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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ciprofloxacin Attending: ___. Chief Complaint: abdominal pain/fever Major Surgical or Invasive Procedure: 1. PTBD Exchange 2. Balloon Cholangioplasty / Sphincteroplasty History of Present Illness: ___ with PMH of Roux en Y gastric bypass ___ ___, multiple SBOs requiring resection, cholecystectomy, and ampullary stenosis s/p PTCD with multiple rounds of dilation recently admitted for abdominal pain and placement of PCBD conversion of ampullary drain who presents 3 days after discharge with progressive abdominal pain, fevers to 101 and purulent drainage from her cholecystostomy site. Note, patient just had ___ Guided placement of internal/external ampullary drain on ___ ___ the ED, initial vitals: 98.9 78 125/71 18 100% RA Exam notable for non-toxic-appearing Labs were significant for normal WBC count, alk phos 121, BUN/Cr ___ CT A/P: 1. Interval development of small subcapsular fluid collection (1.2 x 2.2 x 2.4cm) along the PTBD as it exits the liver anteriorly, likely representing biloma though cannot exclude abscess. 2. Small volume ascites. ___ the ED, she received IV cipro/flagyl, morphine, dilaudid and 2L NS IV. Currently, she reports pain/edema and red/pruritic rash over left wrist when she received ciprofloxacin ___ the ED. ROS positive for nausea, no emesis. OK PO intake, although pain is worse with eating. Her R-sided abdominal pain and epigastric pain both radiate to eh back. No cough, dyspnea, chest pain, although she feels like she can't take a deep breath due to pain. ROS: As per HPI. Remaining 10-point ROS negative. Past Medical History: # ampullary stenosis -___: ERCP (___) -___: PTBD (___) -___: Upsize of internal hepatobiliary catheter and balloon sphicteroplasty (___) # Papillary thyroid cancer - s/p total thyroidectomy & radiation ___ # RNY Gastric bypass - ___, lost 130 pounds (___) # SBR for SBO/intussusception - ___ ___ # Cervical cancer s/p partial hysterectomy ___, total hysterectomy & BSO ___ # Pre-cancerous colonic polypectomy ___ # Lumpectomy of left breast - ___ # Cholecystectomy ___, removed for polyps, surgical path reportedly normal # Umbilical Hernia # Seizures - occurred 3 times ___ ___ after large caffeine ingestion, no seizures since # Vasovagal syncope, on fludrocortisone # Asthma # Spinal fusion L3-S1 - ___ c/b epidural hematoma vs. thrombosis # Neuropathy ___ left lower leg and foot (s/p spinal fusion) # Fibromyalgia vs. Complex Regional Pain Syndrome # MRSA infection of ankle (___) Social History: ___ Family History: Mother - ___ strokes, first ___ ___ Father - MI ___ ___ Brother - died of lung cancer (smoker) Grandparents - colon cancer, prostate cancer Aunt - breast cancer Physical Exam: >> ADMISSION PHYSICAL EXAM: VS: 98.4 72 149/72 17 98RA GEN: Alert, lying ___ bed, appears uncomfortable HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-distended. PTBD site ___ epigastrium erythematous/indurated & exquisitely tender to palpation with purulent material on gauze. Bag with bilious fluid. Abdomen very tender over epigastrium and RUQ. Unable to elicit peritoneal signs due to sensitivity. Mild TTP over R CVA EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, motor function grossly normal . >> DISCHARGE PHYSICAL EXAM: Vitals: T 98.2 135 / 63 69 18 99 RA General: Alert, oriented x 3, comfortable. HEENT: MMM, anicteric sclera, no conjunctival pallor. Neck: No cervical LAD. Lungs: CTAB/L, no adventitial sounds heard. Cardiac: RRR, S1, S2, no extra sounds. Abdomen: Soft, PTBD ___ the epigastrum, dressing intact. Improved erythema at drainage site, with minimal surrounding drainage around site. Tenderness improved ___ the RUQ, and the epigastric. No CVA tenderness. Extremities: Warm, no ___ edema bilaterally. NEURO: CN II-XII grossly intact, motor function grossly normal Pertinent Results: >> ADMISSION LABS: ___ 12:45PM BLOOD WBC-7.1 RBC-4.19 Hgb-12.1 Hct-39.3 MCV-94 MCH-28.9 MCHC-30.8* RDW-14.8 RDWSD-50.4* Plt ___ ___ 12:45PM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-140 K-4.6 Cl-102 HCO3-30 AnGap-13 ___ 12:45PM BLOOD ALT-27 AST-28 AlkPhos-121* TotBili-0.4 DirBili-0.2 IndBili-0.2 ___ 12:45PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.4 Mg-2.0 ___ 12:50PM BLOOD Lactate-1.7 . >> DISCHARGE LABS: ___ 06:15AM BLOOD WBC-6.3 RBC-4.12 Hgb-11.9 Hct-38.5 MCV-93 MCH-28.9 MCHC-30.9* RDW-14.7 RDWSD-50.0* Plt ___ ___ 06:15AM BLOOD Neuts-47.7 ___ Monos-7.2 Eos-5.4 Baso-1.0 Im ___ AbsNeut-2.99 AbsLymp-2.41 AbsMono-0.45 AbsEos-0.34 AbsBaso-0.06 ___ 06:15AM BLOOD ALT-19 AST-27 AlkPhos-99 TotBili-0.1 ___ 06:15AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.9 ___ 06:15AM BLOOD Glucose-74 UreaN-10 Creat-0.7 Na-140 K-4.0 Cl-107 HCO3-22 AnGap-15 . >> MICROBIOLOGY: __________________________________________________________ ___ 8:40 pm BILE GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. FLUID CULTURE (Preliminary): GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. __________________________________________________________ ___ 12:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:09 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 5:55 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:50 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. . >> PERTINENT REPORTS: ___ ABD & PELVIS WITH CO: 1. Interval development of small subcapsular fluid collection (1.2 x 2.2 x 2.4 cm) along the PTBD as it exits the liver anteriorly, likely representing biloma though cannot exclude abscess. 2. Small volume ascites. . ___ CATH REPLACE: FINDINGS: . 1. Preprocedure ultrasound demonstrating 2.3 x 2.0 x 0.7 cm subcapsular collection surrounding the hepatic entry site of the existing catheter. 2. Initial cholangiograms demonstrating narrowing at the level of the ampulla with poor antegrade flow of contrast. 3. 12 mm balloon sphincteroplasty (prolonged inflation for 5 min) with a waist initially noted at the level of the ampulla, with improved flow on post-sphinteroplasty cholangiogram. 4. Ultrasound and fluoroscopy guided aspiration subcapsular collection with minimum amount of fluid returned. No significant fluid was identified ___ this location at the completion of procedure. 5. Successful exchange of 12 ___ PTBD catheter with a new 12 ___ PTBD catheter. . IMPRESSION: . 1. Successful exchange of existing 12 ___ PTBD catheter with a new 12 ___ PTBD catheter. 2. Successful performance of 12 mm balloon cholangioplasty/sphincteroplasty 3. Percutaneous aspiration of 2 cm perihepatic collection surrounding the liver entry site of the existing catheter, with minimal fluid aspirated. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H 2. Citalopram 20 mg PO BID 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Fludrocortisone Acetate 0.05 mg PO QHS 6. Gabapentin 800 mg PO QHS 7. Levothyroxine Sodium 137 mcg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY 11. Vitamin D 3000 UNIT PO DAILY 12. Cal-Citrate (calcium citrate-vitamin D2) ___ mg oral TID 13. Cyanocobalamin 100 mcg PO DAILY 14. grape seed oil (bulk) 100 mg PO DAILY 15. Melatin (melatonin) 10 mg oral QHS 16. Bisacodyl ___AILY 17. Senna 8.6 mg PO BID 18. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q4H 2. Bisacodyl ___AILY 3. Citalopram 20 mg PO BID 4. Cyanocobalamin 100 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Fludrocortisone Acetate 0.1 mg PO DAILY 7. Fludrocortisone Acetate 0.05 mg PO QHS 8. Gabapentin 800 mg PO QHS 9. Levothyroxine Sodium 137 mcg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Senna 8.6 mg PO BID 13. Vitamin D 3000 UNIT PO DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp #*30 Tablet Refills:*0 15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice daily Disp #*6 Tablet Refills:*0 16. Cal-Citrate (calcium citrate-vitamin D2) ___ mg oral TID 17. grape seed oil (bulk) 100 mg PO DAILY 18. Melatin (melatonin) 10 mg oral QHS 19. Multivitamins 1 TAB PO DAILY 20. Medipore H (adhesive tape) 3 X 10 topical DAILY Please dispense 1 Roll RX *adhesive tape 1" X ___ yard Apply dressing daily Disp #*1 Package Refills:*2 21. Gauze Pad (gauze bandage) 4 X 4 topical DAILY RX *gauze bandage 4" X 4" Apply dressing daily Disp #*2 Package Refills:*2 22. Tech Split Drain Sponge ICD 10: 87.51 Duration: Ongoing Please dispense split-drain sponge, 1 Box to apply daily Refill: 2 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ampullary Stricture with PTBD Drain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen pelvis INDICATION: ___ with recent biliary drain exchange, increased ABD pain, fever, purulent drainage from skin puncture site, palpable SQ collection TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. No oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 610 mGy-cm. COMPARISON: Prior exam from ___. FINDINGS: LOWER CHEST: Mild scarring is seen anteriorly at the right lung base. There is mild dependent atelectasis. The imaged portion of the heart is unremarkable. ABDOMEN: HEPATOBILIARY: Pneumobilia again noted with a PTBD in place. The tip of the biliary drain resides within the duodenum. New from prior exam, is a peripherally enhancing subcapsular fluid collection abutting the left hepatic lobe anteriorly best seen on series 602b, image 36 measuring 1.2 x 2.2 x 2.4 cm. The biliary drain courses through this collection. There is a similar mild prominence of the intrahepatic biliary tree. Main portal vein is patent. Gallbladder is surgically absent. PANCREAS: Pancreas appears normal. SPLEEN: The spleen is normal. ADRENALS: Adrenals are normal. URINARY: Kidneys enhance symmetrically and excrete shin of contrast is prompt and equal. No signs of hydronephrosis, pyelonephritis or worrisome renal lesion. No perinephric abnormality. GASTROINTESTINAL: Patient has undergone a prior Roux-en-Y a gastric bypass with no signs of anastomotic obstruction. The excluded stomach is mostly decompressed. Suture material involving distal loops of small bowel are also noted without evidence of complication. Is not definitively visualized though there are no secondary signs of appendicitis. Loops of large bowel contain mild fecal load without wall thickening or signs of acute inflammation. There is a small volume of free fluid in the abdomen and pelvis. No free air. PELVIS: Ureters appear normal. The urinary bladder is moderately distended appearing normal. Uterus is surgically absent. No adnexal mass is seen. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild to moderate atherosclerotic disease is noted. BONES: No worrisome lesion. Laminectomy infusion is seen in the lower lumbar spine. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Interval development of small subcapsular fluid collection (1.2 x 2.2 x 2.4 cm) along the PTBD as it exits the liver anteriorly, likely representing biloma though cannot exclude abscess. 2. Small volume ascites. Radiology Report INDICATION: ___ year old woman with left PTBD with subcapsular collection // PTBD check/change, collection aspiration COMPARISON: CT abdomen pelvis of ___. 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: Sedation was administered by the anesthesiology department. The patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. MEDICATIONS: 1 g ceftriaxone. CONTRAST: 40 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 13.0 min, 14 mGy PROCEDURE: 1. Limited preprocedure right upper quadrant ultrasound. 2. Tube cholangiogram. 3. Over the wire sheath cholangiogram. 4. 12 mm balloon dilatation of the ampulla (prolonged inflation). 5. Post balloon dilatation cholangiogram. 6. Ultrasound and fluoroscopy guided aspiration of subcapsular collection using a combination of a 7 ___ sheath, 5 ___ pigtail catheter, and ___ needle. 7. Exchange of prior 12 ___ PTBD catheter with a new 12 ___ PTBD catheter. 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 mid abdomen was prepped and draped in the usual sterile fashion. A limited preprocedure ultrasound demonstrated 2.3 x 2.0 x 0.7 cm subcapsular hypoechoic area surrounding the hepatic entry site of the existing catheter. Initial scout images showed biliary drain in the appropriate position. A cholangiogram was performed of the existing tube, demonstrating distal tube occlusion. The hub of the catheter was cut and ___ wire was advanced through the catheter into the small bowel. The catheter was removed. The ___ wire was exchanged using a Kumpe catheter for an Amplatz wire. A 7 ___ sheath was advanced over the wire into the small bowel. Pull-back cholangiogram and antegrade cholangiogram were performed to delineate the level of stenosis and assess antegrade biliary drainage, findings below. Based on the results of the cholangiogram, decision was made to perform balloon dilatation of the sphincter. A 12 mm balloon was advanced over the wire through the sheath to the level of the ampulla. Multiple overlapping serial balloon dilatations were performed of the ampulla and distal CBD. A waist was noted at the level of the ampulla. The 12 mm balloon was used to perform a prolonged inflation for 5 min at the level of the ampulla. The waist was noted to fully reduce. The balloon was withdrawn. Post balloon dilatation cholangiogram was performed, demonstrating improved flow through the ampulla. Next, the sheath was slowly withdrawn to the level of subcapsular collection. Using a combination of ultrasound and fluoroscopy to confirm position within the subcapsular collection, aspiration was performed, with a minimum amount of fluid returned. A 5 ___ pigtail catheter was advanced into the collection through the sheath and formed. This was confirmed under US. US images were stored. This was also then used to perform aspiration of the subcapsular collection. No significant fluid was aspirated. ___ needle was advanced percutaneously under ultrasound guidance into the collection. Sonographic image of the needle within the hypoechoic area were archived. Aspiration was attempted, without significant fluid return. All needles and catheters were withdrawn. A 12 ___ PTBD catheter was advanced into the duodenum. Side holes were positioned above and below the level of obstruction to facilitate internal drainage. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Preprocedure ultrasound demonstrating 2.3 x 2.0 x 0.7 cm subcapsular collection surrounding the hepatic entry site of the existing catheter. 2. Initial cholangiograms demonstrating narrowing at the level of the ampulla with poor antegrade flow of contrast. 3. 12 mm balloon sphincteroplasty (prolonged inflation for 5 min) with a waist initially noted at the level of the ampulla, with improved flow on post-sphinteroplasty cholangiogram. 4. Ultrasound and fluoroscopy guided aspiration subcapsular collection with minimum amount of fluid returned. No significant fluid was identified in this location at the completion of procedure. 5. Successful exchange of 12 ___ PTBD catheter with a new 12 ___ PTBD catheter. IMPRESSION: 1. Successful exchange of existing 12 ___ PTBD catheter with a new 12 ___ PTBD catheter. 2. Successful performance of 12 mm balloon cholangioplasty/sphincteroplasty 3. Percutaneous aspiration of 2 cm perihepatic collection surrounding the liver entry site of the existing catheter, with minimal fluid aspirated. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Wound eval Diagnosed with Unspecified abdominal pain temperature: 98.9 heartrate: 78.0 resprate: 18.0 o2sat: 100.0 sbp: 125.0 dbp: 71.0 level of pain: 10 level of acuity: 3.0

Dear ___ was a pleasure taking care of you during your hospital stay at ___. You were hospitalized for concern of your biliary drain, and underwent a procedure by the Interventional Radiology Team to dilate and help this drain more effectively. While here, we were able to control your pain with pain relievers, and started you on antibiotics because we were concerned for a skin infection near your drain entry site. Please continue to take all of your home medications as prescribed. Please follow-up with your primary care physician, and the interventional radiology team as an outpatient. Take Care, Your ___ Team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, rash, fevers Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with a history of morbid obesity, superficial thrombophlebitis (on enoxaparin until stopped ___, LTBI (completed 9 months of isonizaid), Hep C (neg VL ___, previous IVDU (last use ___ years ago), PTSD, presenting with 1 day of increased abdominal redness swelling and warmth as well as arm shaking chills and fever to 101. Pt states was in usual state of health until day prior to admission. In ___ had sudden onset chills, subjective fevers, and noticed increasing redness in lower abdomen. Sensation of fevers and chills lasted approximately one hour, but resolved without intervention. On the day of admission, patient awoke in the morning with another episode of chills, headache and diffuse body aches and measured temperature to be 101.3. At this time she presented to the emergency department. Apart from these two episodes, the patient denies any other recent symptoms. No cough, shortness of breath, n/v/d, or urinary symptoms recently. The patient notes that she has not used IV drugs for over ___ years, and that she is no longer taking subcutaneous lovenox since her prescription ran out in ___. She denies back pain, flank pain, weakness numbness or tingling. The patient was most recently admitted to the OB/GYN service in ___ where she had a C-section complicated by pain control and incisional cellulitis. The cellulitis was treated with PO Bactrim and she was discharged on ___ with improvement in symptoms. During this admission, the patient was noted to have an abdominal rash concerning for cellulitis. She self injects enoxaparin into her abdomen, and has been on this therapy since ___ for superficial thrombophlebitis, though has never been diagnosed with a DVT. She was started on Vancomycin for this, however she had US of the area which was not consistent with an underlying abscess, and later had an ___ guided aspiration, which was found to be a hematoma, which was sent for culture and had no growth and antibiotics were stopped. Initial vital signs were notable for: T:97.8 HR:76 BP:121/68 O2:96% RA No exam documented in the ED. Labs were notable for: 7.1 > 10.5/33.0 < ___ / 12 --------------< 85 8.9 / ___ / 0.8 K:5.2 Lactate:1.3 Studies performed include: CT Abd & Pelvis With Contrast 1. 3.6 x 5.5 cm right upper abdominal subcutaneous fluid collection appears similar in appearance to prior ultrasound dated ___. Previously demonstrated left lower quadrant fluid collection is no longer visualized. No evidence of a new fluid collection in the subcutaneous tissues of the left lower quadrant. 2. Cellulitis involving the lower abdominal wall. 3. Mild positioned IUD. Further evaluation with pelvic ultrasound may be considered. 4. Moderately enlarged spleen measuring up to 17 cm. Patient was given: IV CefTRIAXone 1g PO/NG Gabapentin 800 mg Buprenorphine-Naloxone (8mg-2mg) 1 TAB PO/NG Acetaminophen 1000 mg PO Ibuprofen 800 mg Consults: None Vitals on transfer: T: 100.4 HR: 83 BP: 151/97 RR: 16 O2: 93% RA Upon arrival to the floor, the patient complains of continued abdominal pain around the site of redness, without the sensation of fevers and chills at this time. Review of Systems: Complete ROS obtained and is otherwise negative. Past Medical History: Depression Anxiety PTSD Bipolar w Major Depressive Disorder (Psych Admission for excessive ETOH/Suicidal Ideation at ___ in ___ Alcohol abuse Superficial thrombophlebitis (diagnosed ___, was on Lovenox 60mg daily, followed by Dr. ___ Heme/Onc, no longer on SQ lovenox since ___ when prescription ran out) Asthma Morbid obesity (___ 68) H/o Latent TB (finished 9 months of Isoniazid) Hep C HIV exposure via HIV seropositive partner ___ (was on PrEP, but HIV negative ___ and no longer with exposure) Gastric bypass ___ Social History: ___ Family History: Patient is ___ and ___ in descent. Family history of alcoholism. Physical Exam: Admission Physical Exam: ======================== VITALS: 99.0PO 119 / 67 79 19 96 Ra GENERAL: Alert and interactive. In no acute distress, lying comfortably in bed. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes, good dentition. Tongue and lip piercings. Oropharynx is clear. NECK: No cervical lymphadenopathy. Exam for JVD limited by body habitus. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, obese abdomen. Non-tender in all quadrants, though tenderness over area of erythema (described below) SKIN: 5cm by 10cm area of confluent, well demarcated and slightly elevated erythema across central pannus. No scaling. 2cm by 2cm indurated, raised area in ___ erythema. Tender to palpation and warm to touch. No crepitus. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Discharge Physical Exam: ======================== PHYSICAL EXAM: Vitals: T98.2 BP136/90 P70 R20 O2 95 Ra GENERAL: Alert and interactive. NAD, sitting comfortably in bed. HEENT: EOMI PERRL MMM Tongue and lip piercings CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally, sounds appreciated in all fields. ABDOMEN: Normal bowels sounds, obese abdomen. Firm small lump in R-side of abdomen. Non-tender in all quadrants SKIN: improving erythematous area with decreasing confluence (has improved each of the last 3 days), 5cm by 10cm area of confluent, well demarcated across central pannus. Improvement in tenderness to palpation under indurated area. Same temperature as surrounding skin. NEUROLOGIC: CN2-12 intact. A&Ox3. No focal deficits. Pertinent Results: INITIAL LABS: =============== ___ 11:15AM WBC-7.1 RBC-3.89* HGB-10.5* HCT-33.0* MCV-85 MCH-27.0 MCHC-31.8* RDW-17.2* RDWSD-53.5* ___ 11:15AM NEUTS-73.4* LYMPHS-17.7* MONOS-7.9 EOS-0.3* BASOS-0.4 IM ___ AbsNeut-5.24 AbsLymp-1.26 AbsMono-0.56 AbsEos-0.02* AbsBaso-0.03 ___ 11:15AM GLUCOSE-85 UREA N-12 CREAT-0.8 SODIUM-130* POTASSIUM-8.9* CHLORIDE-104 TOTAL CO2-24 ANION GAP-2* ___ 11:45AM LACTATE-1.3 K+-5.2* DISCHARGE LABS: =============== ___ 06:20AM BLOOD WBC-4.5 RBC-4.09 Hgb-10.9* Hct-35.3 MCV-86 MCH-26.7 MCHC-30.9* RDW-16.5* RDWSD-53.0* Plt ___ ___:20AM BLOOD Glucose-92 UreaN-17 Creat-0.6 Na-143 K-4.7 Cl-105 HCO3-26 AnGap-12 IMAGING: =============== CT A/P w/ contrast (___) IMPRESSION: 1. 3.6 x 5.5 cm right upper abdominal subcutaneous fluid collection appears similar in appearance to prior ultrasound dated ___. Previously demonstrated left lower quadrant fluid collection is no longer visualized. No evidence of a new fluid collection in the subcutaneous tissues of the left lower quadrant. 2. Cellulitis involving the lower abdominal wall. 3. Mild positioned IUD. Further evaluation with pelvic ultrasound may be considered. 4. Moderately enlarged spleen measuring up to 17 cm. MICROBIOLOGY: ================= ___ BLOOD CULTURES X 2 NO GROWTH FINAL ___ URINE CULTURE NO GROWTH FINAL Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze 3. BuPROPion XL (Once Daily) 300 mg PO DAILY 4. Cyanocobalamin 100 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate 110mcg 1 PUFF IH BID 7. Gabapentin 800 mg PO TID 8. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 9. LamoTRIgine 25 mg PO DAILY 10. Latuda (lurasidone) 40 mg oral DAILY 11. Pyridoxine 50 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. Chantix (varenicline) 1 mg oral BID 14. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID 15. ChlorproMAZINE 50 mg PO QAM 16. ChlorproMAZINE 100 mg PO QPM 17. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia Discharge Medications: 1. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp #*25 Tablet Refills:*0 2. Clotrimazole Cream 1 Appl TP BID:PRN rash RX *clotrimazole 1 % one application under breasts and abdominal skin twice daily as needed for fungal skin rash Disp #*30 Gram Gram Refills:*0 3. Miconazole Powder 2% 1 Appl TP TID:PRN rash under breasts and pannus 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze 6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID 7. BuPROPion XL (Once Daily) 300 mg PO DAILY 8. Chantix (varenicline) 1 mg oral BID 9. ChlorproMAZINE 50 mg PO QAM 10. ChlorproMAZINE 100 mg PO QPM 11. Cyanocobalamin 100 mcg PO DAILY 12. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia 13. Docusate Sodium 100 mg PO BID 14. Fluticasone Propionate 110mcg 1 PUFF IH BID 15. Gabapentin 800 mg PO TID 16. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 17. LamoTRIgine 25 mg PO DAILY 18. Latuda (lurasidone) 40 mg oral DAILY 19. Pyridoxine 50 mg PO DAILY 20. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Erysipelas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: ___ with rigors, redness over left lower quadrant. Assess for subcutaneous abscess. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 27.7 mGy (Body) DLP = 1,412.8 mGy-cm. Total DLP (Body) = 1,413 mGy-cm. COMPARISON: Comparison is made to abdominal ultrasound performed ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen is moderately enlarged measuring up to 17 cm (601:44) but demonstrates normal attenuation throughout, without evidence of focal lesions. ADRENALS: The right adrenal gland is normal in shape and size. The left adrenal gland mildly thickened, which is nonspecific. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of hydronephrosis. Small bilateral hypodense renal cortical lesions likely reflect simple renal cysts. A 1.5 x 1.9 cm left lower pole renal cyst measures 26 Hounsfield units (02:37), likely a simple renal cyst. There is no perinephric abnormality. GASTROINTESTINAL: Small hiatal hernia. Patient is status post Roux-en-Y gastric bypass surgery with anastomotic suture material visualized in mid abdomen (601:26). Otherwise, the 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: Malpositioned IUD appears within the uterine endometrium with the cross bars directed more inferiorly than expected (2:67). No evidence of adnexal abnormality. RETROPERITONEUM AND MESENTERY: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. The mesenteric vessels appear patent. BONES: There is mild to moderate degenerative changes of thoracolumbar spine with grade 1 retrolisthesis of L5 on S1. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: A 3.6 x 5.5 cm subcutaneous fluid collection within the right upper quadrant has a fat fluid level (02:38). This appears similar in appearance to prior ultrasound performed ___. A previously seen left-sided abdominal fluid collection on prior ultrasound is not seen on current exam. Lower abdomen skin thickening and fat stranding likely reflects cellulitis (2:87). IMPRESSION: 1. 3.6 x 5.5 cm right upper abdominal subcutaneous fluid collection appears similar in appearance to prior ultrasound dated ___. Previously demonstrated left lower quadrant fluid collection is no longer visualized. No evidence of a new fluid collection in the subcutaneous tissues of the left lower quadrant. 2. Cellulitis involving the lower abdominal wall. 3. Mild positioned IUD. Further evaluation with pelvic ultrasound may be considered. 4. Moderately enlarged spleen measuring up to 17 cm. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Fever Diagnosed with Cellulitis of abdominal wall temperature: 97.8 heartrate: 76.0 resprate: nan o2sat: 96.0 sbp: 121.0 dbp: 68.0 level of pain: 4 level of acuity: 3.0

Dear Ms. ___, What brought you to the hospital? ================================ You came to the hospital because of abdominal pain, rash, fever/chills. What happened while you were in this hospital? ============================================= -You were found to have a skin infection on your abdomen -You receiving imaging of your abdomen and pelvis, which found: -No evidence of an infected collection or "abscess" -You were started on antibiotics and the skin infection was monitored and improved. -You were discharged on a course of antibiotics. What should you do when you leave the hospital? ============================================== -You should take the Cephelaxin 500mg 4x/day (every 6 hours) for another 6 days, last full day ___. You should take the full course of antibiotics as prescribed. -You should carefully clean the skin around the infection, making sure not to be too rough when cleaning to cause cuts or abrasions to the skin. -Please follow up with your ___ clinic provider on ___. You can walk into the ___ clinic. -Please bring your discharge paperwork to your follow up visit with your suboxone provider and your primary care doctor. -You should have a follow up appointment with your primary care physician, ___, on ___ at 2:15. We wish you the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Latex / Penicillins / Codeine / Demerol / Iodine-Iodine Containing / Aminophylline / lisinopril / shellfish derived Attending: ___. Chief Complaint: Vaginal bleeding Major Surgical or Invasive Procedure: ___: ___ placement of 10 ___ pelvic drain ___: Removal of withdrawn ___ pigtail catheter and successful CT-guided placement of a ___ pigtail catheter into the collection. History of Present Illness: ___ is a ___ yo F with history of significant for atrial fibrillation (currently on lovenox with plans to resume coumadin), rheumatoid arthritis (on prednisone), perforated diverticulitis s/p Hartmanns procedure (___) complicated by pelvic hematoma (without drainage) and ostomy revision (___) who now presents with concern for significant rectal bleeding and associated hemodynamic instability. ACS is consulted for urgent management. The patient was originally admitted for perforated diverticulitis ___ s/p Hartmanns procedure (___). Her initial hospitalization was complicated by a pelvic hematoma associated with anemia. She was eventually discharged to home on ___. She was readmitted to the hospital ___ after stomal skin disruption and returned to the OR for ostomy stoma revision on ___. She was discharged on therapeutic lovenox (70mg BID) with plan to transition to Coumadin. She presented to the ED this AM after noting large column bright red blood per rectum. Patient reported that she had an episode of coughing around 10am this morning and subsequently felt that she was bleeding from her rectum. Her husband then checked on her and found a large pool of blood underneath her bottom. He then brought her directly to the Emergency Department for evaluation. At the time of presentation, she was initially normocardic but soon became tachycardic to 150s. Her blood pressure remained in the 120-130s systolic, and she was mentating appropriately throughout. 