLOOD D-Dimer-1791* ___ 04:16PM BLOOD %HbA1c-5.4 eAG-108 ___ 04:15PM BLOOD ___ pO2-33* pCO2-53* pH-7.27* calTCO2-25 Base XS--3 Intubat-NOT INTUBA ___ 01:15AM BLOOD Lactate-2.3* ___ 05:58AM BLOOD Lactate-1.6 DISCHARGE LABS: ================= ___ 08:05AM BLOOD WBC-7.9 RBC-4.06 Hgb-11.5 Hct-36.3 MCV-89 MCH-28.3 MCHC-31.7* RDW-15.2 RDWSD-49.8* Plt ___ ___ 08:05AM BLOOD ___ PTT-27.3 ___ ___ 08:05AM BLOOD Glucose-89 UreaN-22* Creat-1.4* Na-137 K-4.1 Cl-100 HCO3-25 AnGap-16 ___ 08:05AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 OTHER PERTINENT FINDINGS: ========================== Labs: ----- ___ 04:10PM BLOOD cTropnT-0.77* proBNP-2881* ___ 10:28PM BLOOD cTropnT-0.51* ___ 07:45AM BLOOD CK-MB-17* MB Indx-1.9 cTropnT-0.19* ___ 07:45AM BLOOD CK(CPK)-884* ___ 04:10PM BLOOD D-Dimer-1791* ___ 01:15AM BLOOD Lactate-2.3* ___ 05:58AM BLOOD Lactate-1.6 IMAGING/STUDIES: =============== ___ CXR (AP Portable) Central pulmonary vascular engorgement and mild cardiomegaly. Increased opacity projecting over the right mid to lower lung is concerning for pneumonia and/or aspiration ___ TTE The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with near akinesis of the distal half of the ventricle with an apical aneursym. The remaining/basal segments contract normally. Quantitative (3D) LVEF = 30 %. Left vevntricular cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction and apical aneurysm most c/w Takotsubo cardiomyopathy, though cannot exclude a mid-LAD infarction. Mild mitral regurgitation. Moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, the findings are new and c/w Takotsubo or interim myocardial ischemia/infarction. The severity of tricuspid regurgitation and the estimated PA systolic pressure are also now greater. Left Heart Catheterization ___: Coronary Anatomy- Dominance: Right The ___ had not angiographically apparent CAD. The LAD had mild luminal irregularities. The OM had 50% mid vessel disease. The RCA was a large moderately calcified vessel with mild luminal irregularities. The origin PDA had 70% focal stenosis. Impressions: 1. Moderate branch vessel CAD. 2. Low filling pressures. Recommendations 1. Medical Management. Potential for MICROBIOLOGY: ============= ___ Blood cultures x2 - PENDING Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation inhalation BID 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 3. Mirtazapine 15 mg PO QHS 4. Qvar (beclomethasone dipropionate) 80 mcg/actuation inhalation DAILY 5. Atorvastatin 40 mg PO QPM 6. amLODIPine 5 mg PO DAILY 7. Tiotropium Bromide 1 CAP IH DAILY 8. Naproxen 500 mg PO Q12H:PRN pain 9. Loratadine 10 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Loratadine 10 mg PO DAILY 4. Mirtazapine 15 mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation inhalation BID 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 10. Qvar (beclomethasone dipropionate) 80 mcg/actuation inhalation DAILY 11. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 12. Enoxaparin Sodium 80 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneous daily Disp #*15 Syringe Refills:*0 13. Warfarin 5 mg PO DAILY16 RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. Furosemide 20 mg PO 3X/WEEK (___) RX *furosemide 20 mg 1 tablet(s) by mouth 3 times a week (___) Disp #*30 Tablet Refills:*0 15. Outpatient Physical Therapy Straight Cane Dx: Stress induced cardiomyopathy Prognosis: good Length of Need: 13 mo Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: ========== - Takotsubo (stress induced) cardiomyopathy - COPD SECONDARY: =========== - Coronary artery disease - hyperlipidemia - GERD 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 shortness of breath // ?pneumonia TECHNIQUE: AP upright portable view of the chest COMPARISON: ___ FINDINGS: The lungs remain hyperinflated. There is increased opacity projecting over the right mid to lower lung which may be due to infection or aspiration. Subtle lateral left base opacity may be due to atelectasis or additional site of infection. No large pleural effusion is seen. There is no pneumothorax. The cardiac silhouette is mildly enlarged. Mediastinal contours unremarkable. There is central pulmonary vascular engorgement. IMPRESSION: Central pulmonary vascular engorgement and mild cardiomegaly. Increased opacity projecting over the right mid to lower lung is concerning for pneumonia and/or aspiration Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation, Heart failure, unspecified, Shortness of breath temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: unable level of acuity: 1.0

Dear Ms. ___, You were admitted to ___ worsening shortness of breath. WHAT HAPPENED DURING YOUR HOSPITAL STAY? ========================================== - You were given medications to help you breath (nebulizers), antibiotics due to initial concern for infection, and diuretics to help you urinate. - You were placed on a mask to help you breath. Lab tests showed signs of heart dysfunction and an echo/ultrasound showed that your heart was not pumping well. You were observed in the cardiac intensive care unit overnight. - Once your breathing improved with nebulizers and diuretics, you were taken for a cardiac catheterization to evaluate the vessels of the heart. Ultimately, there was mild to moderate narrowing, but not enough to explain the changes. We believe you have "stress induced cardiomyopathy" which can be treated with medications. - You were started medications to help your heart as well as a blood thinner called Coumadin to help prevent strokes from this heart dysfunction in the future. - Once you were deemed stable on your new regimen you were discharged. WHAT SHOULD YOU DO FOLLOWING DISCHARGE? ========================================= - You should take all of your medications as prescribed. -- You should give yourself the Enoxaparin injections once a day, until you are told to stop (once Coumadin levels are appropriate). - You should get blood draws to confirm Coumadin levels are appropriate. These can be done at the ___ ___. Please get your blood drawn next on ___. - You should attend appointments with your PCP and cardiologist, scheduled below. It was a pleasure taking care of you during your hospital stay. If you have any questions about the care you received, please do not hesitate to ask. Sincerely, Your Inpatient ___ Cardiology 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: Bloody Stools Major Surgical or Invasive Procedure: Colonoscopy x 2 ___ and ___ History of Present Illness: Mr ___ is a ___ y/o M with PMH significant for GAVE syndrome (c/b chronic iron deficiency anemia), hx of aortic valve replacement (mech valve, on warfarin w/ goal INR 2.5), DM II, CAD, MGUS, who has had ongoing issues with chronic GI bleeding, and is s/p endoscopy/colonoscopy + polypectomy one week ago with GI here, who presents as a transfer from outside hospital for frequent dark stools for three days. Patient had a recent endoscopy/colonoscopy with polypectomy on ___, but was fine for a few days, but notes 3 days ago he started having frequent dark stools. He is feeling lightheaded and dizzy and generally weak. Presented to outside hospital, where he was noted to have a hemoglobin of 5.5. He received IV PPI and 1 unit PRBCs. He has had occasional soft BP's (as low as 70's systolic) which have quickly bounced back up. In the ED, patient received 2 u RBC and was hemodynamically stable. - Initial vitals were: 98.4 96 99/53 16 99% RA - Labs notable for: Hgb 5.3, WBC 17 - Imaging was notable for: None Past Medical History: - GAVE syndrome - Chronic iron deficiency anemia - Hydrocephalus (s/p VP shunt) - CAD - HTN - DM II - Hx of mechanical aortic valve replacement Social History: ___ Family History: Noncontributory to presenting complaint Physical Exam: ADMISSION EXAM: VITALS: Reviewed in MetaVision. GENERAL: Alert, NAD HEENT: PERRL, EOMI, MMM CARDIAC: RRR, nl s1/s2, ___ valve click PULMONARY: Decreased throughout ABDOMEN: NT/ND, normal bowel sounds, no hepatosplenomegaly EXTREMITIES: WWP, 2+ lower ext edema with chronic skin changes SKIN: No rashes NEURO: AOx3 (tough time with year), ___ strength throughout. Discharge Exam: Vitals: 98.0 BP:99/67 HR:79 P: 16 O2: 97 2L CONSTITUTIONAL: morbidly obese man in NAD, laying in bed, speaking in full sentences, although confused EYE: sclera anicteric, EOMI ENT: MMM, OP clear LYMPHATIC: No LAD CARDIAC: irregular, no M/R/G, mechanical S2 best heard at ___. Trace to +1 edema lower extremities. PULM: normal effort of breathing, LCAB GI: soft, NT, ND, NABS GU: no CVA tenderness. condom catheter in place with clear yellow urine. MSK: no visible joint effusions or acute deformities. DERM: no visible rash. No jaundice. Chronic skin changes, lower extremities. NEURO: AOx2-3 (often forgets dates) and fluently conversant. No facial droop, moving all extremities. PSYCH: Calm, answers appropriately, although occasionally confused Pertinent Results: ADMISSION LABS: ================ ___ 04:00PM BLOOD WBC-17.2* RBC-1.88* Hgb-5.3* Hct-17.8* MCV-95 MCH-28.2 MCHC-29.8* RDW-20.0* RDWSD-63.0* Plt ___ ___ 08:31PM BLOOD WBC-18.5* RBC-2.37* Hgb-6.9* Hct-21.9* MCV-92 MCH-29.1 MCHC-31.5* RDW-18.8* RDWSD-57.7* Plt ___ ___ 02:52AM BLOOD WBC-17.1* RBC-2.44* Hgb-7.0* Hct-22.6* MCV-93 MCH-28.7 MCHC-31.0* RDW-18.6* RDWSD-57.8* Plt ___ ___ 10:24AM BLOOD WBC-15.3* RBC-2.60* Hgb-7.5* Hct-24.3* MCV-94 MCH-28.8 MCHC-30.9* RDW-18.6* RDWSD-58.3* Plt ___ ___ 12:40PM BLOOD WBC-13.8* RBC-2.57* Hgb-7.5* Hct-24.1* MCV-94 MCH-29.2 MCHC-31.1* RDW-18.9* RDWSD-58.8* Plt ___ ___ 04:00PM BLOOD Neuts-76* Bands-1 Lymphs-16* Monos-5 Eos-0 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-13.24* AbsLymp-2.75 AbsMono-0.86* AbsEos-0.00* AbsBaso-0.00* ___ 08:31PM BLOOD Neuts-82* Bands-0 Lymphs-11* Monos-3* Eos-1 Baso-0 ___ Metas-3* Myelos-0 AbsNeut-15.17* AbsLymp-2.04 AbsMono-0.56 AbsEos-0.19 AbsBaso-0.00* ___ 04:00PM BLOOD Hypochr-2+* Anisocy-2+* Poiklo-NORMAL Macrocy-2+* Microcy-1+* Polychr-1+* ___ 08:31PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+* ___ 04:00PM BLOOD ___ PTT-40.6* ___ ___ 02:52AM BLOOD ___ PTT-33.1 ___ ___ 10:24AM BLOOD ___ ___ 04:00PM BLOOD Glucose-83 UreaN-34* Creat-1.1 Na-141 K-3.1* Cl-95* HCO3-32 AnGap-14 ___ 02:52AM BLOOD Glucose-135* UreaN-28* Creat-1.1 Na-142 K-3.4* Cl-98 HCO3-33* AnGap-11 ___ 04:00PM BLOOD ALT-11 AST-17 AlkPhos-72 TotBili-0.4 ___ 02:52AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8 ___ 04:00PM BLOOD Albumin-3.3* ___ 04:15PM BLOOD Lactate-1.7 MICRO: ___ 10:46 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Blood Culture: ___- NGTD, ___- NGTD Colonoscopy ___ Large mucosal defect with clots and granulation tissue and 2 endoclips was found in the ascending colon (Endo Clip, thermotherapy) Colonoscopy ___ Large amounts of blood clots were seen throughout the colon. In the ascending colon, at the area of the previous EMR site, previously placed clips and adherent clot was noted. There was oozing from the base of the site. Epinephrine was injected followed by ablation with bipolar probe. 7 clips were applied for hemostasis successfully. CXR: ___ IMPRESSION: Persistent elevation the right hemidiaphragm with overlying right basilar subsegmental atelectasis. Overall, no significant interval change. Ultrasound Upper Extremity: ___ IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. PICC in the left basilic vein. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Gabapentin 600 mg PO QHS 3. Metoprolol Succinate XL 50 mg PO BID 4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 5. Warfarin 7.5 mg PO DAILY16 6. Atorvastatin 40 mg PO QPM 7. Furosemide 80 mg PO QAM 8. Furosemide 40 mg PO QPM 9. Omeprazole 40 mg PO BID 10. Potassium Chloride 40 mEq PO TID 11. Aspirin 81 mg PO DAILY 12. Metolazone 2.5 mg PO DAILY 13. Glargine 55 Units Breakfast Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Fluticasone Propionate NASAL 2 SPRY NU BID 2. Glucagon 1 mg IM ONCE MR1 hypoglycemia protocol Duration: 1 Dose 3. Glucose Gel 15 g PO PRN hypoglycemia protocol 4. Ramelteon 8 mg PO QHS insomnia 5. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasaldryness 6. Glargine 25 Units Breakfast Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Warfarin 10 mg PO DAILY16 8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. Furosemide 80 mg PO QAM 12. Furosemide 40 mg PO QPM 13. Gabapentin 600 mg PO QHS 14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 15. Metoprolol Tartrate 50 mg PO BID 16. Omeprazole 40 mg PO BID 17. HELD- Metolazone 2.5 mg PO DAILY This medication was held. Do not restart Metolazone until discussing with your doctor 18. HELD- Potassium Chloride 40 mEq PO TID This medication was held. Do not restart Potassium Chloride until discussing with your doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Post- Polypectomy hemorrhage Anemia Delirium S/P mechanical valve on Warfarin Type 2 diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with persistent cough, prolonged hospitalization, s/p ERCP// interval change interval change IMPRESSION: Comparison to ___. Lung volumes are stable. Mild pulmonary edema persist. Moderate cardiomegaly is unchanged. No pleural effusions. No pneumothorax, stable mild retrocardiac atelectasis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: Mr ___ is a ___ y/o M with PMH of GAVE syndrome(c/b chronic iron deficiency anemia), aortic valvereplacement (mech valve, on warfarin w/ goal INR 2.5), DM II,CAD, MGUS, s/p endoscopy/colonoscopy + polypectomy on ___, with FICU admission ___ for GI bleeding with placement of 2 additional endoclips on ___, who now returns to the FICU with hemodynamic instability and blood loss, as well as passing of the endoclip, w concern for rebleed of the polypectemy site, now with cough, change of mental status.// interval change of the effusion, interstitial markers TECHNIQUE: Portable AP radiograph of the chest. COMPARISON: Radiograph performed on ___. FINDINGS: Left-sided PICC line terminates at the cavoatrial junction overall similar in position compared to the prior exam. Mild cardiomegaly is unchanged. Mild bibasilar atelectasis is persistent. Small left pleural effusion is unchanged. Cardiomediastinal contours are otherwise stable. No evidence of pneumothorax. IMPRESSION: Overall, persistent bibasilar atelectasis and possible small left pleural effusion, unchanged compared to the prior exam. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with picc// s/p left 51cm dl picc Contact name: ___: ___ s/p left 51cm dl picc IMPRESSION: Comparison to ___. The patient has received a new left-sided PICC line. The course of the line is unremarkable, the tip of the line projects over mid to lower SVC. No complications, notably no pneumothorax. Otherwise unchanged radiograph. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old man with LUE forearm pain after PICC placement// rule out DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow. The imaged PICC in the left basilic vein appears normal IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. PICC in the left basilic vein. Radiology Report EXAMINATION: Chest radiographs, four AP upright views. INDICATION: Leukocytosis. Query intrapulmonary infection. COMPARISON: None available. FINDINGS: The fourth of a four views shows a Dobhoff tube terminating in the stomach. A ventriculoperitoneal shunt catheter courses over the right lateral chest. Patient is status post aortic valve replacement. There are multiple dishiscences among sternal wires. Heart is probably borderline in size. Given technique, cardiac, mediastinal and hilar contours are unremarkable. Lung volumes are low. Within the limitations of technique, lungs appear clear. There is no pleural effusion or pneumothorax, although noting that the extreme left costophrenic angle is to varying degrees excluded on all views. IMPRESSION: Dobhoff tube terminating in the stomach. No evidence of acute cardiopulmonary disease. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with chf, gi bleeding// r/o chf r/o chf IMPRESSION: Compared to chest radiograph ___. Pulmonary vasculature is engorged. Edema minimal if any. Heart size borderline enlarged. No pleural effusion or pneumothorax. Patient has had median sternotomy and at least one cardiac valve replacement. Uppermost sternal butterfly wire is fractured but not miss aligned. Indwelling shunt catheter traverses the right neck, chest and upper abdomen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with LGIB iso polypectomy, now with new dyspnea and chest pressure, trop neg.// evaluate for new infiltrate, worsening pulmonary edema, atelectasis, or pneumothorax COMPARISON: Chest radiographs from ___. FINDINGS: Single portable semi upright AP view of the chest is provided. Lung volumes are low. Compared to prior, there is persistent elevation of the right hemidiaphragm and overlying subsegmental atelectasis. There is likely mild pulmonary vascular congestion, unchanged. There is no pneumothorax. Left-sided basilar atelectasis with possible tiny left pleural effusion. Re-demonstrated is fracture of the upper-most sternal butterfly wires. Indwelling ventriculoperitoneal shunt catheter projects over the right neck, chest and abdomen. IMPRESSION: Persistent elevation the right hemidiaphragm with overlying right basilar subsegmental atelectasis. Overall, no significant interval change. Radiology Report INDICATION: ___ year old man with recent GI bleed requiring endoclips// evaluation of endoclip placement TECHNIQUE: Portable abdominal radiograph COMPARISON: None available. FINDINGS: There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. Linear metallic densities project over the right hemiabdomen likely represent newly placed clips. IMPRESSION: Linear metallic densities over the right lower quadrant likely represent newly placed endo clips. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Anemia, Melena Diagnosed with Hemorrhage of anus and rectum temperature: 98.7 heartrate: 78.0 resprate: 25.0 o2sat: 100.0 sbp: 147.0 dbp: 107.0 level of pain: 0 level of acuity: 2.0