2 peripheral IVs and a foley were placed. Upon evaluation, she reported lower abdominal pain, intermittent nausea, shortness of breath, and lightheadedness. On exam, her abdomen was soft, non-distended, non-tender. Her ostomy was pink with stool in the bag. Anoscopy exam did not reveal any active bleeding from her rectum. Shortly thereafter, she was found to be sitting in a small pool of blood, and repeat exam revealed bleeding from her vagina. Gynecology was consulted. She received 1L LR, 1u pRBCs, and 1u FFP with improved heart rate to the 110s. Of note, patient has had a hysterectomy in the 1990s. She last ate at 8am this morning, and her last dose of lovenox was at 9am this morning. Past Medical History: Past Medical History: - Atrial fibrillation (on Coumadin) - Rheumatoid arthritis (on MTX/pred) c/b chronic bronchiectasis (on inhalers) - HTN/HLD - IDDM - Iron deficiency anemia - OSA Past Surgical History: - s/p hysterectomy - s/p C-section ___ - s/p laparoscopic ovarian cyst excision - s/p R THR Social History: ___ Family History: Family History: Father - ___ Mother (died at ___) - CVA, HTN Physical Exam: Physical Exam on Admission: ___ Vitals: T 100.7, HR 154, BP 129/83, RR 18, SpO2 95% RA General: awake, alert, AAOx3, in moderate distress CV: sinus tachycardia Pulm: normal respiratory effort GI: abdomen soft, non-distended, non-tender, ostomy with air and stool in the bag, wound vac intact Physical Exam on Discharge: Vitals: 97.7, 102/66, 111, 18, 98% on Ra GEN: A&Ox3, NAD. CV: RRR PULM: non-labored ABD: soft, non tender, non distended. ostomy pink and productive of loose brown stool. SKIN: warm, dry, midline abd incision with wound vac in place, changed prior to discharge. EXT: PPP, no lower ext edema bilat. Pertinent Results: ADMISSION LABS: ___ 05:45AM BLOOD WBC-11.3* RBC-3.04* Hgb-10.2* Hct-33.0* MCV-109* MCH-33.6* MCHC-30.9* RDW-17.1* RDWSD-65.9* Plt ___ ___ 01:02PM BLOOD Neuts-77.4* Lymphs-7.1* Monos-10.3 Eos-0.1* Baso-0.5 NRBC-0.6* Im ___ AbsNeut-13.53* AbsLymp-1.25 AbsMono-1.80* AbsEos-0.02* AbsBaso-0.09* ___ 05:45AM BLOOD ___ PTT-29.0 ___ ___ 05:45AM BLOOD Glucose-207* UreaN-12 Creat-0.7 Na-139 K-5.0 Cl-94* HCO3-30 AnGap-15 ___ 05:45AM BLOOD Calcium-9.8 Phos-3.3 Mg-2.1 DISCHARGE LABS: ___ 06:21AM BLOOD WBC-5.2 RBC-3.34* Hgb-10.9* Hct-33.0* MCV-99* MCH-32.6* MCHC-33.0 RDW-15.7* RDWSD-56.8* Plt ___ ___ 07:14AM BLOOD WBC-5.5 RBC-3.09* Hgb-10.1* Hct-31.0* MCV-100* MCH-32.7* MCHC-32.6 RDW-15.7* RDWSD-57.1* Plt ___ ___ 06:21AM BLOOD ___ ___ 07:14AM BLOOD ___ ___ 07:14AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-142 K-3.9 Cl-101 HCO3-26 AnGap-15 ___ 07:30AM BLOOD Glucose-133* UreaN-10 Creat-0.6 Na-137 K-3.7 Cl-99 HCO3-26 AnGap-12 ___ 07:14AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8 ___ 07:30AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.0 IMAGING: CTA A/P: ___ Rim enhancing pelvic hematoma is slightly decreased in size as well as density compared to prior imaging. No evidence for active extravasation of contrast. The patient is status post ___ pouch and redo left lower quadrant colostomy. No new/acute intra-abdominal or pelvic pathology. Unchanged pancreatic hypodensities which most likely represent side branch IPMNs ranging up to 21 mm. CT ABD & PELVIS WITH CONTRAST: ___ 1. Interval decrease in size and density of pelvic fluid collection status post drain placement. There is persistent fluid and air bubbles within the collection. 2. No evidence of new intra-abdominal or pelvic pathology. 3. The patient is status post ___ pouch and redo of left lower quadrant colostomy with adjacent postsurgical changes. 4. Unchanged pancreatic hypodensities which most likely represent side branch IPMNs measuring up to 20 mm. 5. There is a locule of air at the superior aspect of the urinary bladder please correlate with possible history of recent catheterization or urinalysis. US BUTTOCKS, SOFT TISSUE RIGHT: ___ No superficial drainable collection in the area of clinical concern. CT ABD & PELVIS WITH CONTRAST: ___ 1. The posterior approach percutaneous drain has been withdrawn, now terminating outside the rim enhancing fluid collection in the perirectal space. 2. The pelvic fluid collection has minimally decreased in size, now measuring approximately 6.5 x 4.4 cm, previously 7.3 x 4.6 cm. However, the collection closely abuts the cecum along its superior anterior margin and it is unclear if there is a fistulous connection. If further evaluation is desired, contrast could either be administered via the ostomy or via the percutaneous drain once it is replaced. 3. No evidence of leak from the rectal stump. 4. Stable pancreatic hypodensities measuring to 1.9 cm in the pancreatic head, which most likely represent side branch IPMNs. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Aspirin 81 mg PO DAILY 3. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 4. Ezetimibe 10 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Losartan Potassium 100 mg PO DAILY 8. Metoprolol Tartrate 25 mg PO TID:PRN palpitations 9. Metoprolol Succinate XL 100 mg PO QHS 10. Levalbuterol Neb 0.63 mg NEB BID:PRN shortness of breath 11. Montelukast 10 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL ASDIR chest pain 13. Omeprazole 20 mg PO BID 14. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line Reason for PRN duplicate override: Discontinuing IV zofran 15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 16. Polyethylene Glycol 17 g PO DAILY 17. PredniSONE 5 mg PO BID This is the maintenance dose to follow the last tapered dose 18. Senna 8.6 mg PO BID:PRN Constipation - First Line 19. Ciprofloxacin HCl 500 mg PO Q12H 20. Docusate Sodium 100 mg PO BID 21. MetroNIDAZOLE 500 mg PO Q8H 22. Milk of Magnesia 30 mL PO Q8H:PRN Constipation - First Line 23. Zoledronic Acid (Reclast) (zoledronic acid-mannitol-water) 5 mg/100 mL injection ANNUALLY 24. GlipiZIDE 10 mg PO BID 25. riTUXimab 1000 mg IV EVERY 3 MONTHS 26. Tiotropium Bromide 1 CAP IH AT BEDTIME 27. Warfarin 2.5 mg PO 5X/WEEK (___) 28. Warfarin 3.75 mg PO 2X/WEEK (MO,TH) Discharge Medications: 1. Glargine 18 Units Breakfast Novolog 2 Units Breakfast Novolog 2 Units Lunch Novolog 2 Units Dinner Insulin SC Sliding Scale using Novolog Insulin 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation inhalation 2 puffs daily 4. PredniSONE 5 mg PO DAILY 5. ___ MD to order daily dose PO DAILY16 6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 7. Aspirin 81 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 10. Ezetimibe 10 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY 12. Furosemide 40 mg PO DAILY 13. Levalbuterol Neb 0.63 mg NEB BID:PRN shortness of breath 14. Losartan Potassium 100 mg PO DAILY 15. Metoprolol Succinate XL 100 mg PO QHS 16. Metoprolol Tartrate 25 mg PO TID:PRN palpitations 17. Milk of Magnesia 30 mL PO Q8H:PRN Constipation - First Line 18. Montelukast 10 mg PO DAILY 19. Nitroglycerin SL 0.4 mg SL ASDIR chest pain 20. Omeprazole 20 mg PO BID 21. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line Reason for PRN duplicate override: Discontinuing IV zofran 22. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 23. Polyethylene Glycol 17 g PO DAILY 24. riTUXimab 1000 mg IV EVERY 3 MONTHS 25. Senna 8.6 mg PO BID:PRN Constipation - First Line 26. Tiotropium Bromide 1 CAP IH AT BEDTIME 27. Zoledronic Acid (Reclast) (zoledronic acid-mannitol-water) 5 mg/100 mL injection ANNUALLY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pelvic abscess / hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ year old woman remote ___ hysterectomy (___) sp hartmans (___) and redo colostomy (___) presents with active vaginal bleeding with known pelvic hematoma on therapeutic lovenox// ?interveanable vs active bleeding. Please do at ___. anaphylactic reaction. 1st dose steroids 1530, 2nd dose ___ TECHNIQUE: Multiphasic contrast: MDCT axial images were acquired through the abdomen following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.6 s, 56.7 cm; CTDIvol = 3.6 mGy (Body) DLP = 204.5 mGy-cm. 2) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 731.4 mGy-cm. 3) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 730.7 mGy-cm. 4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 5) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.2 mGy (Body) DLP = 6.6 mGy-cm. Total DLP (Body) = 1,675 mGy-cm. COMPARISON: Prior CT abdomen done ___. Chest CT dated ___. FINDINGS: LOWER CHEST: Subsegmental bibasal atelectasis is improved on the left and similar to minimally increased on the right. No pleural effusion. No pericardial effusion. Mild to moderate coronary artery calcification. Mildly enlarged heart. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Suspected perfusional change in segment 4A of the liver (series 303, image 53). There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout. Multiple pancreatic cystic lesions measuring up to 20 mm in the pancreatic head (series 303, image 62) appear similar compared to prior imaging. The main pancreatic duct is not dilated. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Bilateral renal cortical cysts appear simple, or mildly hyperdense, but without any enhancement nodularity wall thickening or septations. Bilateral renal cortical scarring. No hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. No features of small bowel obstruction. The patient is status post left lower quadrant diverting colostomy with ___ pouch. Stranding in the left lower quadrant is most likely secondary to prior surgical intervention. There is a large rim enhancing collection in the pelvis measuring 40 Hounsfield units in density and 81 x 86 mm in the axial plane (previously measuring 53 Hounsfield units in density and 90 x 90 mm in the axial plane). This collection is inseparable from the proximal aspect of the ___ pouch and posterior cecal wall. Decrease in previously noted hemorrhagic fluid component along the right paracolic gutter. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. PELVIS: The right hemipelvis is obscured by beam hardening artifact from right hip metallic arthroplasty prosthesis. Foley's catheter in situ with air present in the bladder most likely secondary to instrumentation. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: Mild degenerative changes of the lumbar spine with endplate compression fractures of the L3-L5 vertebral bodies. Minimally displaced left lateral ninth rib fracture with blunting of the ends, unchanged. Sclerosis along the right sacral ala suggesting prior nondisplaced fracture, unchanged. Bones appear demineralized. SOFT TISSUES: Postoperative changes are seen in the midline in the anterior abdominal wall. IMPRESSION: Rim enhancing pelvic hematoma is slightly decreased in size as well as density compared to prior imaging. No evidence for active extravasation of contrast. The patient is status post ___ pouch and redo left lower quadrant colostomy. No new/acute intra-abdominal or pelvic pathology. Unchanged pancreatic hypodensities which most likely represent side branch IPMNs ranging up to 21 mm. RECOMMENDATION(S): Follow-up MRCP recommended in ___ months to reassess pancreatic cystic lesions. Radiology Report EXAMINATION: CT interventional INDICATION: ___ year old woman with pelvic hematoma// eval for possible drainage (pelvic abscess) COMPARISON: CT dated ___ PROCEDURE: CT-guided drainage of pelvic collection. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. Based on the CT findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The metal stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 100 cc of bloody fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock and a ___ silk suture. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.1 s, 18.6 cm; CTDIvol = 11.2 mGy (Body) DLP = 193.5 mGy-cm. Total DLP (Body) = 203 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 15 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Preprocedural imaging demonstrates a 9 cm fluid collection. 2. Final images demonstrate a ___ Fr drain in the pelvic fluid collection via a transgluteal approach. IMPRESSION: Successful CT-guided placement of a ___ pigtail catheter into the pelvic collection. Samples were sent for microbiology evaluation. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ w/ afib (on lvx), RA (on prednisone), IDDM, HTN/HLD, perf diverticulitis s/p ___ c/b pelvic hematoma c/b ostomy detachment s/p colostomy revision, now p/w vaginal bleeding. Found to have pelvic hematoma that was drained by ___ via CT guidance. Pt. still c/o abdominal pain, poor PO intake. Please eval interval change in abdominal/pelvic collection.// Please eval interval change in abdominal/pelvic collection. 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 4.2 s, 55.7 cm; CTDIvol = 12.6 mGy (Body) DLP = 703.1 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.4 mGy (Body) DLP = 16.7 mGy-cm. Total DLP (Body) = 722 mGy-cm. COMPARISON: CT abdomen pelvis dated ___ and most recent dated ___. FINDINGS: LOWER CHEST: Significant, interval improvement of bibasilar subsegmental atelectasis. There is no evidence of pleural or pericardial effusion. Mild to moderate coronary artery calcifications. Mildly enlarged heart. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout with smooth contours. There is geographic hypoattenuation at segment IV A which likely represents focal fat deposit. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout without pancreatic ductal dilatation. Multiple pancreatic cystic lesions measuring up to 20 mm at the pancreatic head, (series 601, image 23) appears similar compared to prior imaging. 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: Multiple bilateral renal cortical cysts appear simple or mildly hyperdense but without any nodular enhancement, unchanged over several evaluations. Bilateral renal cortical scarring is likely sequela of prior renal insult. No hydronephrosis. The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The patient is status post left lower quadrant diverting colostomy with ___ pouch. There is edema adjacent to the left lower quadrant colostomy and stranding in the left lower abdominal quadrant which is most likely secondary to prior surgical intervention. The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. PELVIS: There has been interval placement of a percutaneous drain within a rim enhancing hypoattenuating pelvic fluid collection with a density of 35 Hounsfield units which demonstrates few locules of air. The aforementioned fluid collection measures 7.3 x 4.1 cm and previously measured 8.6 x 2.1 cm. Additionally the fluid collection previously demonstrated a density of 53 Hounsfield units on most recent prior. There is a locule of gas at the superior aspect of the urinary bladder. REPRODUCTIVE ORGANS: Uterus is not demonstrated. The bilateral adnexa 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: The patient is status post a right total hip arthroplasty. Redemonstrated is a linear hypodensity at the right sacral ala which may related to an insufficiency fracture, relatively unchanged when compared to CT abdomen and pelvis dated ___. Mild degenerative changes of the lumbar spine with endplate compression fractures at L3 and L5 vertebral bodies. Minimally displaced left lateral ninth rib fracture with blunting of the and unchanged. SOFT TISSUES: Postoperative changes are seen at the midline of the anterior abdominal wall. IMPRESSION: 1. Interval decrease in size and density of pelvic fluid collection status post drain placement. There is persistent fluid and air bubbles within the collection. 2. No evidence of new intra-abdominal or pelvic pathology. 3. The patient is status post ___ pouch and redo of left lower quadrant colostomy with adjacent postsurgical changes. 4. Unchanged pancreatic hypodensities which most likely represent side branch IPMNs measuring up to 20 mm. 5. There is a locule of air at the superior aspect of the urinary bladder please correlate with possible history of recent catheterization or urinalysis. RECOMMENDATION(S): A follow-up MRCP in the ___ months is again recommended to further characterize the pancreatic lesions, or can be followed on future followup examinations. Radiology Report EXAMINATION: US BUTTOCKS, SOFT TISSUE RIGHT INDICATION: ___ w/ afib (on lvx), RA (on prednisone), IDDM, HTN/HLD, perf diverticulitis s/p ___ c/b pelvic hematoma c/b ostomy detachment s/p colostomy revision, now p/w vaginal bleeding// Collection over ___ drain insertion site? (R-buttock). TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the right buttocks at the site drain insertion in area of clinical concern as indicated by the patient. COMPARISON: CT of the abdomen and pelvis from ___ FINDINGS: There is heterogeneous subcutaneous edema without superficial drainable collection in the area of clinical concern. IMPRESSION: No superficial drainable collection in the area of clinical concern. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with Hartmans with persistent fluid collection and rising white count, concern for reversal stump leak- please use gastrigraffin PR to assess, please do NOT use barium. Thank you!// ? Recital stumpLeak TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Rectal contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 60.2 cm; CTDIvol = 9.9 mGy (Body) DLP = 596.5 mGy-cm. 2) Spiral Acquisition 2.6 s, 34.7 cm; CTDIvol = 10.3 mGy (Body) DLP = 356.1 mGy-cm. Total DLP (Body) = 953 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Aside from minimal bibasilar atelectasis, the visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Geographic hypoattenuation in segment ___ again likely represents focal fat deposition. Scattered punctate calcifications within the liver likely represent calcified granulomas. There is no evidence of suspicious 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 pancreatic ductal dilatation. Re-demonstrated are multiple pancreatic cystic lesions measuring up to 1.9 cm in the pancreatic head (02:26), which appear unchanged. 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. As before, multiple bilateral renal cortical cysts appears simple or mildly hyperdense and are unchanged. A 3.1 x 2.3 cm cystic structure in the right mid kidney likely represents a caliceal diverticulum (02:34). There is no evidence of hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Similar to prior, the patient is status post left lower quadrant diverting colostomy with a ___ pouch. Contrast was instilled via the rectum. There is no extraluminal contrast to suggest a leak. There is similar soft tissue stranding adjacent to the bowel loops in the left lower quadrant near the ostomy, likely postsurgical. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. A posterior approach percutaneous drain has been withdrawn, now with tip terminating outside the rim enhancing fluid collection in the perirectal space. A rim enhancing pelvic fluid collection with a few locules of air has slightly decreased in size, now measuring 6.5 x 4.4 cm, previously 7.3 x 4.6 cm (2:76). This collection closely abuts the cecum along its anterior superior margin (2:76, 302:78). PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not visualized. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. The patient is status post right total hip arthroplasty. There is a chronic fracture in the posterior-lateral left ninth rib. There are moderate to severe degenerative changes in the thoracolumbar spine with unchanged multilevel loss of height in the L3, L4 and L5 vertebral bodies. SOFT TISSUES: Aside from expected postsurgical changes, the abdominal and pelvic wall is within normal limits. IMPRESSION: 1. The posterior approach percutaneous drain has been withdrawn, now terminating outside the rim enhancing fluid collection in the perirectal space. 2. The pelvic fluid collection has minimally decreased in size, now measuring approximately 6.5 x 4.4 cm, previously 7.3 x 4.6 cm. However, the collection closely abuts the cecum along its superior anterior margin and it is unclear if there is a fistulous connection. If further evaluation is desired, contrast could either be administered via the ostomy or via the percutaneous drain once it is replaced. 3. No evidence of leak from the rectal stump. 4. Stable pancreatic hypodensities measuring to 1.9 cm in the pancreatic head, which most likely represent side branch IPMNs. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:06 pm, 2 minutes after discovery of the findings. The updated findings and recommendation were discussed with ___ at 19:19 on ___. Radiology Report EXAMINATION: CT Guided Drainage INDICATION: ___ w/ afib (on lvx), RA (on prednisone), IDDM, HTN/HLD, perf diverticulitis s/p ___ c/b pelvic hematoma c/b ostomy detachment s/p colostomy revision, now p/w vaginal bleeding and pelvic abscess sp drainage by ___, drain pulled back by ___ and not now in continuity with abscess, also would appreciate possible tube study? ? cecal involvement on recent CT scan// ? drain study, ? drain upsize and advancement COMPARISON: CT ___ PROCEDURE: CT-guided drainage of pelvic collection. OPERATORS: Dr. ___, radiology fellow 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 left lateral position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection and position of existing tube. Based on the CT findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. The tube was cut and ___ wire was advanced via existing tube in an attempt to negotiate wire along the tract into the collection. Unfortunately, this was unsuccessful and the wire was retracted along with the tube. The same skin entry site was used. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 10 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.4 s, 16.5 cm; CTDIvol = 10.8 mGy (Body) DLP = 163.8 mGy-cm. 2) Stationary Acquisition 8.3 s, 0.7 cm; CTDIvol = 97.0 mGy (Body) DLP = 69.8 mGy-cm. Total DLP (Body) = 243 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 35 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: The original 10 ___ pigtail was retracted and tip was extraluminal to the pelvic fluid collection. IMPRESSION: Remove of withdrawn/malpositioned ___ pigtail catheter and successful CT-guided placement of a ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. RECOMMENDATION(S): Flush catheter at least q 12h Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: BRBPR Diagnosed with Abnormal uterine and vaginal bleeding, unspecified, Other shock, Syncope and collapse, Unspecified atrial fibrillation, Long term (current) use of anticoagulants temperature: 98.0 heartrate: 80.0 resprate: 18.0 o2sat: 98.0 sbp: 127.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted with bleeding from your pelvic fluid collection. You had a drain placed under CT guidance and were started on antibiotics to treat the infected fluid collection. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: tramadol / Ultram / codeine / Demerol / Elavil / Elavil Attending: ___. Chief Complaint: R hip pain Major Surgical or Invasive Procedure: Right hip aspiration History of Present Illness: Ms. ___ is a ___ with a PMH notable for Hep C, HIV on HAART, prior heroin use on methadone therapy, bipolar disorder, ADHD, HTN, and asthma presents with 6 weeks atraumatic right hip pain. The patient reports that she went to an OSH 6 weeks ago where she had an unremarkable hip xray and then had an MRI but is uncertain of the results. She had a followup xray taken several weeks later which showed collapse of the right femoral head and she was sent to ___ where she was diagnosed with AVN and referred to outpatient clinic. She is here today because she is continuing to have severe pain and her appointment isn't until ___. The patient has been walking with a cane since 6 weeks ago due to pain and concern that she will fall, especially since she lives alone in a ___ floor apartment. She has been taking oxycodone 5mg q4hrs that doesnt help, daily methadone that helps somewhat, and ibuprofen 600mg q3-4hrs x 6 weeks that helps somewhat. She has peripheral neuropathy at baseline. In the ED, initial vitals: 97.8 48 104/64 14 99% - Exam notable for no ext ernal deformaty, edema, or ROM deficits. 1+ ___ pulses, foot warm and well-perfused - Labs notable for: ___ ___ aspiration femoral head consistent with AVN ___ Hip aspirate Prelim-No PMN, no micro - Imaging notable for: XR: Dysmorphic, collapsed, flattened right femoral head, compatible with advanced AVN. Mild lateral subluxation of the right femoral head also present. - Pt given: All home meds with the exception that Adderall was held - Vitals prior to transfer: 97.9 52 111/62 18 98%RA On arrival to the floor, pt reports right hip pain, ___. Endorses intermittent nausea due to pain. ROS: She denies fever, chills, headache, chest pain, abdominal pain, diarrhea, constipation, respiratory distress. She has baseline abdominal distension due to HIV lipodystrophy Past Medical History: HTN HLD Bipolar ADHD Opiate abuse Hep C HIV - on HAART therapy Social History: ___ Family History: Not contributory. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 97.2 120/553 16 97%RA General- Alert, oriented, no acute distress while lying in bed HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2 Abdomen- soft, non-tender, quiet bowel sounds present, no rebound tenderness or guarding, abdomen distended GU- no foley Ext- warm, well perfused, no clubbing, cyanosis or edema Neuro- EOMI, tongue midline, face symmetric, motor function grossly normal Right lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Patient unable to actively range hip due to pain. Full PROM intact but painful. Full, painless AROM/PROM of knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused - Patient reports TN palsy with foot drop, but patient has good dosriflexion ability Left lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - 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 Pertinent Results: ========LABS======== ___ 09:23PM BLOOD WBC-4.4 RBC-3.81* Hgb-10.8* Hct-33.9* MCV-89 MCH-28.3 MCHC-31.9* RDW-13.7 RDWSD-44.8 Plt ___ ___ 09:23PM BLOOD ___ PTT-31.8 ___ ___ 09:23PM BLOOD Glucose-112* UreaN-28* Creat-0.6 Na-139 K-3.3 Cl-98 HCO3-32 AnGap-12 ___ 09:23PM BLOOD ALT-11 AST-14 AlkPhos-70 TotBili-0.8 ___ 09:23PM BLOOD Calcium-9.3 Phos-2.5* Mg-1.7 ___ 10:10AM BLOOD CRP-1.7 =======IMAGING ========= TECHNIQUE: AP view of the pelvis, and right femur, three views. COMPARISON: None. FINDINGS: The right femoral head is dysmorphic, collapse, and flattened, compatible with advanced AVN. Mild lateral subluxation is also identified. Significant right hip degenerative joint disease with near complete loss of joint space also noted. Mild osteoarthritic changes of the left hip and lower lumbar spine are identified, with joint space narrowing and osteophytosis. There is also mild osteoarthritis at the right knee, with a small posterior flabella. No knee joint effusion identified. IMPRESSION: Dysmorphic, collapsed, flattened right femoral head, compatible with advanced AVN. Mild lateral subluxation and significant DJD also noted at the right hip. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 600 mg PO Q6H:PRN Pain 2. Ranitidine 150 mg PO BID 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN respiratory distress 4. Metoprolol Tartrate 50 mg PO BID 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 6. Atazanavir 300 mg PO DAILY 7. RiTONAvir 100 mg PO DAILY 8. Calcium Carbonate 600 mg PO BID 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Fenofibrate 145 mg PO DAILY 11. ClonazePAM 1 mg PO TID 12. Divalproex (DELayed Release) 250 mg PO QAM 13. Hydrochlorothiazide 25 mg PO DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q4-6H PRN Pain 15. Escitalopram Oxalate 40 mg PO QHS 16. Methadone 170 mg PO DAILY 17. dextroamphetamine-amphetamine 20 mg oral TID 18. Gabapentin 100 mg PO TID 19. Pregabalin 50 mg PO BID 20. Divalproex (DELayed Release) 500 mg PO QPM Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN respiratory distress 2. Atazanavir 300 mg PO DAILY 3. Calcium Carbonate 600 mg PO BID 4. ClonazePAM 1 mg PO TID 5. Divalproex (DELayed Release) 250 mg PO TID 6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 7. Escitalopram Oxalate 40 mg PO QHS 8. Fenofibrate 145 mg PO DAILY 9. Methadone 170 mg PO DAILY 10. Metoprolol Tartrate 50 mg PO BID 11. Multivitamins W/minerals 1 TAB PO DAILY 12. OxycoDONE (Immediate Release) 5 mg PO Q4-6H PRN Pain RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*50 Tablet Refills:*0 13. Pregabalin 50 mg PO BID 14. Ranitidine 150 mg PO BID 15. RiTONAvir 100 mg PO DAILY 16. Hydrochlorothiazide 25 mg PO DAILY 17. dextroamphetamine-amphetamine 20 mg ORAL TID 18. Gabapentin 100 mg PO TID 19. Ibuprofen 600 mg PO Q6H:PRN Pain 20. Bisacodyl 10 mg PO DAILY:PRN constipation 21. Docusate Sodium 100 mg PO BID:PRN Constipation 22. Enoxaparin Sodium 40 mg SC QPM Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc qpm Disp #*30 Syringe Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: right femoral avascular necrosis Secondary: Hep C, HIV, HTN, HLD, bipolar disorder, panic disorder, ADHD 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: ORIF. TECHNIQUE: One view right hip COMPARISON: ___ FINDINGS: There is a right total hip arthroplasty. There is a non cemented femoral stem. No periprosthetic fracture or lucency is identified. Air in the soft tissues is an expected postsurgical finding. IMPRESSION: Expected postsurgical findings status post right total hip arthroplasty. Radiology Report EXAMINATION: PELVIS (AP ONLY) PORT INDICATION: ___ year old woman with R hip AVN s/p R THA // s/p THA COMPARISON: ___, FINDINGS: Compared with the prior study, the patient has undergone placement of a right total with a prosthesis, in overall anatomic alignment on this single AP view. No periarticular fracture is detected. Subcutaneous emphysema, soft tissue swelling common skin staples are present, consistent with recent surgery. A linear density overlies soft tissues of the medial proximal right thigh. It is not clear whether this represents a catheter or something outside of the the patient. Clinical correlation is requested. Incidental note is made of hydroxyapatite or an enthesophyte at the left ischial tuberosity, unchanged. IMPRESSION: As above. Radiology Report EXAMINATION: DX PELVIS AND FEMUR INDICATION: ___ with right hip pain, OSH images concerning for AVN. Please eval for AVN of the hip. TECHNIQUE: AP view of the pelvis, and right femur, three views. COMPARISON: None. FINDINGS: The right femoral head is dysmorphic, collapse, and flattened, compatible with advanced AVN. Mild lateral subluxation is also identified. Significant right hip degenerative joint disease with near complete loss of joint space also noted. Mild osteoarthritic changes of the left hip and lower lumbar spine are identified, with joint space narrowing and osteophytosis. There is also mild osteoarthritis at the right knee, with a small posterior flabella. No knee joint effusion identified. IMPRESSION: Dysmorphic, collapsed, flattened right femoral head, compatible with advanced AVN. Mild lateral subluxation and significant DJD also noted at the right hip. Radiology Report EXAMINATION: INJ/ASP MAJOR JT W/FLUORO INDICATION: ___ year old woman with right hip pain // arthrocentesis of right hip COMPARISON: Pelvic and right hip radiographs on ___. PROCEDURE: The procedure was supervised by Dr. ___, the attending radiologist, who was present for the critical portions of the procedure. The risks, benefits, and alternatives were explained to the patient and written informed consent obtained. A pre-procedure timeout confirmed three patient identifiers. Under fluoroscopic guidance, an appropriate spot was marked. The area was prepared and draped in standard sterile fashion. 3 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent fluoroscopic guidance, an 18-gauge spinal needle was advanced into the right hip joint. Approximately 3 cc of yellow fluid was aspirated from the right hip joint. Samples were sent for cell count, crystal analysis, culture and Gram stain. The needle was removed, hemostasis achieved, and a sterile bandage applied. The patient tolerated the procedure well and left the department in stable condition. There were no immediate complications or complaints. FINDINGS: Dysmorphic, collapsed and flattened right femoral head consistent with AVN and associated secondary degenerative changes. IMPRESSION: 1. Imaging Findings - see above. 2. Procedure - Technically successful aspiration of the right hip joint. I Dr. ___ personally supervised the Fellow during the key components of the above procedure and I have reviewed and agree with the Fellow findings/dictation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Hip pain Diagnosed with ASEPTIC NECROSIS FEMUR, JOINT PAIN-PELVIS, ASYMPTOMATIC HIV INFECTION temperature: 97.8 heartrate: 48.0 resprate: 14.0 o2sat: 99.0 sbp: 104.0 dbp: 64.0 level of pain: 9 level of acuity: 3.0