================================================ Discharge Worksheet ================================================ Dear Mr. ___, You came to ___ because you were having bloody bowel movements. You received multiple units of blood and had two colonoscopies with placement of clips. Your bleeding stopped and you were started on a heparin drip for your mechanical valves and started on your home dose of Coumadin. Once your INR was in the therapeutic range your heparin was discontinued. Your blood counts remained stable. You were also treated for congestive heart failure which was likely caused by the blood transfusions. Your insulin doses were decreased because you are eating less. You should continue to monitor your sugars. You will be discharged to rehab to improve your functional status. It was a pleasure participating in your care. We wish you the best! Sincerely, 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: Abdominal pain Major Surgical or Invasive Procedure: ___ EGD ___ Intubation History of Present Illness: Ms. ___ is a ___ year old woman with no significant known medical history presenting with epigastric/LUQ pain w/ CT abd/pelvis concerning for gastric volvulus. Patient was in her usual state of health until 12pm on ___ when she had shortness of breath. This resolved over time, then she had acute onset epigastric/LUQ abdominal pain starting at 5pm on ___ associated with vomiting of coffee ground emesis multiple times. This has never happened to her before, she has never had an EGD, no history of GERD. She initially presented to ___, where she had a CXR showing large hiatal hernia and CT abd/pelvis with gastric volvulus. Her lab work was significant for WBC 17, lactate 2.7. An NGT was placed which put out 500cc fluid and she was transferred to ___ for further care. Past Medical History: PMH: sundowning, no significant past medical history PSurgHx: no prior abdominal surgeries Social History: ___ Family History: not pertinent to HPI Physical Exam: Admission EXAM: ================= Vitals - T 97.6; BP 134/76; HR 108; RR 22; SPO2 96% RA GEN - Well appearing HEENT - NCAT, EOMI, sclera anicteric CV - HDS PULM - No signs of respiratory distress. ABD - soft, nontender, nondistended. NGT output dark blood tinged bilious DISCHARGE EXAM: ================== ___ ___ Temp: 97.6 PO BP: 118/66 L Lying HR: 81 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: older female awake and alert, seated at bedside with care taker assisting her with cleaning her mouth HEENT: Pupils with post surgical changes with L pupil 1mm larger than R. No scleral icterus. Moist mucous membranes. ABDOMEN: Soft, non-tender, non-distended EXTREMITIES: Thin, warm, no edema NEUROLOGIC: appears alert, following basic commands, moving all extremities Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ ___ 04:35AM BLOOD WBC-17.6* RBC-4.17 Hgb-12.8 Hct-38.5 MCV-92 MCH-30.7 MCHC-33.2 RDW-13.8 RDWSD-46.4* Plt ___ ___ 04:35AM BLOOD ___ PTT-27.1 ___ ___ 07:05AM BLOOD Glucose-133* UreaN-34* Creat-0.6 Na-144 K-4.8 Cl-106 HCO3-23 AnGap-15 ___ 07:05AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1 ___ 04:42AM BLOOD Glucose-131* Lactate-2.5* Creat-0.53 Na-145 K-5.0 Cl-104 calHCO3-29 ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== ___ 06:17AM BLOOD WBC-8.7 RBC-3.36* Hgb-10.4* Hct-30.6* MCV-91 MCH-31.0 MCHC-34.0 RDW-14.1 RDWSD-45.8 Plt ___ ___ 07:20AM BLOOD Glucose-55* UreaN-16 Creat-0.5 Na-141 K-4.8 Cl-99 HCO3-19* AnGap-23* ___ 06:17AM BLOOD WBC-8.7 RBC-3.36* Hgb-10.4* Hct-30.6* MCV-91 MCH-31.0 MCHC-34.0 RDW-14.1 RDWSD-45.8 Plt ___ ___ 06:17AM BLOOD Plt ___ ___ 05:42AM BLOOD Glucose-91 UreaN-31* Creat-0.6 Na-142 K-4.5 Cl-103 HCO3-24 AnGap-15 ___ 05:42AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.8 =========================== REPORTS AND IMAGING STUDIES =========================== ------ ___ CT ABDOMEN w/o CONTRAST ------ FINDINGS: Chest is reported separately. Gallbladder is distended probably due to fasting state. A few hepatic cysts are identified. Small calcification in the left lateral segments of the liver, as before. There is no biliary dilatation. The pancreas appears normal. The spleen is normal in size and appearance. Each adrenal is again mildly thickened. There is no evidence for stones or hydronephrosis involving either kidney. Renal cysts are identified in the left kidney that appear simple and benign. Nearly the whole stomach is in the chest. Short segment of the transverse colon also herniates into the chest without obstruction. This visualized small bowel is unremarkable. There is no ascites or lymphadenopathy. There are no suspicious bone lesions. Bones appear demineralized. Mild compression deformity of the L3 vertebral body appears unchanged. IMPRESSION: Chest is reported separately. No significant abnormality involving the abdomen. ------ ___ CT CHEST W/O CONTRAST ----- FINDINGS: Tracheostomy terminates shortly above the carina. Feeding tube terminates in a large hiatal hernia. Heart is mildly enlarged with mild coronary artery calcification. Patchy calcification is also found along the aortic valve. Thoracic aorta is normal in caliber and mildly calcified. Central pulmonary arteries are mildly calcified. There is no lymphadenopathy in the chest. There is no pericardial effusion. Trace pleural effusions are found bilaterally. This study shows a large hiatal hernia containing essentially the entire stomach with an air contrast level. The hernia appears somewhat less distended, although mostly full. The transverse colon enters and exits the hernia sac without obstruction, as before. Increased opacities in each lower lobe may be due to atelectasis or pneumonia. More extensive in the left lung than right are patchy new consolidations, not exclusively dependent. These areas suggest active pneumonia. Ground-glass opacities in the upper lobes have increased and are less specific; these could be seen with the mild pulmonary edema or could accompany a more widespread infectious process. Regional bronchiectasis is very similar in the left upper lobe. The right mainstem bronchus some most fully collapses, more so than the left, which suggests malacia. The abdomen is reported separately. Bones appear demineralized. There are no suspicious bone lesions. Prior bilateral rib fractures appear unchanged. Moderate to severe compression fracture of the T10 vertebral body appears unchanged. IMPRESSION: 1. Large hiatal hernia containing the whole stomach and a contrast fluid level. Less distention than before, however. Similar nonobstructed transverse colon within the hernia. 2. New moderately extensive multifocal opacities, left greater than right, suggesting pneumonia, possibly due to aspiration as an etiology. 3. Ground-glass opacities in the upper lobes, edema versus infection. 4. Suspected bronchomalacia. ___ EGD - Esophageal hiatal hernia - Gastric ulcer - Normal mucousa in the whole examined duodenum - Whorled mucousa at level of distal body/antrum with turn consistent with hiated, inverted stomach. We were able to traverse the area easily with a pediatric gastroscope. The pylorus was widely patent and we were able to move into the duodenal bulb. - Normal mucosa in the whole esophagus - Resistance met at the upper esophageal sphincter and we could not traverse the area with gastroscope. We converted to a pediatric gastroscope and were able to traverse the area easily. ============ MICROBIOLOGY ============ ___ Blood Culture = No growth ___ Urine Culture = No growth Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mirtazapine 15 mg PO QHS 2. Donepezil 5 mg PO QHS 3. BusPIRone 10 mg PO TID 4. QUEtiapine Fumarate 50 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Reason for PRN duplicate override: Alternating agents for similar severity 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Aspiration pneumonia Acute hypoxic respiratory failure 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: CT CHEST/ABD/PELVIS W/ CONTRAST INDICATION: ___ year old woman with gastric volvulus, abdominal pain, hematemesis// Characterize gastric volvulus TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 17.5 mGy (Body) DLP = 876.1 mGy-cm. Total DLP (Body) = 876 mGy-cm. COMPARISON: CT abdomen and pelvis ___. FINDINGS: The study is limited by motion artifact. Within these confines: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Evaluation of lungs is limited by motion artifact. Mild, dependent atelectasis. Ground-glass opacities in the bilateral lower lobes likely reflect aspiration, in the setting of the large hiatal hernia, described in further detail below. The central airways appear patent. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. BONES: Chronic appearing rib deformities of the right lateral third through fifth ribs and left anterolateral fourth through fifth ribs. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Again seen are multiple circumscribed, hypodense lesions within the liver, measuring up to approximately 2.5 cm, likely cysts. Focal calcification within the left hepatic lobe. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas is atrophic, 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 adrenal gland is normal. The left adrenal gland appears nodular and thickened. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Multiple renal hypodensities measure up to 3.7 cm, likely cysts. Other, subcentimeter bilateral renal hypodensities are too small to characterize. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Again seen is a large hiatal hernia, with the entirety of the stomach herniated above the diaphragm. An enteric tube terminates within the stomach, and the stomach is mildly decompressed compared to the prior examination. At approximately the level of the pylorus (601:32, 602:38) is a transition point with a small twist, measuring approximately 90 degrees, with a caliber change leading to decompressed small bowel loops. There is no pneumatosis or intraperitoneal free air. Small and large-bowel loops are included in the large hiatal hernia. Otherwise, the colon and rectum are within normal limits. PELVIS: Hyperdensity within the bladder is compatible with previously excreted contrast. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is normal in size. No adnexal masses. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Moderate atherosclerotic disease is noted. BONES: Levoconvex curvature of the lumbar spine. A left femoral prosthesis is in place, limiting evaluation of adjacent structures. Moderate to severe multilevel degenerative changes, including mild anterolisthesis of L4 on L5. Compression deformities of T10 and L3 are of uncertain chronicity. Fractures are focal suspicious osseous abnormality. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Complete herniation of the stomach above the diaphragm, mildly decompressed following interval placement of an enteric tube, with redemonstration of a sharp transition point at the level of the pylorus. A small twist measuring approximately 90 degrees is at the level of the pylorus. No evidence of perforation or pneumatosis. 2. Ground-glass opacities of the bilateral lower lobes likely reflect aspiration, in the setting of the large hiatal hernia. 3. Compression deformities of the T10 and L3 vertebral bodies, of uncertain chronicity. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with gastric volvulus hypoxia// pulmonary edema? asp iration TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with mild pulmonary vascular congestion. There is large hiatus hernia. The NG tube projects to the hiatus hernia. Cardiomediastinal silhouette is stable. No pneumothorax. No effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with no past medical history presenting with large hiatal hernia // interval change TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume. The NG tube is coiled up within the stomach. There is a moderate to large hiatus hernia. There is mild interstitial edema. There are trace bilateral effusions. No pneumothorax. Cardiomediastinal silhouette is stable. There are no pleural effusions. Radiology Report EXAMINATION: Chest radiograph, portable AP semi-upright. INDICATION: Status post nasogastric and endotracheal tube placements. COMPARISON: Prior study from earlier on the same day. FINDINGS: A nasogastric tube terminates in a large hiatal hernia which is mostly air-filled. Although relatively large it does not appear densely distended at this time. Endotracheal tube terminates about 3.5 cm above the carina. Cardiac, mediastinal and hilar contours appear stable including mild to moderately enlarged heart. Medial atelectasis at each lung base appears very similar. Very similar left apical subpleural scarring. Small pleural effusions seem likely. No visible pneumothorax. IMPRESSION: Nasogastric tube terminating in hiatal hernia. Status post endotracheal intubation. Persistent large hiatal hernia with atelectasis at each lung base and possible small pleural effusions. Radiology Report EXAMINATION: CT ABDOMEN W/O CONTRAST Q421 INDICATION: ___ year old woman with large hiatal hernia // Please perform with PO contrast, no IV contrast. Eval for progression of torsion, hernia, NG tube position, whether or not bowel has reduced, e/o bowel ischemia TECHNIQUE: Multidetector CT images of the abdomen were obtained with out intravenous contrast. Oral contrast was administered. DOSE: Acquisition sequence: 1) Spiral Acquisition 9.7 s, 37.1 cm; CTDIvol = 9.9 mGy (Body) DLP = 350.9 mGy-cm. Total DLP (Body) = 364 mGy-cm. COMPARISON: ___ and chest CT from the same day. FINDINGS: Chest is reported separately. Gallbladder is distended probably due to fasting state. A few hepatic cysts are identified. Small calcification in the left lateral segments of the liver, as before. There is no biliary dilatation. The pancreas appears normal. The spleen is normal in size and appearance. Each adrenal is again mildly thickened. There is no evidence for stones or hydronephrosis involving either kidney. Renal cysts are identified in the left kidney that appear simple and benign. Nearly the whole stomach is in the chest. Short segment of the transverse colon also herniates into the chest without obstruction. This visualized small bowel is unremarkable. There is no ascites or lymphadenopathy. There are no suspicious bone lesions. Bones appear demineralized. Mild compression deformity of the L3 vertebral body appears unchanged. IMPRESSION: Chest is reported separately. No significant abnormality involving the abdomen. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST Q411 INDICATION: ___ year old woman with large hiatal hernia // Please perform with PO contrast, no IV contrast. Eval for progression of torsion, hernia, NG tube position, whether or not bowel has reduced, e/o bowel ischemia TECHNIQUE: Multidetector CT images of the chest were obtained without intravenous contrast. Sagittal and coronal reformations of also been performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 9.7 s, 37.1 cm; CTDIvol = 9.9 mGy (Body) DLP = 350.9 mGy-cm. Total DLP (Body) = 364 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABDOMEN W/O CONTRAST) COMPARISON: CT of the chest is available from ___. FINDINGS: Tracheostomy terminates shortly above the carina. Feeding tube terminates in a large hiatal hernia. Heart is mildly enlarged with mild coronary artery calcification. Patchy calcification is also found along the aortic valve. Thoracic aorta is normal in caliber and mildly calcified. Central pulmonary arteries are mildly calcified. There is no lymphadenopathy in the chest. There is no pericardial effusion. Trace pleural effusions are found bilaterally. This study shows a large hiatal hernia containing essentially the entire stomach with an air contrast level. The hernia appears somewhat less distended, although mostly full. The transverse colon enters and exits the hernia sac without obstruction, as before. Increased opacities in each lower lobe may be due to atelectasis or pneumonia. More extensive in the left lung than right are patchy new consolidations, not exclusively dependent. These areas suggest active pneumonia. Ground-glass opacities in the upper lobes have increased and are less specific; these could be seen with the mild pulmonary edema or could accompany a more widespread infectious process. Regional bronchiectasis is very similar in the left upper lobe. The right mainstem bronchus some most fully collapses, more so than the left, which suggests malacia. The abdomen is reported separately. Bones appear demineralized. There are no suspicious bone lesions. Prior bilateral rib fractures appear unchanged. Moderate to severe compression fracture of the T10 vertebral body appears unchanged. IMPRESSION: 1. Large hiatal hernia containing the whole stomach and a contrast fluid level. Less distention than before, however. Similar nonobstructed transverse colon within the hernia. 2. New moderately extensive multifocal opacities, left greater than right, suggesting pneumonia, possibly due to aspiration as an etiology. 3. Ground-glass opacities in the upper lobes, edema versus infection. 4. Suspected bronchomalacia. Radiology Report EXAMINATION: Abdominal radiographs, four views. INDICATION: Evaluate for progression of PO contrast below the diaphragm. COMPARISON: CT is available from ___, earlier on the same day. Contrast as at least largely left the stomach and proceeded into the distal bowel. Endo FINDINGS: Contrast has largely left a large hiatal hernia. The contrast visibly opacifies loops of bowel in the pelvis. These probably consist of small bowel loops. A nasogastric tube again terminates in a large hiatal hernia. Bowel gas pattern is unremarkable. No free air. IMPRESSION: Anterograde progression of enteric contrast, now mostly opacifying distal small bowel loops in the deep pelvis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with intubated, s/p EGD and PO contrast through NG tube // eval for interval change TECHNIQUE: Portable AP radiograph COMPARISON: Prior chest radiograph done ___ FINDINGS: ET tube in situ with the tip projecting over the medial clavicles. Enteric tube in situ with the tip present in a large retrocardiac hernia. The hernia is suboptimally characterized on the current study as there is less gaseous distention. Bilateral perihilar vascular congestion. Background structural lung changes with increased superimposed airspace opacification is slightly worse compared to prior. Parahilar vascular congestion. IMPRESSION: ETT in situ and unchanged in position. Enteric tube in situ with the tip present in a large retrocardiac hiatal hernia. Background structural lung changes with increased superimposed airspace opacification is worsened compared to prior suggesting increased pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with large hiatal hernia // eval interval change TECHNIQUE: Portable chest x-ray AP view. COMPARISON: Multiple chest x-rays, most recent dated ___. CT chest dated ___. FINDINGS: The heart is top-normal in size. The aorta is tortuous with atherosclerotic calcification. There is redemonstration of a large hiatal hernia interval enlarged from previous study likely due to distended stomach. There are bilateral hilum opacification consistent with pulmonary vascular congestion which is more prominent from previous study. There are bilateral small pleural effusion. There is contrast material seen in the colon likely from previous PO contrast. IMPRESSION: 1. Interval slightly enlarged hiatal hernia likely secondary to distended stomach. 2. Interval slightly worsening pulmonary vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old woman with respiratory distress // ?aspiration pneumonia ?aspiration pneumonia IMPRESSION: Compared to chest radiographs ___. Stomach and loops of bowel in the large hiatus hernia are now fluid filled. Previous mild pulmonary edema has improved. Small right pleural effusion has increased. Basilar atelectasis is presumed, but not clearly changed. Upper lungs are clear. No pneumothorax. Healed rib fractures fractures noted right lower chest cage laterally. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with aspiration pneumonia // ? interval change ? interval change IMPRESSION: Cardiomegaly and superimposed large hiatal hernia artery demonstrated. Since previous examination there is no substantial change in small bilateral pleural effusions but there is more of vascular congestion currently present. No pneumothorax. No definitive consolidation to suggest aspiration in the lung bases but the assessment is difficult giving the dilated stomach projecting over the substantial portion of the lung bases. Mid left lung opacity might potentially be new and reflecting aspiration. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with hiatal hernia and recently on mechanical ventilation for resp failure and aspiration PNA, now extubated on face mask on Abx // Please evaluate for interval changes TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: With worsening interstitial abnormality. Widened cardiomediastinal silhouette is stable. There are no pleural effusions. No pneumothorax is seen. Radiology Report EXAMINATION: Video oropharyngeal swallow study. INDICATION: ___ year old woman with dysphagia // video study TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the Speech-Language Pathologist from the Voice, Speech & Swallowing Service. Multiple consistencies of barium were administered. DOSE: Fluoro time: 4 minutes 28 seconds COMPARISON: Is made to prior chest radiographs, as there is no prior swallow study or barium esophagram. FINDINGS: Trace penetration with thins by cup and straw. No gross aspiration. IMPRESSION: Trace penetration with thins by cup and straw without gross aspiration. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, SBO, Transfer Diagnosed with Other diseases of stomach and duodenum temperature: 97.6 heartrate: 108.0 resprate: 22.0 o2sat: 96.0 sbp: 134.0 dbp: 76.0 level of pain: u/a level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you while you were admitted to ___ ___. WHY WERE YOU ADMITTED TO THE HOSPITAL? You were having pain in your abdomen. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We put in a breathing tube to put a camera down into your stomach - We found that you have a large hernia of your stomach - You received antibiotics and supportive treatment because you were having trouble breathing after food went down the wrong pipe (aspiration) - Our speech therapists did tests to evaluate your safety for eating and recommended a modified way of eating that will be safer for your WHAT SHOULD YOU DO WHEN YOU GO HOME? - Eat ___ small meals daily - Always stay upright for an hour after your meals - Only eat food that has been pureed Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins / ciprofloxacin / vancomycin / Bactrim / nafcilliln / Iodinated Contrast- Oral and IV Dye Attending: ___. Chief Complaint: exposed shunt hardware Major Surgical or Invasive Procedure: ___: Externalization of VP shunt and wound revision ___: Removal of right frontal EVD ___: Placement of left frontal EVD ___: Removal of left frontal EVD History of Present Illness: ___ year old nursing home resident noted 3 days prior to admission to have breakdown of the skin on her scalp and visible shunt and shunt hardware. Per the patient's son, nursing home staff had noted a scab over the site of her proximal VP shunt tubing; while brushing her hair, the scab fell off revealing exposed tubing. The patient denies any headache, vision changes, dizziness, recent illness/fevers, numbness/tingling, weakness. She does complain of chronic back pain which has been worse for the past several weeks. She has a chronic ulcer to her right knee which is followed by the wound RN at her facility and which has been evaluated by BI orthopedics. She has DTI to her right heel. Past Medical History: HTN Depression/Anxiety osteoporosis Arthritis Gout Pancreatic cyst Epilepsy Incomnia Dementia Essential tremor RA PSHx: Fractured tibia ___ Brain aneurysm repair ___ @ ___ Right hip repair ___ Right hip & pelvis repair ___ Social History: ___ Family History: Diabetes, brain aneurysm Physical Exam: Upon admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Full Neck: Supple. Lungs: No respiratory distress Extrem: Warm and well-perfused. R knee stage 3 ulcer with collagenase packing and mepilex. Scattered skin tears to BLE's. Deep tissue injury to R heel. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, hospital, unable to name hospital. Language: Speech fluent with impaired comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. LUE resting/intention tremor. Strength full power ___ bilateral upper extremities. LLE ___. RLE antigravity at ___, limited due to pain. Right pronator drift. Wound: VP shunt valve to R scalp with good recoil. There is approx. 1cm of exposed VP shunt catheter exposed proximally to valve with surrounding eroded skin. No evidence of infection or Upon discharge: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Self - nods to name with choices Follows commands: [x]Simple [ ]Complex [ ]None Pupils: PERRL EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [ ]Yes [x]No Motor: Does not follow a complete motor exam. Bilateral upper extremities grossly full strength. Left lower extremity lifts antigravity off bed and wiggles toes to command. Right lower extremity faintly wiggles toes. Wound: [x]Clean, dry, intact [x]Staples Pertinent Results: Please see OMR for pertinent results Medications on Admission: trazodone 50 mg tablet oral 1 tablet(s) Once Daily evening tramadol 50 mg tablet oral 1 tablet(s) Three times daily levetiracetam 500 mg tablet oral 1 tablet(s) Once Daily divalproex ___ mg tablet,delayed release oral 4 tablet at bedtime metoprolol tartrate -- 50mg in am 100mg in evening sertraline 25 mg tablet oral 1 tab Once Daily am ,50mg pm clopidogrel 75 mg tablet oral 1 tablet(s) Once Daily amlodipine 10 mg tablet oral 1 tablet(s) Once Daily Laxative (bisacodyl) -- Unknown Strength 1 suppository(s) Once Daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN thick secreations 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. DiphenhydrAMINE 50 mg IV Q6H:PRN allergic reaction 5. Docusate Sodium 100 mg PO BID 6. EPINEPHrine (EpiPEN) 0.3 mg IM Q1H:PRN allergic reaction 7. Heparin 2500 UNIT SC BID 8. Ipratropium Bromide Neb 1 NEB IH Q6H sob 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB 10. Meropenem Desensitization 1000 mg IV Q8H end ___ This is the maintenance dose to follow the last tapered dose 11. Miconazole Powder 2% 1 Appl TP TID:PRN excoriation 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Sarna Lotion 1 Appl TP QID:PRN itching 14. Senna 17.2 mg PO QHS 15. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 16. Valproic Acid ___ mg PO QHS 17. amLODIPine 10 mg PO DAILY 18. Clopidogrel 75 mg PO DAILY 19. LevETIRAcetam 750 mg PO DAILY 20. LevETIRAcetam 500 mg PO QPM 21. Metoprolol Tartrate 150 mg PO DAILY 22. Sertraline 75 mg PO DAILY 23. TraMADol 50 mg PO TID W/MEALS RX *tramadol 50 mg 1 tablet(s) by mouth TID W/MEALS Disp #*21 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: VP Shunt infection Exposed shunt Hardware Aspiration Pneumonitis Dysphagia Carotid Stenosis Chronic Pressure Ulcer (present prior to admission) 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: CTA NECK WANDW/OC AND RECONS Q25 CT NECK INDICATION: ___ year old woman with carotid stenosis// eval carotid stenosis TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 13.0 mGy (Body) DLP = 374.0 mGy-cm. 2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.4 mGy-cm. 3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 19.0 mGy (Body) DLP = 9.5 mGy-cm. Total DLP (Body) = 385 mGy-cm. COMPARISON: Comparison includes CT head dated ___. FINDINGS: CTA HEAD: The circle of ___ and their principal intracranial branches are only partially visualized. Within that limitation, the ophthalmic and communicating portions of the left internal carotid are absent ( 2:226). The dural venous sinuses are patent. CTA NECK: The left internal carotid artery is completely occluded at the C4 level, proximal to the left carotid bifurcation by calcified atherosclerotic plaque (601:34). The proximal right internal carotid is narrowed to 4.0 mm. The distal cervical portion of the right internal carotid measures 5.6 mm. Vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. OTHER: Study is moderately degraded by motion. Partially visualized lungs, demonstrate nodular and diffuse ground-glass opacification,(02:28), better seen on CT a chest with and without contrast dated ___. The visualized portion of the thyroid gland is within normal limits. There is a right axillary node that measures approximately 1 cm on short axis, (02:50). Extensive atherosclerotic plaque is seen along the aortic arch and left subclavian artery. IMPRESSION: 1. Complete occlusion of the left internal carotid artery by calcified atherosclerotic plaque proximal to the left bifurcation. 2. Mild narrowing of the right internal carotid artery, proximal to the carotid bifurcation. 3. Patent bilateral vertebral arteries. Radiology Report EXAMINATION: CTA chest INDICATION: ___ year old woman with new tachycardia, tachypnea// r/o PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 7.7 mGy (Body) DLP = 229.2 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 1.7 mGy (Body) DLP = 0.8 mGy-cm. 3) Stationary Acquisition 1.2 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. Total DLP (Body) = 232 mGy-cm. COMPARISON: Chest radiograph dated ___. FINDINGS: The aorta and its major branch vessels are patent, with no evidence of occlusion, dissection, or aneurysmal formation. Severe calcified and noncalcified atherosclerotic plaque is noted in the aortic arch and descending thoracic aorta with severe narrowing at the level of the aortic arch. There is also greater than 50% is narrowing of the proximal left subclavian artery. Motion artifact limits evaluation for pulmonary embolism. However, no large central pulmonary embolism is identified. There is question of a filling defect within the right upper lobe posterior segmental branch (301:71) however this region is significantly degraded by motion artifact and this finding may be artifactual. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, mediastinal, or hilar lymphadenopathy. A borderline sized right axillary lymph node is noted measuring up to 0.9 cm. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is a trace right pleural effusion with associated passive atelectasis. There are multiple subcentimeter ground-glass nodules in the right upper lobe with a branching distribution with patchy underlying ground-glass opacification. Fluid/debris is present within the trachea. Limited images of the upper abdomen demonstrate an enteric tube with tip passed the GE junction. A subcentimeter hypodensity is noted in hepatic segment 7, that is too small to characterize. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: Limited evaluation for pulmonary embolism due to motion artifact. Within this limitation, no large central PE is identified. Severe atherosclerotic disease within the thorax. Please refer to the concurrent CTA of the head and neck for details on the arch vessels Multiple subcentimeter ground-glass nodules in the right upper lobe with a branching distribution and underlying patchy ground-glass opacification. Findings may represent areas of mucous impaction in small airways disease possibly likely reflective of aspiration/aspiration pneumonia. Trace right pleural effusion with associated atelectasis. Radiology Report INDICATION: ___ year old woman with new aspiration PNA// DHT placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from earlier in the day FINDINGS: 2 sequential images demonstrate advancement of a Dobhoff from the mid esophagus into the stomach. An IVC filter is present. Bibasilar opacities are noted right greater than left. There is mild pulmonary edema. No pleural effusion or pneumothorax. IMPRESSION: The final image demonstrates the tip of the Dobhoff to project over the stomach. Mild pulmonary edema and right lower lobe atelectasis. Radiology Report EXAMINATION: KNEE (2 VIEWS) RIGHT INDICATION: ___ year old woman with history of h/o fibula fx and chronic wounds now with resp failure// eval eval TECHNIQUE: Frontal and lateral portable views of the right knee were obtained COMPARISON: ___ IMPRESSION: There is no acute fracture or dislocation seen. Severe degenerative changes are present, particularly involving the medial tibiofemoral compartment. Mild degenerative changes are present around the lateral tibiofemoral compartment and patellofemoral compartment. There is no joint effusion. The bones are diffusely demineralized. There is apparent subcutaneous emphysema projecting adjacent to the fibular head. Clinical correlation is recommended. No underlying focal osteopenia or periosteal reaction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with aspiration PNA// interval eval interval eval IMPRESSION: Compared to chest radiographs ___. New heterogeneous opacification at the base the right lung could be pneumonia, probably small to moderate right pleural effusion as well. New large elliptical opacity projecting over the right main bronchus could be external, or, if internal, loculated fissural pleural fluid. It should be evaluated with conventional radiographs as soon as feasible. Left lung is clear. Heart size is normal. No pneumothorax. Feeding tube passes below the diaphragm and out of view. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:31 am, 1 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman s/p aspiration// Please evaluate for interval change TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: The NG tube is unchanged. Lungs are low volume. Small bilateral effusions right greater than left are stable. Cardiomediastinal silhouette is unchanged. No pneumothorax is seen. Mild interstitial edema is stable. Radiology Report INDICATION: ___ year old woman with CSF infection and EVD externalization// interval eval TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is stable. The NG tube is unchanged. There are trace bilateral effusions. No pneumothorax is seen Radiology Report INDICATION: ___ year old woman with fever// eval for interval change TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: NG tube is unchanged. Cardiomediastinal silhouette is stable. Small bilateral effusions are unchanged. There is bibasilar atelectasis. No pneumothorax is seen Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with EBv// eval drain 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: Again demonstrated, is a right frontal approach ventriculostomy with the tip terminating near the right foramina ___. There is persistent pneumocephalus surrounding the drain. There is redistribution of intraventricular air with interval decrease in lateral ventricular air and interval increase in left temporal horn air. There is minimal interval increase in hydrocephalus. There is interval resolution of small layering blood in the bilateral occipital horns. There is no evidence of acute large territorial infarction, intracranial hemorrhage, edema, or mass. Left frontoparietal encephalomalacia is unchanged. No osseous abnormalities seen. Patient is intubated. There is unchanged mucosal thickening of the ethmoidal air cells. Otherwise, the remaining the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Possible minimal, if any, increase in ventriculomegaly. Interval redistribution of intraventricular air, decrease in lateral ventricles and increased in the left temporal horn. 2. Stable right frontal approach ventriculostomy with surrounding pneumocephalus. 3. Interval resolution of intraventricular hemorrhage. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman s/p removal R frontal EVD and placement of L frontal EVD. Non-contrast head CT to rule out hemorrhage. Please perform ___ prior to going to ___. Will need to be reviewed by Neurosurgery prior to transfer to ___.// Post-operative NCHCT to evaluate for post-operative hemorrhage and evaluate for ventricle size. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP = 746.1 mGy-cm. Total DLP (Head) = 758 mGy-cm. COMPARISON: CT head without contrast from ___ FINDINGS: There has been interval exchange of a ventriculostomy catheter with a new left frontal approach ventriculostomy catheter seen with the tip terminating near the left foramen of ___. There is again pneumocephalus with a new component seen along the left frontal convexity. Previously seen hydrocephalus is similar to the recent prior exams. No new large acute territorial infarct or intracranial hemorrhage is identified. Left frontoparietal encephalomalacia is unchanged. There is no midline shift. There is no osseous abnormality. Air-fluid levels are again seen in the right sphenoid sinus and opacification of the right posterior ethmoid air cells. Otherwise, the remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. Patient remains intubated. IMPRESSION: 1. Interval exchange of a ventriculostomy catheter with a new left frontal approach ventriculostomy catheter seen terminating with the tip near the left foramen of ___. No new intracranial hemorrhage or acute major infarct. 2. Stable hydrocephalus with ventriculomegaly as compared to the recent prior studies. Radiology Report INDICATION: ___ year old woman with cough and secretions, bilat pleural effusions// eval for PNA, Pulm edema TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is stable. The NG tube projects below the left hemidiaphragm and projects over the stomach. There is a small left effusion. No pneumothorax is seen Radiology Report INDICATION: ___ year old woman with right PICC// right PICC 38cm, ___ ___ Contact name: ___: ___ TECHNIQUE: Portable AP radiograph the chest. COMPARISON: Radiograph of the chest performed 4 hours prior. FINDINGS: Heart size is normal. The aorta is tortuous. An enteric tube extends below the diaphragm with the tip in the body stomach. A right-sided PICC line is malpositioned, traversing cranially through the neck, with the tip out of view of this film. The visualized osseous structures are unremarkable. IMPRESSION: Mild positioned right-sided PICC line, traversing cranially through the neck, with the tip out of view of this film. NOTIFICATION: The findings were discussed with ___: ___ by ___ ___, M.D. on the telephone on ___ at 2:58 pm, 10 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with right PICC TECHNIQUE: Portable AP radiograph the chest. COMPARISON: Radiograph of the chest performed 2 hours prior. FINDINGS: Heart size is normal. Hilar and mediastinal contours are normal. Right-sided PICC line has been repositioned and appropriately terminates within the mid SVC. Enteric tube is seen unchanged in position. Lungs are grossly unremarkable. IMPRESSION: Right-sided PICC line appropriately terminates within the mid SVC. Radiology Report EXAMINATION: CT ABDOMEN/PELVIS WITH CONTRAST INDICATION: ___ year old woman with VPS recently removed now with CSF infection concern for abdominal source of infection given recent shunt removal// ___ year old woman with VPS recently removed now with CSF infection concern for abdominal source of infection given recent shunt removal 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 3.6 s, 48.2 cm; CTDIvol = 15.7 mGy (Body) DLP = 756.9 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.4 mGy (Body) DLP = 6.7 mGy-cm. Total DLP (Body) = 765 mGy-cm. COMPARISON: No prior similar for comparison. FINDINGS: LOWER CHEST: Bibasilar subsegmental atelectatic changes are noted. HEPATOBILIARY: There is a 1 cm right hepatic cyst and the liver is otherwise unremarkable. Portal vein and hepatic veins are patent. There is no biliary ductal dilatation. The gallbladder is within normal limits. PANCREAS: Unremarkable. SPLEEN: Unremarkable. ADRENALS: Unremarkable. URINARY:There is no hydronephrosis. There are a few bilateral renal hypodense lesions are too small to characterize. GASTROINTESTINAL: The enteric tube terminates within the stomach. There is no bowel obstruction. PERITONEUM: There is no free air or free fluid. LYMPH NODES: There is no abdominopelvic adenopathy. VASCULAR: Infrarenal IVC filter is noted with throngs extending beyond the confines of the IVC. PELVIS: The uterus and adnexa are unremarkable for age. BONES:Status post open reduction and internal fixation of a right femoral fracture. No aggressive osseous lesions. IMPRESSION: 1. No source of infection identified in the abdomen or pelvis. 2. Additional incidental findings as above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p aneurysm rupture in ___ s/p clipping and VP shunt placement presents with exposed VP shunt hardware now s/p externalized EVD and removal of abdominal hardware now w/ ?allergic reaction to contrast vs meropenem.// new o2 requirement new o2 requirement IMPRESSION: Comparison to ___. No relevant change is noted. The right PICC line and the feeding tube are in stable correct position. Borderline size of the cardiac silhouette without pulmonary edema. No pneumonia, no pleural effusions, no pneumothorax. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ w/ hx aneurysm rupture s/p VP shunt now w/ exposed hardware s/p EVD plan for removal// please evaluate ventricle size 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: Right ICA aneurysm clip and overlying hardware streak artifact limits examination. Again demonstrated, is a left frontal approach ventriculostomy terminating along the medial aspect of the left ventricle. No evidence of hemorrhage along the ventriculostomy tract. There is a calvarial defect in the right frontal bone from prior ventriculostomy with persistent residual pneumocephalus along its tract (02:24). Evolving postsurgical changes related to prior right frontal approach ventriculostomy catheter removal again noted. There has been interval redistribution of intraventricular air with a small pocket of air along the frontal horn of the left lateral ventricle and a small pocket of air in the left temporal horn. Ventricular size and configuration is similar compared to most recent prior from ___. No evidence of acute large territorial infarction, intracranial hemorrhage, or significant mass effect. There is a small amount of residual left frontal pneumocephalus (02:22). Left frontoparietal encephalomalacia is unchanged. A right aneurysmal clip is again demonstrated. Periventricular and subcortical white matter hypodensities are nonspecific, though likely sequelae of chronic small vessel ischemic disease. No new osseous abnormalities seen. There is similar scattered mucosal thickening of the ethmoidal air cells. There is partial opacification of the mastoid air cells which can be seen in a prolonged patient setting. Air-fluid levels are again seen in the right sphenoid sinus, similar to prior. The middle ear cavities are clear. A nasogastric tube is partially imaged. IMPRESSION: 1. Right internal carotid artery aneurysm clip and overlying hardware streak artifact limits examination. 2. Grossly stable ventriculomegaly with evolving postoperative changes as described. 3. Grossly stable position of left frontal approach ventriculostomy catheter. 4. No new acute intracranial hemorrhage. 5. Stable paranasal sinus disease as described above. Radiology Report INDICATION: ___ s/p aneurysm rupture in ___ s/p clipping and VP shunt placement presents with exposed VP shunt hardware now s/p externalized EVD and removal of abdominal hardware now w/ ?allergic reaction to contrast vs meropenem. // new o2 requirement, ?PNA vs pulm edema TECHNIQUE: Chest portable AP COMPARISON: ___ FINDINGS: There has been no interval change since the previous exam. The right PICC line terminates in the mid SVC. The right enteric tube terminates below the diaphragm. Cardiac silhouette within normal limits in size without pulmonary edema. No pneumonia or pleural effusions. No pneumothorax. IMPRESSION: No interval change. Radiology Report INDICATION: ___ s/p aneurysm rupture in ___ s/p clipping and VP shunt placement presents with exposed VP shunt hardware now s/p externalized EVD and removal of abdominal hardware now w/ ?allergic reaction to contrast vs meropenem.// Questions to be answered: new o2 requirement, ?PNA vs pulm edema TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of a right PICC line projects over the mid SVC. A feeding tube extends below the level the diaphragm but beyond the field of view of this radiograph. There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiac silhouette is within normal limits. IMPRESSION: No focal consolidation or evidence of pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p aneurysm rupture in ___ s/p clipping and VP shunt placement presents with exposed VP shunt hardware now s/p externalized EVD and removal of abdominal hardware now w/ ?allergic reaction to contrast vs meropenem.// New o2 requirement, ?PNA vs pulm edema IMPRESSION: In comparison with the study of ___, the monitoring and support devices are unchanged. There are lower lung volumes, but otherwise no evidence of cardiomegaly, vascular congestion, or acute focal pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ w/ hx of aneurysm rupture s/p clipping and VP shunt p/w exposed VP shunt hardware and CSF infection now s/p externalized EVD p/w allergic reaction to meropenem vs. IV contrast, in ICU for monitoring and meropenem desensitization.// assess size of ventriles 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 = 747.1 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Comparison include CT head dated ___ and CTA dated ___.. FINDINGS: Re-demonstrated, is a left frontal approach ventriculostomy with a tip that terminates in the body of the left ventricle, (2:18). No interval change in ventricular size when compared to prior CT head dated ___. Re-demonstrated, unchanged right frontoparietal and left parietal temporal encephalomalacia, (02:25). Again seen, there are confluent hypodensities in the subcortical and periventricular white matter, nonspecific, but likely sequela of chronic microvascular ischemic disease. Metallic artifact from aneurysm clip results in suboptimal evaluation of adjacent structures. Interval improvement in degree of pneumocephalus. There is no evidence of fracture. There is mucosal thickening of the ethmoid sinus, (02:11). There is mucosal thickening air fluid level of the right sphenoid sinus, (02:10). Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Re-demonstrated, is a nasogastric tube in the right nares, (2:5). IMPRESSION: 1. Again seen, is a left frontal approach ventriculostomy the tip terminating in the left ventricle. 2. No interval change in ventricular size when compared to prior dated ___. 3. Unchanged right frontoparietal and left parietal temporal encephalomalacia. No acute intracranial hemorrhage or large territory infarct. 4. Interval improvement in degree of pneumocephalus. Radiology Report EXAMINATION: Video oropharyngeal swallow study INDICATION: ___ w/ hx of aneurysm rupture s/p clipping and VP shunt p/w exposed VP shunt hardware and CSF infection now s/p externalized EVD p/w allergic reaction to meropenem vs. IV contrast, in ICU for monitoring and meropenem desensitization.// ?aspiration--perform on ___ TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the Speech-Language Pathologist from the Voice, Speech & Swallowing Service. Multiple consistencies of barium were administered. DOSE: Fluoro time: 01:53 min. COMPARISON: None available. FINDINGS: Penetration was noted. No aspiration. Moderate residuals noted. IMPRESSION: Penetration without aspiration. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with hydrocephalus s/p VP shunt removal and EVD removal. Post-EVD removal scan. 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 = 747.1 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: CT head without contrast ___ and multiple earlier dates. FINDINGS: Patient is status post left frontal EVD removal. Bilateral frontal burr holes and right-sided craniotomy are noted. There is increased pneumocephalus compared to ___ within right greater than left frontal horns and along the right frontal parenchymal tract of the more remote right VP shunt catheter which was last seen on ___. However, there is no evidence for pneumocephalus along the left frontal track of the recently removed left EVD. Diffuse ventriculomegaly is unchanged. Left parietal and posterior frontal encephalomalacia is again seen. Hypodensity with mild volume loss is also again seen in the anterior right temporal lobe. No new edema is seen. Allowing for streak artifact from the presumed aneurysm clip in the anterior right suprasellar cistern, there is no evidence for acute hemorrhage. Nasogastric tube is partially visualized. There are dependent secretions versus dependent mucosal thickening in the right sphenoid sinus, as well as right posterior and anterior ethmoid air cells, similar to prior, which may be due to prolonged supine positioning in the inpatient setting. IMPRESSION: 1. Status post left frontal EVD removal. Stable diffuse ventriculomegaly. 2. Increased pneumocephalus compared to ___ within right greater than left frontal horns and along the right frontal parenchymal tract of the more remote right VP shunt catheter which was last seen on ___. However, there is no evidence for pneumocephalus along the left frontal track of the recently removed left EVD. 3. No evidence for acute hemorrhage or new areas of edema. 4. Left parietal/posterior frontal encephalomalacia, and mild volume loss in the anterior temporal lobe, are again demonstrated. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 INDICATION: ___ year old woman with s/p EVD removal// hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Head CT dated ___. FINDINGS: The patient is status post bilateral craniotomies. Status post removal of bilateral ventriculostomy catheters with foci of pneumocephalus along the previous catheter tracts, right greater than left. Extent of pneumocephalus within the frontal horns of the lateral ventricles has decreased on the right, and resolved on the left. Aneurysm clip is seen within the right suprasellar cistern. Ventricular size and configuration is unchanged compared to prior. There is no evidence of hemorrhage or acute territorial infarction. Encephalomalacia within the left parietal lobe and right temporal lobe is unchanged. Periventricular white matter hypodensities are also unchanged, likely representing the sequela of chronic microvascular ischemia. There is no evidence of fracture. Mild ethmoid opacification bilaterally. Air-fluid levels noted within the right sphenoid sinus, unchanged. The visualized portion of the mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. A ___ intestinal tube is partially imaged. IMPRESSION: 1. Stable ventriculomegaly. New small focus of pneumocephalus along the catheter tract. No evidence of new hemorrhage. 2. Unchanged encephalomalacia within the left parietal and right temporal lobes. Radiology Report INDICATION: ___ year old woman with exposed vp shunt// ?obstruction TECHNIQUE: SHUNT SERIES AP AND LATERAL VIEWS OF THE HEAD AND NECK, FRONTAL VIEW OF THE CHEST AND FRONTAL VIEW OF THE ABDOMEN COMPARISON: None. FINDINGS: VP shunt from a right frontal approach is seen coursing over the right head, along the right neck, right chest, and into the right abdomen, where it coils in the pelvis. No definite shunt discontinuity or kink is seen. Multilevel degenerative changes along the cervical spine are not well assessed, but appears severe at least at C2 and C3, not well evaluated at other levels. Chest: Minimal left base atelectasis is seen without focal consolidation. Minimal biapical pleural thickening. No pleural effusion or pneumothorax is seen. Cardiac silhouette size is top-normal. Mediastinal contours are unremarkable. Abdomen: Moderate colonic fecal loading is seen without evidence of bowel obstruction. Partially imaged hardware in the right femur. Severe right hip degenerative changes. IMPRESSION: Right-sided VP shunt which coils distally in the pelvis. No definite shunt discontinuity or kink. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with exposed shunt// ?___ 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 7.0 s, 14.5 cm; CTDIvol = 48.4 mGy (Head) DLP = 702.4 mGy-cm. Total DLP (Head) = 702 mGy-cm. COMPARISON: Shunt series performed less than an hour ago. FINDINGS: The right frontal approach VP shunt terminates in the body of the right lateral ventricle. The size of the ventricles is prominent. There is left frontoparietal encephalomalacia. There is no evidence of large territorial infarction,hemorrhage,edema, or mass. Bilateral periventricular and subcortical white matter hypodensities are nonspecific but most likely representing sequela of chronic small vessel ischemic changes. Atherosclerotic calcifications are seen in the bilateral carotid siphons. There is no evidence of acute fracture. Evidence of right temporal craniotomy. There is partial opacification of the ethmoid air cells and sphenoid sinuses. Otherwise, the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Right frontal approach VP shunt terminates in body of the right lateral ventricle. The ventricles appear prominent, with possible mild hydrocephalus. Interval change cannot be evaluated due to lack of prior examination. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman s/p VP shunt externalization and wound closure on ___ now drain not draining for several hours. Concern for development of hydrocephalus. STAT NCHCT to evaluate ventricle size.// Concern for hydrocephalus in setting of non-functioning EVD. STAT NCHCT to evaluate ventricle size. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 6.4 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 1,605 mGy-cm. COMPARISON: ___ CT head without contrast FINDINGS: Post right frontotemporal craniotomy changes are again noted. The right frontal approach ventriculostomy catheter tip terminates within the body of the right lateral ventricle, in unchanged position. There is no significant change in size of the previously seen ventriculomegaly. New small hyperdense blood is visualized in the dependent regions of the occipital horns of the bilateral lateral ventricles. There is no evidence of acute large territory infarction,edema, or mass. The left frontoparietal encephalomalacia is unchanged. There is no evidence of fracture. Unchanged moderate mucosal thickening of the ethmoid air cells and mild mucosal thickening of maxillary sinuses. The remainder of 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. A right frontal approach ventriculostomy catheter tip remains in unchanged position. 2. Unchanged ventriculomegaly. 3. New small hyperdense blood within the dependent regions of the occipital horns. 4. Pneumocephalus which is new since the previous CT and could be related to manipulation of the shunt catheter. Radiology Report INDICATION: ___ year old woman with new onset tachypnea s/p vomiting. Concern for aspiration PNA.// CXR to evaluate for etiology of tachypnea. TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with bibasilar atelectasis. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. Patchy parenchymal opacity in the left lung base most likely represents subsegmental atelectasis. The VP shunt has been removed in the interim. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Wound eval Diagnosed with Oth complication of nervous system prosth dev/grft, init, Oth places as the place of occurrence of the external cause temperature: 97.9 heartrate: 74.0 resprate: 17.0 o2sat: 93.0 sbp: 126.0 dbp: 72.0 level of pain: 0 level of acuity: 3.0

Discharge Instructions Ventriculoperitoneal Shunt Infection and Removal of shunt Surgery You had surgery to have your VP shunt removed. Your incisions should be kept dry until sutures or staples 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 You have been discharged on Keppra (Levetiracetam) and Valproic Acid. These medications help to prevent seizures. Please continue these medication as indicated on your discharge instruction. It is important that you take these medications consistently and on time. You have been discharged on Meropenem. This medication is for treating infection. Please continue this medication as indicated on your discharge instruction. It is important that this medication is given consistently and on time, as you needed to undergo desensitization to this medication. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: Headache or pain along your incision. Some neck tenderness along the shunt tubing. 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. 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: lisinopril Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Small bowel resection, lysis of adhesions History of Present Illness: ___ with h/o severe HTN, Hep C, stage IV CKD ___ cryoglobulinemia/MPGN, SBO from internal hernia s/p reduction ___ by ___, transferred from ___ for management of SBO seen on imaging. Patient reports ___ days of intermittent crampy upper abdominal pain, radiating to lower abdomen. Progressive abdominal distention, no BMs, no flatus as well for ___ days. +NBNB emesis for ___ days now. Presented to ___, had a KUB there with +dilated small bowel loops and air fluid levels suggestive of small bowel obstruction. NGT was placed, unknown amount of output at ___. Given that patient has most of her care here, she was transferred to ___ for further management of her SBO. In the ___ ED, initial vitals were 98.4 70 ___. She was no longer complaining of any n/v or abdominal pain at that time. NGT put out 250cc of bilious material there. She specifically denied any headaches, vision changes, chest pain, shortness of breath or lateralizing weakness in the setting of her elevated BPs. Reportedly has been taking her home anti-hypertensives, but has long-standing history of poorly controlled BPs. Patient was seen by surgery in the ED for her SBO, they recommended conservative management, no CT abdomen/pelvis and admission to medicine given uncontrolled blood pressures. Patient was given IV boluses of labetalol, 10mg followed by 20mg in addition to IV hydralazine x1 with no improvement in her BPs. She was subsequently started on a labetalol drip with improvement in her BPs to the 180s-190s/100s, she was admitted to ___ MICU given that she was on a labetalol drip for her uncontrolled BPs. Past Medical History: -HCV infection -Cryoglobulinemia (derm & renal) -Systolic CHF (EF 30%) -Pericardial effusion and severe hypertension after ERCP in ___ to remove a CBD stone, c/b pancreatitis, c/p ileus requiring exlap with LOA and reduction of internal hernia -CKD Stage IV (baseline Cr around 2.5) -Chronic anemia requiring transfusions -Portal gastropathy -s/p cholecystectomy -Choledocholithiasis Social History: ___ Family History: No family history of liver disease. Reports history of HTN in Mother and ___ Aunt. No history of CAD. Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress, appears fatigued HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple CV: Regular rate and rhythm, normal S1/S2, +S3, ___ systolic murmur throughout precordium, best heard @___ Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, nondistended, +diffusely ttp, worst ___, no rebound or guarding, hypoactive bowel sounds GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred DISCHARGE PHYSICAL EXAM: VITALS: 98.5, 178/91, 64, 18, 97% GENERAL: NAD, pleasant HEENT: Sclera anicteric NECK: supple CV: RRR, normal S1/S2, +S3, ___ systolic murmur throughout precordium loudest at ___ Lungs: CTAB Abdomen: +BS, soft, non-tender, non-distended, steri stripsa in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ pitting edema in the bilateral lower extremities Skin: hyperpigmentation of the bilateral legs, which she reports is chronic Neuro: A+Ox3, CNII-XII grossly intact Pertinent Results: ADMISSION LABS: ___ 12:24AM BLOOD WBC-6.3 RBC-3.87* Hgb-10.3* Hct-31.3* MCV-81* MCH-26.7* MCHC-33.0 RDW-14.9 Plt ___ ___ 12:24AM BLOOD Neuts-78.9* Lymphs-9.7* Monos-6.9 Eos-4.0 Baso-0.4 ___ 12:24AM BLOOD ___ PTT-34.6 ___ ___ 12:24AM BLOOD Glucose-93 UreaN-38* Creat-1.8* Na-143 K-3.3 Cl-108 HCO3-25 AnGap-13 ___ 12:24AM BLOOD ALT-16 AST-35 LD(LDH)-242 AlkPhos-66 TotBili-0.4 ___ 12:24AM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.3# Mg-2.3 ___ 12:42AM BLOOD Lactate-0.6 ___ 05:27AM BLOOD Cortsol-28.2* ___ 05:27AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.3 ___ 05:27AM BLOOD Glucose-107* UreaN-28* Creat-2.3* Na-140 K-3.7 Cl-100 HCO3-29 AnGap-15 ___ 05:27AM BLOOD WBC-8.0 RBC-4.08* Hgb-10.7* Hct-32.9* MCV-81* MCH-26.3* MCHC-32.7 RDW-14.5 Plt ___ MICRO: - ___ 8:59 am PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: Reported to and read back by ___ ___ 9:50AM. BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. - ___ 3:00 am IMMUNOLOGY **FINAL REPORT ___ HCV VIRAL LOAD (Final ___: 977,197 IU/mL. IMAGING: - CT ABD/PEL (___): IMPRESSION: 1. High-grade, partial small bowel obstruction with a possible transition point in the right upper quadrant, likely related to surgical adhesions. No free air. 2. Small right nonhemorrhagic pleural effusion. - ECHO (___): The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is high (>4.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. 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 increased transaortic velocity is likely related to high cardiac output. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a very small pericardial effusion. ***IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional systolic function. Increased PCWP. Increased PCWP. Compared with the prior study (images reviewed) of ___, regiong left ventricular systolic function is now normal and the severity of mitral regurgitation is now reduced. - RENAL U/S (___): IMPRESSION: No evidence of renal artery stenosis. There is a slight increase in size of the right upper pole simple cyst. - CT ABD/PEL (___): IMPRESSION: 1. New moderate amount of non hemorrhagic ascites. There is no evidence for leak or perforation. 2. No obstruction. Nonspecific scattered air fluid levels within large and small bowel without dilatation. Edematous loops of bowel within the mid abdomen. 3. Prominent ascending aorta, measuring 4.3 cm. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY Hold if SBP <100 2. HydrALAzine 100 mg PO TID Hold if SBP <100 3. Labetalol 600 mg PO TID Hold if SBP <100 or HR <60 4. Aspirin 81 mg PO DAILY 5. Torsemide 40 mg PO DAILY 6. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 7. CloniDINE 0.2 mg PO BID 8. Isosorbide Mononitrate 30 mg PO TID Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. CloniDINE 0.2 mg PO BID 3. HydrALAzine 100 mg PO Q6H RX *hydralazine 100 mg 1 tablet(s) by mouth every six (6) hours Disp #*90 Tablet Refills:*0 4. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY RX *isosorbide mononitrate 30 mg 3 tablet extended release 24 hr(s) by mouth once a day Disp #*90 Tablet Refills:*0 5. Labetalol 400 mg PO TID RX *labetalol 200 mg 2 tablet(s) by mouth three times a day Disp #*180 Tablet Refills:*0 6. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Simethicone 80 mg PO QID RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*30 Tablet Refills:*0 8. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 10. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*0 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 12. Aspirin 81 mg PO DAILY 13. Vitamin D 50,000 UNIT PO 1X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Small bowel obstruction, hypertensive urgency, acute on chronic kidney disease, Cryoglobulinemia Secondary: hepatitis C, chronic systolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report AP CHEST, 10:12 A.M., ___ HISTORY: A ___ woman with a nasogastric tube for small bowel obstruction. Evaluate tube placement. IMPRESSION: AP chest compared to most recent prior chest radiograph ___: Nasogastric tube ends in the distal stomach. Gastric fundus is not distended, but the rest the stomach is excluded from the examination. Mild cardiomegaly unchanged. Moderate left lower lobe atelectasis and small to moderate left pleural effusion both increased. Small right pleural effusion unchanged. Lungs are otherwise clear. No pneumothorax. Radiology Report HISTORY: ___ woman with likely recurrent SBO, prior history of small bowel obstruction in the jejunum. Study requested for evaluation of complete versus incomplete obstruction. COMPARISON: Prior abdominal/pelvic CT from ___ and ___. TECHNIQUE: 64 row MDCT axial images were obtained through the abdomen and pelvis after the administration of oral contrast. No IV contrast was provided as requested by team (Cr 2.0). Coronal and sagittal reformats were generated. Total exam DLP: 342.77 mGy-cm. FINDINGS: There is a small nonhemorrhagic right pleural effusion. The heart is enlarged. Visualized portions of the pericardium are unremarkable. CT OF THE ABDOMEN: Evaluation of solid abdominal viscera is limited by lack of IV contrast. No liver lesions are identified. There is no intrahepatic biliary duct dilatation. The gallbladder has been surgically removed. Cholecystectomy clips are present in the right upper quadrant. Limited examination of the pancreas, spleen and adrenal glands are unremarkable. There is re- demonstration of a 7.7 x 7.3 cm cyst arising from the upper pole of the right kidney (2:19). The kidneys are otherwise within normal limits. A nasogastric tube terminates in the gastric fundus. Multiple loops of dilated small bowel are present, with a possible transition point likely within the right upper abdomen (2:43, 300b:25). The distal ileum is collapsed. Air however is seen within the colon but there is no contrast within the colon. Surgical sutures are seen within a small bowel (2: 66). No ascites, free air or abdominal wall hernias are noted. The intra-abdominal aorta and its branches demonstrate atherosclerotic calcifications. CT OF THE PELVIS: The uterus has been surgically removed. Visualized portions of the urinary bladder are within normal limits. OSSESOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is present. IMPRESSION: 1. High-grade, partial small bowel obstruction with a possible transition point in the right upper quadrant, likely related to surgical adhesions. No free air. 2. Small right nonhemorrhagic pleural effusion. These findings were discussed with ___ by Dr. ___ telephone on ___ at 3:00 ___, time of discovery. Radiology Report HISTORY: Evaluation for contrast in the colon in a patient with a small bowel obstruction. COMPARISON: CT abdomen and pelvis ___. FINDINGS: Portable supine frontal abdominal radiographs demonstrate dilated loops of small bowel with a paucity of air in the colon consistent with small bowel obstruction. An upper enteric tube ends in the stomach. There are clips in the right upper quadrant. No contrast is seen in the small or large bowel. IMPRESSION: 1. No contrast is identified in the small or large bowel. 2. Dilated loops of small bowel consistent with obstruction. Radiology Report EXAM: Chest single AP portable view. CLINICAL INFORMATION: Small-bowel obstruction, status post ex lap, CO2 retention post-op. ___. FINDINGS: An enteric tube is again seen coursing below the level of the diaphragm, inferior aspect not included on the image. There is persistent left base opacity which may be due to atelectasis with possible small pleural effusion. A trace right pleural effusion is difficult to exclude. Cardiac and mediastinal silhouettes are stable. IMPRESSION: Persistent left base opacity, likely combination of pleural effusion and atelectasis. Radiology Report INDICATION: PICC placement. COMPARISON: Chest radiograph on ___. FINDINGS: AP view of the chest. Right PICC ends in the low SVC. Heart size is top normal which is stable. Mediastinal and hilar contours are stable. There is mild left lower lobe atelectasis and likely small left pleural effusion which is unchanged. No pneumothorax. The right lung is clear. IMPRESSION: Right PICC ends in the low SVC. Unchanged small left pleural effusion and left basilar atelectasis. Radiology Report HISTORY: Evaluation for ileus or obstruction in a patient with small bowel obstruction status post exploratory laparotomy with lysis of adhesions and bowel resection. COMPARISON: Abdominal radiograph ___. FINDINGS: Portable supine frontal abdominal radiograph demonstrate gasesous distention and minimal dilation of the small bowel consistent with ileus. There is minimal air in non-dilated loops of colon. There are clips in the right upper quadrant. There are new midline staples. The previously seen upper enteric tube has been removed. IMPRESSION: Mild dilatation of the small bowel is consistent with ileus. Radiology Report HISTORY: Hypertension evaluate for renal artery stenosis. TECHNIQUE: Grayscale and duplex Doppler of ultrasound of the kidneys were obtained. COMPARISON: ___. FINDINGS: The right kidney measures 13 cm. The left kidney measures 11 cm. There is a thin-walled anechoic cyst arising from the upper pole of the right kidney measuring 7.5 x 6.5 x 7.1 cm. There is no evidence of hydronephrosis or solid masses. Renal parenchyma is echogenic consistent with parenchymal disease. Doppler examination is somewhat compromised due to the patient movement. The resistive indices of the intrarenal arteries as well as the main renal artery ranges from 0.7-0.9. The bilateral main renal veins are patent with appropriate directional flow. IMPRESSION: No evidence of renal artery stenosis. There is a slight increase in size of the right upper pole simple cyst. Radiology Report PORTABLE CHEST, ___ COMPARISON: ___ radiograph. FINDINGS: Recently placed nasogastric tube terminates within the stomach. Cardiomediastinal contours are stable in appearance. Moderate right pleural effusion has substantially increased in size since the previous study, and a small-to-moderate left pleural effusion is also slightly larger. Adjacent areas of atelectasis are present in the bases, but remainder of the lungs are clear. Radiology Report INDICATION: New right IJ placement. COMPARISON: Chest radiograph ___. FINDINGS: There is interval placement of a right internal jugular line with tip terminating in the mid SVC. There is no pneumothorax. Again demonstrated is a right PICC line terminating in the mid to upper SVC. There is also an enteric tube with the tip not visualized. There is a stable small left pleural effusion. There is also a stable moderate right pleural effusion. There is no focal consolidation concerning for pneumonia. IMPRESSION: Successful placement of a right internal jugular line with tip in the mid SVC. No pneumothorax. Radiology Report HISTORY: Severe abdominal pain after surgery. FINDINGS: In comparison with study of ___, there is persistent opacification at the right base consistent with pleural effusion and volume loss in the right lower lobe. There is stable enlargement of the cardiac silhouette. Pulmonary vasculature is essentially within normal limits. The right IJ catheter remains in place but the nasogastric tube appears to have been removed. In the absence of a true upright image, the possibility of free intraperitoneal gas cannot be excluded. Radiology Report HISTORY: Severe abdominal pain after surgery. FINDINGS: In comparison with study of ___, there is less dilatation of gas-filled bowel which is essentially within normal limits. If there is serious clinical concern for a perforation or obstruction, CT would be the next imaging procedure. Radiology Report HISTORY: Severe hypertension, hepatitis and stage IV chronic kidney disease, status post exploratory laparotomy and small bowel resection for a small bowel obstruction. Now presenting with persistent abdominal pain. TECHNIQUE: MDCT axial images were acquired from the dome of the liver to the pubic symphysis without the administration of intravenous contrast. Oral contrast was provided. DLP: 638.60 mGy/cm COMPARISON: CT pelvis ___. FINDINGS: Abdomen: There are bilateral moderate-sized pleural effusions, right greater than left, which have increased from prior. There is adjacent compressive atelectasis. The heart is enlarged. The ascending aorta is prominent, measuring 4.3 cm. Evaluation of the intra-abdominal contents is limited by the lack of IV contrast. Within this limitation the liver, adrenal glands, spleen and pancreas are unremarkable. The gallbladder is surgically absent. A large simple appearing cyst is again seen in the upper pole of the right kidney, measuring 6 cm and is unchanged from prior. There is no hydronephrosis or nephrolithiasis. The adrenal glands are normal. There is a new moderate amount of ascites. There is no evidence for obstruction and contrast has progressed to the descending colon. Surgical sutures are noted within the right lower quadrant. There are scattered air fluid levels within loops of small and large bowel, however no dilatation. There appears to be edematous loops of small bowel within the mid abdomen. There is no free air. There is no pneumatosis or portal venous air. Pelvis: The bladder, rectum and uterus are unremarkable. Bones: There are no suspicious osseous lesions. IMPRESSION: 1. New moderate amount of non hemorrhagic ascites. There is no evidence for leak or perforation. 2. No obstruction. Nonspecific scattered air fluid levels within large and small bowel without dilatation. Edematous loops of bowel within the mid abdomen. 3. Prominent ascending aorta, measuring 4.3 cm. These findings were discussed with Dr. ___ by Dr. ___ at the time of image acquisition in person. Radiology Report HISTORY: New ascites with abdominal pain. COMPARISON: CT abdomen pelvis: ___ OPERATORS: Drs. ___ and ___ PROCEDURES: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure four-quadrant ultrasound identified a suitable pocket for access in the left lower quadrant. The patient was prepped and draped in the usual sterile fashion. A preprocedure timeout was performed using 3 patient identifiers per ___ protocol. Local anesthesia was achieved through the infiltration of 1% lidocaine into the skin and subcutaneous tissues. Under continuous ultrasound guidance, a 5 ___ ___ catheter was inserted into the peritoneal cavity. Initially, 20 cc were withdrawn for requested hematology, chemistry and micro studies and subsequently 1 liter of serous ascites was withdrawn for cytologic assessment. The catheter was removed and a bandage applied. The patient tolerated the procedure well without immediate postprocedure complications. The attending physician, ___, was present for this procedure. IMPRESSION: Technically successful ultrasound-guided diagnostic and therapeutic paracentesis yielding 1 liter of serous ascites. Radiology Report HISTORY: Cryoglobulinemia, hypertensive urgency, small-bowel obstruction status post ex lap lysis of adhesions, resection of distal small bowel stricture, primary anastomosis with leukocytosis found to have SBP, now complaining of worsening abdominal pain, evaluate for free air and bowel gas pattern. COMPARISON: Abdominal radiograph from ___ and CT abdomen and pelvis from ___ 1,013. FINDINGS: Upright and supine frontal radiographs of the abdomen demonstrate decrease in small bowel dilatation with forward progress of oral contrast from prior CT now reaching the sigmoid colon. No free intraperitoneal air. Persistent left lower quadrant retrocardiac opacity with air bronchograms is better evaluated on chest radiograph ___. IMPRESSION: Decrease in small bowel dilatation with forward progress of oral contrast from prior CT now reaching the sigmoid colon. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ABD PAIN/?SBO Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 98.4 heartrate: 70.0 resprate: 18.0 o2sat: 98.0 sbp: 202.0 dbp: 130.0 level of pain: 0 level of acuity: 3.0

Dear ___, ___ was pleasure taking care of you at ___ ___. You were initially admitted to the ICU for treatment of your small bowel obstruciton (SBO) and very elevated blood pressure. You underwent a surgical operation to relieve your SBO, and you tolerated this procedure well. You were able to eat and drink and have normal bowel movements prior to discharge. While you were having your SBO, you also developed some acute decrease in your kidney function. This gradually improved as your condition improved. You were found to have an infection in your belly called peritonitis. For this you are on treatment with two antibiotics, one called ciprofloxacin and one called flagyl. You will take ciprofloxacin twice a day for 4 more days, then daily ongoing. You will take flagyl three times per day for 4 more days, then stop. For treatment of your very elevated blood pressure you required high doses of IV blood pressure medications. Your blood pressure gradually decreased. You were transitioned to oral blood pressure medicaitons prior to discharge. It appears that you have very elevated blood pressure at baseline, and your blood pressure was at your baseline prior to discharge. Please continue to take these blood pressure medications after you are discharged from the hospital. Also, please discuss with your PCP if you require any additional work-up of your high blood pressure as an outpatient. Despite your elevated blood pressure, you did not have any symptoms. If you develop symptoms of headache, vision changes, or any other symptoms that concern you while your blood pressure is very elevated, please return to the Emergency Department immediately. For your cryoglobulinemia you were evaluated by the phresis team. They felt that you would benefit from phresis treatments. A large dialysis line was placed in your neck vein, and you were started on phresis. You will need to follow up with your renal doctors to determine if you need any additional treatments after discharge. 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: F Service: MEDICINE Allergies: Enalapril / Januvia / felodipine Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F with multiple medical problems here with BLE weakness found to be due to an L4 vertebral fracture. Patient called PCP yesterday complaining of BLE weakness. She uses walker at baseline, but over the ___ hours prior to presentation she had been unable to get out of bed. There was no lateralization or upper extremity symptoms. At some point, patient rolled out of bed and hit back. No head strike or LOC. Patient is unable to tell me exactly when this happened. She says it was ___ or ___ but does not believe it was 1 week ago. Patient's PCP called EMS and patient was BIBA for evaluation. In the ED, initial vital signs were 98.6, 64, 230/78, 20, 95% RA. Labs were remarkable for Hgb 10.4 (baseline), Cr 2.2 (baseline), troponin 0.29 (baseline), BNP 20,384, and lactate 0.9. Imaging was remarkable for CT ___ with burst fracture of L4 vertebral body with 6 mm of retropulsion. MRI ___ with no abnormal cord signal and mild canal narrowing. Ortho Spine consulted. They recommended against MRI. The recommended that TLSO brace to be worn out of bed. No need for cervical or log roll precautions. Patient was given gentle IVF and hydralazine with some improvement in hypertension. She was admitted to Medicine. On transfer, vital signs were 98, 60, 197/80, 22, 95% RA. On the floor, patient reports that she is feeling well. She denies back pain, although she did have some mild lumbar back pain earlier. Patient denies fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, and urinary symptoms. She reports that her lower extremity strength and sensation feels at baseline. She denies fecal or urinary incontinence and saddle anesthesia. Review of Systems: As per HPI Past Medical History: - Hypertension - Hyperlipidemia - Type 2 diabetes. Diet-controlled. - Diastolic CHF - CKD stage V with baseline Cr 1.8-2.2 - OSA on CPAP - Osteoporosis - Osteoarthritis - Incidental syrinx at C1-T10 - Gout - Hypercalcemia NOS Social History: ___ Family History: Father died of cerebral hemorrhage. Mother died of PNA. Son with glomerulonephritis. Physical Exam: Admission GENERAL: Elderly female in no distress HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear NECK: Supple, JVP at angle of mandible CARDIAC: RRR, nl S1/S2, SEM at RUSB radiating to carotids, crescendo/decrescendo murmur at apex LUNG: Limited exam, faint crackles at bases bilaterally ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: 2+ pitting edema bilaterally NEURO: AAOx2 (thinks it is ___ CN II-XII intact, upper extremity strength intact, able to lift both legs off bed against resistance, ___ plantarflexion and dorsiflexion bilaterally, sensation intact throughout, DTR's 1+ bilaterally SKIN: Warm and dry, no concerning lesions Discharge GENERAL: Elderly female in no distress HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear NECK: Supple, JVP 9cm CARDIAC: RRR, nl S1/S2, SEM at RUSB radiating to carotids, crescendo/decrescendo murmur at apex LUNG: Limited exam, faint crackles at bases bilaterally ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: 2+ pitting edema bilaterally NEURO: AAOx2 CN II-XII intact, upper extremity strength intact, able to lift both legs off bed against resistance, ___ plantarflexion and dorsiflexion bilaterally, sensation intact throughout, DTR's 1+ bilaterally SKIN: Warm and dry, no concerning lesions Pertinent Results: Admission ___ 05:40PM BLOOD WBC-8.3 RBC-3.56* Hgb-10.4* Hct-33.3* MCV-94 MCH-29.3 MCHC-31.3 RDW-17.0* Plt ___ ___ 05:40PM BLOOD Neuts-77.7* Lymphs-14.3* Monos-5.9 Eos-1.9 Baso-0.3 ___ 05:40PM BLOOD Glucose-131* UreaN-42* Creat-2.2* Na-144 K-4.5 Cl-111* HCO3-24 AnGap-14 ___ 05:40PM BLOOD CK(CPK)-219* ___ 05:40PM BLOOD CK-MB-4 cTropnT-0.29* ___ ___ 07:27AM BLOOD Albumin-3.1* Calcium-10.4* Phos-3.3 Mg-2.0 ___ 11:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:30PM URINE Blood-SM Nitrite-NEG Protein-600 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 11:30PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 Discharge ___ 07:00AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.2* Hct-27.8* MCV-92 MCH-30.4 MCHC-33.0 RDW-17.7* Plt ___ ___ 03:00PM BLOOD Glucose-132* UreaN-76* Creat-2.7* Na-142 K-3.8 Cl-108 HCO3-24 AnGap-14 Pertinent ___ 05:40PM BLOOD Glucose-131* UreaN-42* Creat-2.2* Na-144 K-4.5 Cl-111* HCO3-24 AnGap-14 ___ 07:29AM BLOOD UreaN-64* Creat-2.3* Na-146* K-4.3 Cl-114* HCO3-24 AnGap-12 ___ 07:32AM BLOOD Glucose-104* UreaN-67* Creat-2.4* Na-142 K-3.9 Cl-110* HCO3-21* AnGap-15 ___ 06:50AM BLOOD Glucose-110* UreaN-68* Creat-2.5* Na-144 K-3.5 Cl-109* HCO3-26 AnGap-13 ___ 06:45AM BLOOD Glucose-109* UreaN-76* Creat-2.7* Na-140 K-4.0 Cl-107 HCO3-26 AnGap-11 ___ 03:00PM BLOOD Glucose-132* UreaN-76* Creat-2.7* Na-142 K-3.8 Cl-108 HCO3-24 AnGap-14 ___ 07:29AM BLOOD RENIN-0.74 ___ 07:29AM BLOOD ALDOSTERONE-PND Renal U/S ___ IMPRESSION: 1. No evidence of tardus parvus waveforms. 2. Patent bilateral main renal veins. 3. Multiple bilateral renal cysts which appear simple ___ CT head w/o contrast IMPRESSION: 1. No signs of intracranial bleed. 2. Involutional changes and probable chronic small vessel ischemic disease. MR ___ ___ IMPRESSION: 1. Study is degraded by motion, especially on axial images. 2. Please note that the numbering of vertebral body levels in this study designates the lowest rib bearing vertebral body level as the T12 level, which differs from the ___ CT lumbar spine CT (where this level is designated L1, and in which the compression fracture of concern is designated the L4 level). Please note that prior to any surgical intervention, appropriate levels should be established. 3. Transitional lumbar spine anatomy with partial sacralization of L5 vertebral body. 4. Compression fracture of L3 with 6 mm retropulsion of the superior endplate resulting in moderate to severe spinal canal narrowing at L2-3 in combination with additional degenerative changes. 5. Additional multilevel multifactorial lumbar spondylosis as described above. 6. Partially visualized nonspecific at least partially cystic bilateral renal lesions as described. While findings may represent renal cysts, other etiologies are not excluded on the basis of this noncontrast examination. Recommend clinical correlation. If clinically indicated, further evaluation may be obtained via renal ultrasound. CT ___ IMPRESSION: 1. Unstable 2 -column burst fracture of the L4 vertebral body with 6 mm of retropulsion. Moderate multilevel degenerative changes. 2. Multi-cystic right kidney, incompletely imaged. When compared to CT torso of ___, these are unchanged. CT head ___ IMPRESSION: No acute intracranial abnormality. CT T-spine ___ IMPRESSION: 1. No fracture traumatic or malalignment of the thoracic spine. 2. 7 mm peripheral nodular density in the right lower lobe, possibly scarring from prior infection. Followup chest CT is recommended in three months to ensure stability. 3. Trace to small nonhemorrhagic bilateral pleural effusions. 4. Moderate cardiomegaly and trace pericardial effusion. CT c-spine ___ IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Mild to moderate multilevel degenerative disc disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QMON 3. Ferrous GLUCONATE 324 mg PO DAILY 4. Gabapentin 300 mg PO DAILY 5. HydrALAzine 50 mg PO TID 6. Simvastatin 40 mg PO DAILY 7. Sodium Bicarbonate 650 mg PO BID 8. Isosorbide Dinitrate SA 40 mg PO Q8H 9. Valsartan 80 mg PO BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion 11. Furosemide 20 mg PO BID 12. Aspirin 81 mg PO DAILY 13. Carvedilol 25 mg PO BID 14. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Carvedilol 25 mg PO BID 4. Ferrous GLUCONATE 324 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion 6. Gabapentin 300 mg PO DAILY 7. HydrALAzine 50 mg PO TID 8. Isosorbide Dinitrate 40 mg PO Q8H 9. Simvastatin 20 mg PO DAILY 10. Sodium Bicarbonate 650 mg PO BID 11. Valsartan 160 mg PO BID 12. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 13. Amlodipine 5 mg PO DAILY 14. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON 15. Acetaminophen 1000 mg PO Q8H pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary L4 burst fracture Hypertensive Emergency/Urgency Hypernatremia Acute on chronic kidney injury Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane) with LSO BRACE. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ woman with a history of L4 fracture and a TLSO brace and partially presenting with nausea vomiting. Evaluate for intracranial bleed. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 785 mGy-cm CTDI: 54 mGy COMPARISON: CT from ___ and ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There are prominent ventricles and sulci. Subcortical and periventricular white matter hypodensities are again seen. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are intact, and the right lens is not seen. IMPRESSION: 1. No signs of intracranial bleed. 2. Involutional changes and probable chronic small vessel ischemic disease. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with refractory HTN TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Renal ultrasound dated ___ FINDINGS: The right kidney measures 10.9 cm. Multiple cysts are noted within the right renal cortex, the largest within the interpolar region measuring 6.4 x 5.0 x 5.0 cm. This appears minimally increased when compared to prior examination dated ___. The left kidney measures 10.1 cm. Within the lower pole of the left kidney, a 2.3 x 1.1 x 2.0 cm cyst demonstrates no internal flow. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is moderately well distended and normal in appearance. Doppler: Evaluation is limited secondary to patient rapid breathing. Flow is seen within the right and left main renal vein. Intrarenal arterial waveforms demonstrate a brisk systolic upstroke and antegrade diastolic flow. Peak systolic velocity within the right main renal artery is 25.3 centimeters/second. Peak systolic velocity within the left main renal artery is 33.7 centimeters/second. IMPRESSION: 1. No evidence of tardus parvus waveforms. 2. Patent bilateral main renal veins. 3. Multiple bilateral renal cysts which appear simple. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL, CONGESTIVE HEART FAILURE, UNSPEC temperature: 98.6 heartrate: 64.0 resprate: 20.0 o2sat: 95.0 sbp: 230.0 dbp: 78.0 level of pain: 7 level of acuity: 2.0

Dear ___, ___ were admitted after falling at home. ___ were found to have a fracture(a break in the bone) of one of your back bones. ___ were seen by the bone surgeons and were given a brace(support structure) to wear when out of bed. ___ were seen by our physical therapy team who recommended continuing your care at a rehabilitation facility. Your blood pressure was very elevated and we increased the dose of your home valsartan/clonidine and started ___ on amlodipine. Given some signs of kidney injury, home lasix(water pill) held on discharge to rehab. The providers at the rehabilitation facility will restart the water pill when appropriate. Sincerely, ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Labetalol / lisinopril / ciprofloxacin Attending: ___ Chief Complaint: Chest Pain, Dyspnea On Exertion Major Surgical or Invasive Procedure: Left heart catheterization ___ History of Present Illness: ___ yoF with extensive CAD history with numerous stents most recently last year on Plavix, h/o instent restenosis, HTN, IDDM, and HLD who presents with an acute onset of left back, shoulder, and chest discomfort, as well as nausea and lightheadedness. She states that she has experienced progressive worsening of DOE, generalized fatigue, and chest discomfort over the past 3 days. Pain is described as dull, non-pleuritic, radiating to the back, and without exacerbating factors. In the ED patient's nausea and lightheadedness resolved. She was given ASA 325, SLN and started on nitro gtt with improvement in chest pain. She states that chest pain has had different qualities in prior MIs. No clinical signs of infection. -In the ED, initial vitals were: 98.3 72 140/95 20 99% RA -EKG: NSR at 73, NA/NI, new lateral T-wave flattening, <1mm STE in II consistent with prior -Labs/studies notable for: normal BNP 140, WBC 12.9, Cr 1.2 (baseline 1.1), trop neg x 1, UA with only a few bacteria -CTA was performed, which showed no evidence of PE or aortic dissection -Patient was given: 0.4 mg SL nitro x 1, 12.5 mg D50 x 2, 1L NS, and was started on nitro gtt. -Vitals on transfer: 98.4 64 129/64 18 100% RA On the floor patient states chest pain has resolved on nitro gtt. SLN did not help with chest pain. She endorses only mild ___ back pain. She states that all her previous MIs have had different pain patterns. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: CABG x 3v ___ with LIMA to the LAD, SVG-D1 (OM1 on other notes), SVG-PDA (now known occluded). - PERCUTANEOUS CORONARY INTERVENTIONS: ___ - PTCA & 2 stents (LCX) ___ - Instent restenosis. No intervention ___ - PTCA OMB ___ - OMB (stented) occluded. RCA 90%. Patent graphs. ___ - SVG to PDA 40%, stented. ___ - Occlusion of Stent to SVG-PDA ___: a complex PCI of the SVG to the PDA (5 Stents). Based on enzymes, she suffered an IMI. ___: Right PDA instent restenosis treated with 3 DES. LIMA and SVG-D1 patent ___: occluded SVG-PDA, patent but tortuous LIMA, and 80% stenosis of SVG-OM, along with native 3 vz CAD (100% ___ LAD, mild Lcx dz with previously stented OM - occluded, occluded SVG-RCA (has had numerous PCI before), heavily calcified, filling with faint collaterals from LAD. She had a large BMS (5.0x18 mm Ultra) to SVG-OM with utilization of distal embolic device (Spider 5.0). ___: confirmed patent PCI to SVG-OM with very mild residual mid stent waist (unchanged) and stable native CAD. - PACING/ICD: none OTHER PAST MEDICAL HISTORY: DM Type 2: A1c was 9.4 ON ___ Hypercholesterolemia: LDL was 73 ON ___ Hypertension OSA, uses CPAP at home set at 9 Obesity Retinopathy from DM chronic lower back pain, gets steroid injections Social History: ___ Family History: Diabetes: paternal side of the family Heart disease in the ___ for maternal side of family Physical Exam: ON ADMISSION: Vitals: 97.6 120s-130s/60s-70s 75 18 98%RA Wt: 94.6 kg General: AAOx3, in NAD HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: JVP 8cm Heart: Regular rate and rhythm, normal S1/S2, no m/r/g Lungs: CTAB without crackles, wheezing or rhonchi Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly Extremities: Warm and well perfused, no edema, 2+ distal pulses Back: no midline TTP, no CVAT Neuro: Grossly non-focal ON DISCHARGE: Vitals: 97.8 51 (51-70) 131/58 (91-152/50-78) 16 99% on CPAP Wt: 92.5kg 8hr I/O ___ 24hrs I/O 1630/1650 General: AAOx3, in NAD HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: JVP not elevated Heart: Regular rate and rhythm, normal S1/S2, no m/r/g Lungs: CTAB without crackles, wheezing or rhonchi Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly Extremities: Warm and well perfused, no edema, 2+ distal pulses Back: no midline TTP, no CVAT Neuro: Grossly non-focal Pertinent Results: ON ADMISSION: ___ 11:55AM BLOOD WBC-12.9* RBC-4.29 Hgb-13.0 Hct-39.9 MCV-93 MCH-30.3 MCHC-32.6 RDW-12.5 RDWSD-42.5 Plt ___ ___ 11:55AM BLOOD Neuts-68.2 ___ Monos-7.0 Eos-1.9 Baso-0.8 Im ___ AbsNeut-8.75* AbsLymp-2.73 AbsMono-0.90* AbsEos-0.25 AbsBaso-0.10* ___ 11:31PM BLOOD ___ PTT-32.1 ___ ___ 11:55AM BLOOD Glucose-79 UreaN-25* Creat-1.2* Na-138 K-3.8 Cl-102 HCO3-21* AnGap-19 ___ 11:31PM BLOOD ALT-13 AST-15 AlkPhos-56 TotBili-0.4 ___ 11:55AM BLOOD proBNP-140 ___ 11:55AM BLOOD cTropnT-<0.01 ___ 07:30PM BLOOD cTropnT-<0.01 ___ 11:31PM BLOOD cTropnT-<0.01 ___ 11:31PM BLOOD Calcium-9.4 Phos-3.6 Mg-1.5* ON DISCHARGE: ___ 05:40AM BLOOD WBC-10.5* RBC-4.18 Hgb-12.6 Hct-38.7 MCV-93 MCH-30.1 MCHC-32.6 RDW-12.9 RDWSD-43.0 Plt ___ ___ 05:40AM BLOOD Glucose-162* UreaN-22* Creat-1.1 Na-139 K-4.4 Cl-105 HCO3-23 AnGap-15 ___ 05:40AM BLOOD cTropnT-<0.01 ___ 05:40AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.9 OTHER STUDIES: ___ CTA CHEST: 1. Motion-limited study. No evidence of an acute central pulmonary embolus or an acute aortic abnormality. 2. A 4 x 8-mm nodule in the right upper lobe is stable since ___, but does not yet demonstrate over ___ years of stability. Therefore, an ___ ___ chest CT is suggested. 3. Multiple right thyroid nodules, one measuring at least 2 cm in size for which non-urgent thyroid ultrasound is recommended to further evaluate. 4. Small hiatal hernia. RECOMMENDATION(S): 1. One year followup chest CT for the right upper lobe pulmonary nodule. 2. Non-urgent thyroid ultrasound. ___ TTE The left atrium is elongated. 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. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy. Preserved global biventricular systolic function. Cannot exclude regional wall motion abnormalities. No clinically significant valvular regurgitation or stenosis. Normal pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of ___, mild mitral regurgitation is no longer appreciated. Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is normal. * Left Anterior Descending The LAD is 100% occluded proximally. * Circumflex The ___ Marginal is 100% occluded proximally, and fills distally via collaterals from LAD. * Right Coronary Artery The RCA is diffusely diseased with 70% ___, 95% mid, and tandem 95% distal stenoses. Tjhere is TIMI 2 flow into distal RCA. SVG to D1 has 30% ___ stenosis. There is a previously placed (underdeployed) stent in mid segment of the SVG with mild-moderate (maximally 60%) in-stent restenosis in distal segment. LIMA to LAD is widely patent. SVG to PDA known occluded from prior cath, and no attempt made to re-visualize. Intra-procedural Complications: None Impressions: 3 vessel native CAD - angiographically unchanged cf prior cath ___. 2 of 3 bypass grafts are widely patent. Negative pressure wire study across moderate in-stent restenosis in SVG to D1. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO HS 3. Chlorthalidone 25 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Diltiazem Extended-Release 180 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY 8. Losartan Potassium 50 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO BID 10. ranolazine 500 mg ORAL BID 11. Lantus (insulin glargine) 40 units SUBCUTANEOUS QAM 12. Lantus (insulin glargine) 30 units SUBCUTANEOUS QPM 13. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily 14. MetFORMIN (Glucophage) 1000 mg PO QAM 15. MetFORMIN (Glucophage) 500 mg PO NOON 16. MetFORMIN (Glucophage) 1000 mg PO HS 17. Multivitamins 1 TAB PO DAILY 18. Vitamin D 5000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO HS 3. Chlorthalidone 25 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Diltiazem Extended-Release 180 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY 8. Losartan Potassium 50 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO BID 10. Multivitamins 1 TAB PO DAILY 11. ranolazine 500 mg ORAL BID 12. Vitamin D 5000 UNIT PO DAILY 13. Lantus (insulin glargine) 40 units SUBCUTANEOUS QAM 14. Lantus (insulin glargine) 30 units SUBCUTANEOUS QPM 15. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily 16. MetFORMIN (Glucophage) 1000 mg PO QAM 17. MetFORMIN (Glucophage) 500 mg PO NOON 18. MetFORMIN (Glucophage) 1000 mg PO HS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Chest pain SECONDARY DIAGNOSIS: DM Type 2 HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA chest INDICATION: ___ woman presenting with chest pain radiating to the back. Evaluate for pulmonary embolus. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 580 mGy-cm. COMPARISON: CTA chest dated ___. FINDINGS: The study is markedly limited by respiratory and cardiac motion artifact as well as streak artifact. The heart is mildly enlarged. The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. The patient is status-post CABG. The central and lobar pulmonary arteries are well opacified bilaterally without filling defect to suggest pulmonary embolism. More distal branches including the segmental and subsegmental branches particularly on the right are limited by respiratory and cardiac motion artifact. The main and right pulmonary arteries are normal in caliber. A prominent right lower paratracheal station lymph node retains its normal fatty hilum and is similar to the prior exam (series 3, image 67). No supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid is heterogeneous with several mixed density nodules on the right, one measuring at least 2 cm in size. There is no evidence of pericardial effusion. There is no pleural effusion. Detailed evaluation of the parenchyma is limited by respiratory and cardiac motion artifact. There is an oblong 4 x 8 mm nodule in the right upper lobe (3:70), unchanged since ___. An additional 3 mm lingular nodule (03:106) is also unchanged. Other than bibasilar atelectasis, no suspicious pulmonary nodule is identified. The airways are patent to the subsegmental level. Limited images of the upper abdomen are unremarkable other than a small hiatal hernia. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. Motion-limited study. No evidence of an acute central pulmonary embolus or an acute aortic abnormality. 2. A 4 x 8-mm nodule in the right upper lobe is stable since ___, but does not yet demonstrate over ___ years of stability. Therefore, an ___ follow-up chest CT is suggested. 3. Multiple right thyroid nodules, one measuring at least 2 cm in size for which non-urgent thyroid ultrasound is recommended to further evaluate. 4. Small hiatal hernia. RECOMMENDATION(S): 1. One year followup chest CT for the right upper lobe pulmonary nodule.. 2. Non-urgent thyroid ultrasound. NOTIFICATION: The findings and recommendations were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 4:09 ___, 10 minutes after discovery of the findings. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain, Dyspnea on exertion Diagnosed with Other chest pain temperature: 98.3 heartrate: 72.0 resprate: 20.0 o2sat: 99.0 sbp: 140.0 dbp: 95.0 level of pain: 2 level of acuity: 2.0

Dear Ms. ___, You were admitted to the hospital for chest pain. Your chest pain resolved with medication and you had a cardiac catheterization which showed no new blockages in the coronary arteries of the heart, which is reassuring that your chest and back pain is unlikely related to a new heart attack. It is very important that you continue to take all your medications as prescribed. All of your medications are detailed in your discharge medication list. You should review this carefully and take it with you to any follow up appointments. The details of your follow up appointments are given below, for primary care ___ and cardiology ___. It was a pleasure taking care of you. Sincerely, Your ___ Cardiology 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: DKA vs ___ Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: ___ with hx of idiopathic chronic pancreatitis s/p pancreatectomy with islet cell autotransplantation in ___, alcoholism, splenectomy, appendectomy, complication of bowel obstruction and resection, gallbladder surgery, type 1 diabetes now ID, non compliant, found by sister in ___ with dark stool around the apt, pale/altered, brought to ___. Pt states onset sx on ___. He felt dizzy and lightheaded on ___ night, went to get juice for possible low blood sugar, fell to the ground, unsure having a seizure, denies extended confused state, tongue biting, or loss of urinary/fecal incontinence. He also reports multiple episodes of vomiting that night, with dark red/black in color, large volume. Since then has been having bloody stool, with first episode on ___, large volume and dark red/black. Has had multiple episodes of dark red stool since. He also reports continued vomiting, though non-bloody, since ___. He has ___ R sided abdominal pain, wit radiation to R back/flank. He has had SOB since ___, worse with exertion, made better when lying down, not associated with pain. He endorses increased urinary frequency. States that he has diabetes and takes his insulin regularly, Insulin R 6units with meals and NPH 25 units BID. Has not taken his blood sugar during this time. Patient endorses previous episodes of DKA with hospitalization, with ICU admission. Unclear history of seizures, potentially related to previous ___ admissions. Patient denies chest pain, headache, changes in vision. =========================== In the ED, Initial Vitals: 128, 116/53, 22, 100% RA Exam: Pale, Epigastric tenderness, maroon hemoccult pos stool. Labs: Gluc 937, OSH Crit 10, WBC 30 Imaging: CTA A/P no active bleeding Consults: GI Interventions: protonix bolus/drip, octreotide bolus/gtt, Ceftri, 4U PRBC total given VS Prior to Transfer: ROS: Positives as per HPI; otherwise negative. Past Medical History: Type 1 DM, IDD (non-compliant) Idiopathic Chronic pancreatitis Islet cell autotransplantation, ___ Alcoholism Splenectomy Appendectomy SBO s/p resection Pericarditis in ___ (unknown etiology treated with Indocin) lap chole ___ PE s/p Eliquis? Hyperthyroid? GERD iron deficiency anemia s/p Feraheme tx last in ___ Social History: ___ Family History: Mother Living ___ HYPERTENSION Father Living ___ HYPERTENSION MGM Deceased GASTRIC CANCER PGM Deceased GALLBLADDER CANCER Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.9F, 102HR, 107/60, 97%, 16RR GEN: Uncomfortable, NAD HEENT: NT/AC, MMM NECK: Supple CV: Tachy, Normal S1S2, RRR, No M/R/G RESP: CTA B/L No W/R/R GI: TTP diffusely, worst in RUQ, with guarding, no rebound. No OM or distension MSK: Peripheral pulses intact SKIN: Warm and dry NEURO: AOx3, normal mentation Pertinent Results: ADMISSION LABS ================= ___ 02:35AM BLOOD WBC-32.8* RBC-2.44* Hgb-7.8* Hct-25.1* MCV-103* MCH-32.0 MCHC-31.1* RDW-14.5 RDWSD-54.4* Plt ___ ___ 02:35AM BLOOD Neuts-80* Lymphs-8* Monos-12 Eos-0* Baso-0 NRBC-0.1* AbsNeut-26.24* AbsLymp-2.62 AbsMono-3.94* AbsEos-0.00* AbsBaso-0.00* ___ 02:35AM BLOOD Anisocy-2+* Poiklo-2+* Macrocy-1+* Microcy-2+* Polychr-1+* Echino-2+* RBC Mor-SLIDE REVI ___ 02:35AM BLOOD ___ PTT-21.3* ___ ___ 02:35AM BLOOD Glucose-511* UreaN-27* Creat-1.0 Na-140 K-3.9 Cl-100 HCO3-11* AnGap-29* ___ 02:35AM BLOOD ALT-42* AST-53* AlkPhos-100 TotBili-0.2 ___ 02:35AM BLOOD Albumin-2.9* Calcium-7.8* Phos-4.4 Mg-2.2 ___ 08:38AM BLOOD %HbA1c-6.9* eAG-151* ___ 02:35AM BLOOD ASA-7 Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 08:49AM BLOOD Glucose-104 Lactate-1.0 PERTINENT LABS ================= ___ 03:04AM BLOOD ___ pO2-43* pCO2-30* pH-7.30* calTCO2-15* Base XS--9 ___ 05:19AM BLOOD ___ pH-7.40 ___ 08:49AM BLOOD ___ Temp-37.0 pO2-51* pCO2-43 pH-7.40 calTCO2-28 Base XS-0 ___ 03:12PM BLOOD Type-CENTRAL VE Temp-36.9 pO2-36* pCO2-47* pH-7.33* calTCO2-26 Base XS--1 Intubat-NOT INTUBA DISCHARGE LABS ================= MICROBIOLOGY ================= IMAGING/STUDIES ================= CHEST XR PORTABLE AP ___ IMPRESSION: NG tube projects below the left hemidiaphragm and the tip projects over the stomach. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. Patchy opacities are seen in both lower lobes. CT HEAD W/O CONTRAST ___ IMPRESSION: 1. No acute intracranial abnormality on noncontrast CT head. Specifically no acute large territory infarct or intracranial hemorrhage. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. Apixaban 2.5 mg PO BID 4. Pantoprazole 40 mg PO Q24H 5. Creon 12 6 CAP PO TID W/MEALS 6. insulin NPH isoph U-100 human 25 units subcutaneous BID 7. Vitamin D ___ UNIT PO 1X/WEEK (TH) 8. Levothyroxine Sodium 75 mcg PO DAILY 9. ___ KwikPen Insulin (insulin lispro) 8 units subcutaneous TID W/MEALS Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Glargine 28 Units Bedtime ___ 10 Units Breakfast ___ 10 Units Lunch ___ 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR 28 Units before BED; Disp #*10 Syringe Refills:*0 RX *insulin lispro 100 unit/mL AS DIR Up to 10 Units each per meal Disp #*10 Syringe Refills:*0 3. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate Duration: 3 Doses RX *oxycodone 5 mg 1 tablet(s) by mouth once a day Disp #*3 Capsule Refills:*0 5. Apixaban 10 mg PO BID DVT Duration: 5 Days RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 6. Creon 12 6 CAP PO TID W/MEALS RX *lipase-protease-amylase [Creon] 12,000 unit-38,000 unit-60,000 unit 6 capsule(s) by mouth TID with meals Disp #*540 Capsule Refills:*0 7. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 8. Levothyroxine Sodium 75 mcg PO DAILY RX *levothyroxine 75 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Vitamin D ___ UNIT PO 1X/WEEK (TH) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth once a week Disp #*4 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: duodenal ulcer Secondary diagnosis: proximal iliofemoral DVT 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 AMS, here w GI bleed, v unclear history, h/o EtOH*** WARNING *** Multiple patients with same last name!// eval ICH 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, 17.3 cm; CTDIvol = 46.5 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of large territory infarction,hemorrhage,edema, or mass effect. 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: 1. No acute intracranial abnormality on noncontrast CT head. Specifically no acute large territory infarct or intracranial hemorrhage. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with DKA, elevated WBC, upper abdominal pain radiating to middle right back/flank// Presence of infection given elevated WBC in context of DKA TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: NG tube projects below the left hemidiaphragm and the tip projects over the stomach. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. Patchy opacities are seen in both lower lobes. Radiology Report INDICATION: ___ year old man with GI bleed// obstruction? TECHNIQUE: Supine and upright portable abdominal radiographs were obtained. COMPARISON: ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. There is a moderate stool burden seen throughout the colon. Cholecystectomy clips project over the right upper quadrant. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Nonspecific, nonobstructive bowel gas pattern. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with UGI bleed, status post DKA// Source of infection, duct dilation TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MRI of the abdomen from ___. FINDINGS: LIVER: The hepatic parenchyma appears heterogenous. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: Patient is status post total pancreatectomy. SPLEEN: Patient is status post splenectomy. KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 11.2 cm Left kidney: 11.3 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Heterogenous liver parenchyma without evidence of concerning liver lesion 2. No evidence of intrahepatic biliary duct dilation. 3. Patient is status post cholecystectomy, total pancreatectomy and splenectomy. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with history of total pancreatectomy and history of duodenectomy status-post gastrojejunostomy now with recent UGI bleed, found to have a marginal ulcer developing worsening epigastric and RUQ pain as well as elevation of AST, ALT, and alk phos. Concern for intrahepatic/common bile duct pathology TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 7.5 s, 1.0 cm; CTDIvol = 17.4 mGy (Body) DLP = 17.4 mGy-cm. 3) Spiral Acquisition 13.6 s, 46.7 cm; CTDIvol = 5.8 mGy (Body) DLP = 263.3 mGy-cm. Total DLP (Body) = 295 mGy-cm. COMPARISON: Abdomen/pelvis CTs and MRCPs between ___ and ___ FINDINGS: LOWER CHEST: There is linear bibasilar atelectasis. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: Patient is status-post total pancreatectomy. SPLEEN: Patient is status-post splenectomy. 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. There is no perinephric abnormality. GASTROINTESTINAL: The distal thoracic esophagus contains enteric contrast. The stomach is distended with debris and enteric contrast. The gastrojejunostomy is patent. Contrast courses into proximal loops of jejunum. Patient is status-post duodenectomy. A small bowel loop in the right upper quadrant, presumably a hepaticojejunostomy loop, contains fluid and debris without evidence of obstruction. There is severe colonic fecal loading. Cecum is located in the midline pelvis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is unremarkable. LYMPH NODES: There is extensive mesenteric lymphadenopathy more impressive in lymph node number than size, measuring up to 1.3 cm short axis. No pelvic lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is mild abdominopelvic atherosclerosis and severe partially imaged femoral atherosclerosis.. There is a linear filling defect in the left common femoral vein extending to the level of the left external iliac vein (series 5, images 63-78). 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. Nonocclusive left common iliac, external iliac, and common femoral deep vein thrombosis. 2. Nonspecific mesenteric lymphadenopathy more notable for lymph node number than size, measuring up to 1.3 cm. 3. No evidence of acute hepatobiliary pathology. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 8:08 pm, approximately 20 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by HELICOPTER Chief complaint: GI bleed Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Mr. ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== -Bloody diarrhea and bloody vomit WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were given blood through a transfusion while you were in the ICU because your red blood cell counts were low. - Our gastroenterology team did an imaging study where they looked inside your stomach with a camera to look for a source of bleeding. During that procedure an ulcer was found in your duodenum, which was likely the source of the bleeding and stomach pain. You were started on a medication called Pantoprazole to reduce the acid production in your stomach, which should help the ulcer heal. You were also started on another medication to help the ulcer heal, called sucralfate. - Your blood sugar was very elevated on admission (over 900). We started you on an insulin drip to bring down the sugar and ketones in your blood while you were on the intensive care unit. When you left the ICU, you were seen by the diabetes specialist team who started you on a new insulin regimen for better blood sugar control. - Due to the pain you were having in your stomach, we started you on a pain control regimen with acetaminophen and Oxycodone. - You were found to have a large clot in your iliac and femoral veins. You were started on an increased dose of the blood thinner you were on before your GI bleed, called Apixaban. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. - Please take the new insulin regimen prescribed to you by our diabetes team - Please take your increased dose of apixaban (10mg twice a day) until the end of the day on ___. At this point you will be transitioned to a lower dose (5mg twice a day) We wish you all the best! Sincerely, Your ___ 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: increasing frequency of focal seizures Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a pleasant ___ ___, right-handed woman, currently 19 weeks pregnant, as well as a history of focal epilepsy since ___, who presents with acute worsening of her seizure frequency starting on 2 days prior to admission, patient started to have ___ of her typical focal seizures per day. Her history of her epilepsy is as follows. She developed the seizures in ___, which were clinically diagnosed, and involved right leg extension, and shaking of both extremities with preservation of awareness. She was started on Dilantin at that time. She never lost awareness during these episodes. She reports that she is aware of the surroundings and can hear voices, was unable to speak. In ___, she was reportedly at an outside hospital delivering a baby, and developed a new type of seizure-like episode with right upper extremity shaking as well. After the delivery, her Dilantin was increased as well as Keppra being added to her regimen. She did have an LTM admission here in ___. EEGs showed multiple stereotyped awakenings from sleep with posturing of bilateral hands, with right upper extremity stiffening and left arm rubbing her nose. This was associated with tachycardia and sometimes bradycardia with occasional pauses, but no clear electrographic correlate. Due to this, she had an implantable loop recorder placed prior to discharge. MRI at this time showed a left temporal flair hyperintensity, concerning for either a neuronal migratory defect or gliosis. Since her discharge in ___, she continued to report nocturnal seizures and her Keppra was increased to 1500 mg in the morning and 2250 mg at night. Her oxcarbazepine was also increased to 600 mg in the morning and then 900 mg at night. In terms of possible provoking factors, she reports that since 4 nights ago, members of her extended family had visited her at home and have been holding late night parties. Previously she had been sleeping about 12 hours per day, but now sleeping more like 6. In addition, she has had 2 of her children the sick over the past several days, and she has developed a new left maxillary sinus pressure. She denies any fevers or chills or signs or symptoms of infection including urinary tract infection. She reports being compliant with medications, though according to her primary epileptologist, she has had issues with medication adherence in the past. Past Medical History: Periodontitis Seizures Social History: ___ Family History: There is no family history of seizures. Physical Exam: Physical Exam: 24 HR Data (last updated ___ @ 1149) Temp: 98.3 (Tm 98.7), BP: 110/73 (89-111/59-75), HR: 80 (72-99), RR: 20 (___), O2 sat: 97% (96-99), O2 delivery: Rr General: Overweight woman lying comfortably in bed HEENT: EEG leads in place Neurologic: -MS-awake, alert. Able to converse normally. Speech is fluent. -CN- PERRL 4->3mm, brisk b/l. EOMI, with ___ beats of end-gaze nystagmus. No facial asymmetry. Tongue midline -Motor-no pronator drift, [Delt] [Bic] [Tri] [ECR] [FEx] [IP] L 5 5 5 5 5 5 R 5 5 5 5 5 5 -Coordination- intact FNF b/l -Gait:deferred Pertinent Results: ___ 05:05AM BLOOD WBC-11.2* RBC-4.13 Hgb-10.8* Hct-33.0* MCV-80* MCH-26.2 MCHC-32.7 RDW-14.1 RDWSD-40.5 Plt ___ ___ 05:05AM BLOOD Glucose-77 UreaN-12 Creat-0.4 Na-134* K-4.1 Cl-100 HCO3-22 AnGap-12 ___ 05:05AM BLOOD Calcium-9.0 Phos-4.5 Mg-1.9 Medications on Admission: Medications: Medications - Prescription FOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth daily LEVETIRACETAM - levetiracetam 750 mg tablet. 2 tablet(s) by mouth in ___ morning and 3 tablets at night OXCARBAZEPINE - oxcarbazepine 600 mg tablet. 1 tablet by mouth in the morning and 1.5 tablets at night Medications - OTC PNV ___ FUMARATE-FA [PRENATAL] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. LevETIRAcetam 2250 mg PO BID RX *levetiracetam 750 mg 3 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*2 2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 Days RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 3. OXcarbazepine 1200 mg PO QHS RX *oxcarbazepine 600 mg 2 tablet(s) by mouth at night Disp #*60 Tablet Refills:*2 4. OXcarbazepine 900 mg PO QAM RX *oxcarbazepine 300 mg 3 tablet(s) by mouth in the morning Disp #*90 Tablet Refills:*2 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Focal seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with seizures// Please eval for pneumonia or effusion TECHNIQUE: Chest AP and lateral COMPARISON: None available. FINDINGS: The lung volume is small, exaggerating bronchovascular markings. No focal consolidation. No pulmonary edema. No pleural abnormalities. The cardiomediastinal silhouette is exaggerated by AP technique but otherwise unremarkable. External cardiac monitoring device projects over the left chest. IMPRESSION: Low lung volume without focal consolidation, pulmonary edema, or pleural effusion. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: Pregnant, Seizure Diagnosed with Diseases of the nervous sys comp pregnancy, second trimester, Other epilepsy, not intractable, without status epilepticus, 19 weeks gestation of pregnancy temperature: 98.5 heartrate: 87.0 resprate: 18.0 o2sat: 100.0 sbp: 131.0 dbp: 81.0 level of pain: 8 level of acuity: 2.0

Dear ___, You were hospitalized because you had greatly increased seizure frequency at home. This was likely caused by a combination of your recent lack of sleep, your pregnancy, and a urinary tract infection. Keppra was increased to 2250 mg twice a day. Tripleptal was increased to 900 mg in the morning and 1200 mg at night. You were seen to have multiple seizures overnight that was recorded on the EEG monitor. We strongly encouraged you to stay in the hospital for another night for seizure monitoring while we are adjusting your medication. Risks of undertreated seizures include prolonged seizures, which can lead to breathing or heart problems, and sometimes death (Sudden unexpected death in epilepsy patients). You understood the risks of going home, despite our advice that you stay for optimization of your seizure control. Please come back to the hospital or go to the nearest ED if you experience more than your typical seizures per day. As you know, please avoid any activities that could be dangerous if you were to have a seizure during them including but not limited to swimming alone, cooking near a hot stove, operating heavy machinery, driving for 6 months from most recent seizure as per ___ law. Sincerely, Your ___ neurology team