Dear Ms. ___, It was a pleasure to take part in your care at ___ ___. You were admitted for right hip pain. An xray revealed that your hip has avascular necrosis (bone collapse) and you underwent orthopedic hip surgery. 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 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 40mg 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. - No dressing is needed if wound continues to be non-draining. 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 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: Touch down weight bearing right lower extremity Posterior precautions of right hip Treatments Frequency: - 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.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Lower extremity edema, dyspnea Major Surgical or Invasive Procedure: Right heart cath ___ Placement of ___ coronary sinus lead ___ History of Present Illness: Mr. ___ is an ___ man with a history of heart failure with reduced ejection fraction (EF 35%), right ventricular dilation with free wall hypokinesis, moderate tricuspid regurgitation, permanent atrial fibrillation on rivaroxaban, chronotropic incompetence while in AF status post single-chamber pacemaker (___), severe OSA, DMII, prostate cancer status post TURP, chronic lower back pain, depression and history of medication nonadherence who presents with lower extremity swelling and shortness of breath concerning for heart failure exacerbation. Notably, he was hospitalized in ___ for heart failure exacerbation in the setting of not taking any diuretics as an outpatient. He was diuresed with furosemide boluses until being transitioned to torsemide 10 mg PO daily. He was discharged on losartan 50mg daily, metoprolol succinate 12.5 mg daily, and spironolactone 12.5mg daily. He had persistent lower extremity edema, at least partially attributable to venous insufficiency, and was not willing to wear compression stockings or use ACE wraps. In ED, he reports dyspnea. He also reported swelling in his bilateral legs that they were itchy. He also reported some pain in the left side of his chest but does not remember when it started. He says he thinks he took his medications today but is not sure. Per his chart. He has had frequent admissions for heart failure exacerbations that were likely due to medication nonadherence. In the ED initial vitals were: T 97.9F HR 104 BP 180/111 RR 20 O2 97% RA EKG: AF, V paced Labs/studies notable for: CBC unremarkable. Cr 1.2 BUN 20, otherwise BMP unremarkable. BNP 1219 (last admission: 1675) INR 1.5 CXR 1. Mild pulmonary edema, similar to prior. 2. Indistinct left hemidiaphragm with patchy left lower lobe opacities may reflect atelectasis, although pneumonia cannot be excluded in the proper clinical setting. Patient was given: IV Furosemide 40 mg with significant urine output. On the floor, the patient endorses the above history. He reports that he has been feeling short of breath for several days. This is worse when he lies down and with exertion. He reports that he has been taking his medications as prescribed but notes that his daughter has been out of town so things are more difficult for him. He also notes that his legs are much more swollen than usual. He denies any recent infectious symptoms such as fever/chills, URI symptoms, nausea/vomiting/diarrhea. His chest pain that he reported in the ED is now resolved. REVIEW OF SYSTEMS: Positive per HPI. Past Medical History: Diabetes (A1c 6.7 in ___ Atrial fibrillation w/slow ventricular rate on rivaroxaban HFPEF Post-op afib/flutter in ___, resolved Prostate CA (s/p RRP/pelvic lymphadenectomy ___ Severe OSA Secondary polycythemia Osteoarthritis Depression Chronic distal sensorimotor polyneuropathy per ___ EMG Impotence (+)PPD s/p R S2 dermatomal herpes zoster ___ (+) RPR/late latent syphilis treated ___ (doxycycline), ___ (PCN with desensitization) s/p H. pylori-associated gastritis ___ (treated) s/p arthroscopic rotator cuff repair ___ s/p anterior cervical decompression and fusion C3-C4 C5-C6/anterior cervical arthrodesis/posterior cervical laminectomy C4-C7/posterior cervical arthrodesis C3 to ___ s/p TKR RLE ___ s/p medial meniscectomy RLE ___ s/p LIH repair ___ Social History: ___ Family History: -Maternal h/o cardiac disease, unspecified Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: T ___ PO BP 159/80 L Lying HR 61 RR 20 ___ GENERAL: Pleasant man in no acute distress. Fully oriented. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP elevated to midneck. CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Bibasilar crackles present. No wheezes or rhonchi. ABDOMEN: Soft, non-tender, distended. EXTREMITIES: Warm, well perfused. 4+ pitting edema to sacrum bilaterally. No clubbing, cyanosis. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ======================== GENERAL: Elderly gentleman sitting up in chair, NAD NECK: JVP 10 at 90 degrees. CARDIAC: Regular rate and rhythm, no murmurs. LUNGS: Vesicular breath sounds bilaterally. ABD: Large, mildly distended, non-tender to palpation EXTREMITIES: improvement in bilateral lower extremity edema, though still distended. There is significant discoloration with skin appearing dark red/purple. The extremities are warm. Pertinent Results: ADMISSION LABS: ============== ___ 10:12PM BLOOD WBC-6.5 RBC-5.12 Hgb-14.2 Hct-48.2 MCV-94 MCH-27.7 MCHC-29.5* RDW-15.9* RDWSD-55.0* Plt ___ ___ 10:12PM BLOOD Neuts-65.2 ___ Monos-8.3 Eos-4.8 Baso-0.8 Im ___ AbsNeut-4.23 AbsLymp-1.34 AbsMono-0.54 AbsEos-0.31 AbsBaso-0.05 ___ 10:12PM BLOOD ___ PTT-33.6 ___ ___ 10:12PM BLOOD Glucose-129* UreaN-20 Creat-1.2 Na-138 K-4.8 Cl-105 HCO3-24 AnGap-9* ___ 10:12PM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0 ___ 11:26PM BLOOD Na-142 K-3.8 DISCHARGE LABS: =============== ___ 06:36AM BLOOD WBC-6.5 RBC-5.04 Hgb-14.0 Hct-45.9 MCV-91 MCH-27.8 MCHC-30.5* RDW-15.7* RDWSD-53.0* Plt ___ ___ 06:36AM BLOOD ___ PTT-38.0* ___ ___ 06:36AM BLOOD Glucose-103* UreaN-42* Creat-1.3* Na-141 K-4.9 Cl-99 HCO3-25 AnGap-17 ___ 06:36AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.4 STUDIES: ======= CXR - ___: IMPRESSION: 1. Mild pulmonary edema, similar to prior. 2. Indistinct left hemidiaphragm with patchy left lower lobe opacities may reflect atelectasis, although pneumonia cannot be excluded in the proper clinical setting. RIGHT ___ ___ IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. ABDOMINAL ULTRASOUND ___ IMPRESSION: 1. No focal liver lesion identified. No biliary dilatation. 2. Mild splenomegaly. 3. No ascites visualized in the abdomen. RIGHT HEART CATH ___ Label Systolic Diastolic Mean dP/dt A wave V Wave AO 121 69 86 PA 53 19 31 PCW 15 13 27 RA 12 19 9 RV 45 1 14 432 CORONARY SINUS LEAD PLACEMENT ___ Left pectoral pocket was opened and old MDT Sensia SR was extracted with no difficulty. Left subclavian v. access via Seldinger: MDT ___ LV lead to posterolateral LV. Local delay 160 msec. New MDT ___ CRT-P implanted in same pocket. No complications. CHEST X-RAY ___ IMPRESSION: Mild cardiomegaly with the left basilar and retrocardiac opacification. Atelectasis versus pleural effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Escitalopram Oxalate 20 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Torsemide 10 mg PO DAILY 6. GlipiZIDE XL 2.5 mg PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Rivaroxaban 15 mg PO DAILY 9. Spironolactone 12.5 mg PO DAILY Discharge Medications: 1. Cephalexin 500 mg PO/NG Q8H Duration: 5 Days 2. Losartan Potassium 25 mg PO DAILY 3. Rivaroxaban 20 mg PO DINNER 4. Spironolactone 25 mg PO DAILY 5. Torsemide 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Escitalopram Oxalate 20 mg PO DAILY 9. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: - Acute heart failure reduced ejection fraction from ventricular dyssynchrony SECONDARY: - Atrial fibrillation - Acute kidney injury 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: ___ male with history of CHF who presents with signs of volume overload, assess for evidence of heart failure TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior chest radiographs, most recently ___ FINDINGS: Left-sided pacer device is again noted with lead in unchanged position within the right ventricle. Moderate enlargement of the cardiac silhouette is stable. Mild pulmonary edema appears overall similar to prior. Indistinct left hemidiaphragm with patchy left lower lobe opacities, better seen on the lateral projection, may reflect atelectasis, although pneumonia cannot be excluded in the proper clinical setting. Mild-to-moderate degenerative changes are again seen throughout the thoracic spine. Cervical spinal fusion hardware is incompletely assessed, although their is unchanged fracture through the pedicular screws of the T1 level. IMPRESSION: 1. Mild pulmonary edema, similar to prior. 2. Indistinct left hemidiaphragm with patchy left lower lobe opacities may reflect atelectasis, although pneumonia cannot be excluded in the proper clinical setting. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT PORT INDICATION: ___ year old man admitted for HF exacerbation with BLE edema now with asymmetry in color, significant pain to palpation right leg and with right dorsiflexion. Evaluation for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: Comparison to bilateral lower extremity venous ultrasound from ___. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old man with abdominal distention and bloating and lower extremity edema out of proportion to JVP and concern for possible intra abdominal tumor, will start with u/s and consider CT pending results// Evaluate for ascites 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 a small hyperechoic avascular lesion in the left lobe of the liver which likely represents a hemangioma. No suspicious liver lesion is visualized. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 4 mm GALLBLADDER: The gallbladder is partially contracted. No gallstones are visualized. PANCREAS: The pancreas is unremarkable but is only minimally visualized due to overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 13.1 cm KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. Right kidney: 10.5 cm Left kidney: 9.2 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. No focal liver lesion identified. No biliary dilatation. 2. Mild splenomegaly. 3. No ascites visualized in the abdomen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with CMP ___ CRT-P upgrade// r/o pneumothorax. TECHNIQUE: Portable chest AP. COMPARISON: Chest radiograph from ___. FINDINGS: Left upper chest pacing device and leads are in similar configuration. Lung volumes are low. Prominent central pulmonary vascular and perihilar interstitial markings, compatible with mild to moderate pulmonary edema. Bibasilar densities with prominent retrocardiac density largely obscuring the left hemidiaphragm may reflect a combination of atelectasis, edema, and pleural effusion, better seen on lateral projection in the prior study. There is no pneumothorax. Cardiomediastinal silhouette is similarly enlarged. There is no pneumothorax. Cervical fusion hardware is partially imaged. IMPRESSION: -Similar to slightly increased mild-to-moderate pulmonary edema. -No pneumothorax. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with CMP ___ CRT-P upgrade// lead position lead position COMPARISON: Chest x-ray ___ FINDINGS: Left chest wall dual lead pacer and leads unchanged in positioning. The heart remains enlarged. Right costophrenic angle is sharp. There is blunting of the left costophrenic angle with retrocardiac opacification which could represent atelectasis or effusion. No pneumothorax. Mild pulmonary vascular congestion. IMPRESSION: Mild cardiomegaly with the left basilar and retrocardiac opacification. Atelectasis versus pleural effusion. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Leg swelling Diagnosed with Heart failure, unspecified, Dyspnea, unspecified temperature: 97.9 heartrate: 104.0 resprate: 20.0 o2sat: 97.0 sbp: 180.0 dbp: 111.0 level of pain: 5 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital because of your heart failure. Please see below for more information on your hospitalization. It was a pleasure participating in your care! We wish you the best! - Your ___ Healthcare Team What happened while you were in the hospital? - You were given medication to help reduce the amount of fluid in your body to help improve your breathing and leg swelling. - You were evaluated for a double pacemaker to help both sides of your heart beat more synchronously. This was done on ___. You had some bleeding around the device afterwards which was causing some pain, but the device specialists said this should improve with time. - You were improved significantly and were ready to leave the hospital. What should you do after leaving the hospital? - Weight yourself daily. On the day of discharge, your weight is 231 pounds. Call your doctor if your weight increases by more than three pounds. You might need - Please take your medications as listed in discharge summary and follow up at the listed appointments.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Compazine / Sulfur / Vicodin / Morphine / Penicillins / Macrodantin / Iodine / Clindamycin / azithromycin / Cipro Attending: ___. Chief Complaint: left lower extremity swelling for past two days Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with ___, CKD stage 4, LLE DVT ___ complicated by BRBPR now off coumadin who presents with two day history of left lower extremity swelling noted by her daughter who is a ___. She does not report chest pain, shortness of breath, orthopnea, paroxysmal noctural dyspnea, long travels, plain rides, trauma or BRBPR. In the ED, initial VS 99.5 72 157/91 18 99% RA. Labs notable for creatinine of 1.8 (baseline) and BNP in 6000s (better than baseline in 9000s). LLE US showed left common femoral and femoral vein similar to ___ and thus started on IV heparin without bolus and admitted to medicine for further management. On the floor, she reported no complains. Past Medical History: ___: EF 75-80% LLE DVT off comuadin secondary to BRBPR Hyperlipidemia Hyperparathyroid Hypothyroid PMR CRI venous insufficiency hx aspiration pna Social History: ___ Family History: Mother deceased of stroke. Husband deceased of stroke. No other known family hx of clot Physical Exam: Physical Exam on admission: VS - 97.5 200/78 60 99%RA GENERAL - Alert, interactive, well-appearing woman in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - Left lower extremity 2 cm bigger than right lower extremity NEURO - awake, A&Ox2, CNs II-XII grossly intact Physical Exam on discharge: VS - T 98.2 BP 176/73 P 67 RR 18 96% RA GENERAL - Alert, interactive, well-appearing woman in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - Left lower extremity 2 cm larger than right lower extremity NEURO - awake, A&Ox2, CNs II-XII grossly intact Pertinent Results: Labs on admission: ___ 10:30PM BLOOD WBC-11.8* RBC-3.30* Hgb-9.6* Hct-30.1* MCV-91 MCH-29.0 MCHC-31.8 RDW-17.1* Plt ___ ___ 10:30PM BLOOD Neuts-82.0* Lymphs-14.0* Monos-3.5 Eos-0.4 Baso-0.1 ___ 10:38PM BLOOD ___ PTT-21.5* ___ ___ 10:30PM BLOOD Glucose-118* UreaN-44* Creat-1.8* Na-138 K-5.0 Cl-105 HCO3-21* AnGap-17 ___ 10:30PM BLOOD CK(CPK)-35 ___ 10:30PM BLOOD CK-MB-4 cTropnT-0.03* proBNP-___* ___ 06:10AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.4 ___ 01:18PM BLOOD D-Dimer-5751* ___ 12:24PM BLOOD D-Dimer-5485* Labs on discharge: ___ 06:10AM BLOOD WBC-10.0 RBC-3.40* Hgb-10.0* Hct-31.1* MCV-92 MCH-29.5 MCHC-32.2 RDW-17.0* Plt ___ ___ 06:10AM BLOOD Neuts-66.9 ___ Monos-4.3 Eos-2.0 Baso-0.2 ___ 06:10AM BLOOD Glucose-80 UreaN-40* Creat-1.8* Na-141 K-4.3 Cl-105 HCO3-27 AnGap-13 CXR ___: AP AND LATERAL CHEST RADIOGRAPHS: Lungs are reasonably well expanded with persistent right lower lung opacity decreased in conspicuity from the previous examination, which could reflect scarring from prior pneumonia; however, recurrent pneumonia cannot be excluded. Interstitial prominence likely reflects chronic pulmonary disease. Cardiomegaly and dual-lead pacer are =unchanged with extensive atherosclerotic calcification of the aorta. Trace right effusion or pleural thickening may also be present. IMPRESSION: Right lower lobar opacity could reflect scarring from prior pneumonia, though recurrent pneumonia cannot be excluded. ___ ___: IMPRESSION: Chronic-appearing thrombus of the left CFV and superficial femoral vein with incompletely assessed calf veins bilaterally. No right lower extremity DVT was seen. Medications on Admission: ACETAMINOPHEN 650 mg Q8H PRN pain Amlodipine 2.5 mg po qhs Ascorbic acid ___ mg po qdaily Carvedilol 3.125 mg po qhs Cetirizine 10 mg po qhs Vitamin D3 1,000 unit po qdaily Ferrous sulfate 325 mg po qdaily Levothyroxine 88 mcg po qdaily Lidocaine patch daily Multivitamin po qdaily Omeprazole 40 mg po qdaily Miralax daily Prednisone 15 mg po qdaily Sennosides 8.6 mg po BID Aloe Vesta BID Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 13. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Aloe Vesta 2 % Ointment Sig: One (1) Topical twice a day. 16. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Chronic Deep Venous Thrombosis Secondary: Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ woman with left leg swelling. Assess for DVT. COMPARISONS: ___. FINDINGS: Grayscale and color Doppler sonographic evaluation was performed of the bilateral lower extremities. The left common femoral and superficial femoral veins were incompletely compressible with internal echogenic material compatible with thrombus in a similar appearance to the recent comparison, though on the current examination no thrombus was seen in the left popliteal vein. The right common femoral, superficial femoral and popliteal veins were normal with normal compressibility and flow. The calf veins were incompletely seen with a single peroneal and posterior tibial veins seen bilaterally, which were patent. IMPRESSION: Chronic-appearing thrombus of the left CFV and superficial femoral vein with incompletely assessed calf veins bilaterally. No right lower extremity DVT was seen. This was discussed with Dr. ___ by Dr. ___ at 2320 on ___ by phone. Radiology Report INDICATION: ___ woman with chest pain. COMPARISONS: ___. AP AND LATERAL CHEST RADIOGRAPHS: Lungs are reasonably well expanded with persistent right lower lung opacity decreased in conspicuity from the previous examination, which could reflect scarring from prior pneumonia; however, recurrent pneumonia cannot be excluded. Interstitial prominence likely reflects chronic pulmonary disease. Cardiomegaly and dual-lead pacer are unchanged with extensive atherosclerotic calcification of the aorta. Trace right effusion or pleural thickening may also be present. IMPRESSION: Right lower lobar opacity could reflect scarring from prior pneumonia, though recurrent pneumonia cannot be excluded. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: LT, CALF SWELLING Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY, CHEST PAIN NOS, ATRIAL FIBRILLATION temperature: 99.5 heartrate: 72.0 resprate: 18.0 o2sat: 99.0 sbp: 157.0 dbp: 91.0 level of pain: 5 level of acuity: 3.0

Dear Ms. ___, It was a sincere pleasure taking care of you during your hospitalization at ___. You were admitted with swelling of your left leg. We found that the clot in your leg was likely old or "chronic." After discussions of the risks and benefits of treatment with you and your family, it was decided that you would not restart coumadin. If you are to develop any worsening redness, pain or swelling in your leg, or shortness of breath/chest pain, you should report immediately to the emergency department. PLEASE NOTE THE FOLLOWING MEDICATION CHANGES: RESTARTED ASPIRIN 81 MG DAILY

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: ___ ERCP ___ Laparoscopic Cholecystectomy History of Present Illness: Mrs ___ is a pleasant ___ woman who presented to ___ ___ on day of admission with complaints of nausea, NBNB vomiting, and intermittent RUQ abd pain. She states that the nausea was worse than the abd pain, which was moderate in severity. Her last episode of emesis was on ___, however the nausea has been present for the last ___ days, and the abd pain started last night. She has had poor PO intake because of her sxs, however is now feeling improved with the fluids and anti-emetics that she received in the ED. No fevers, chills, no previous history of abdominal pain. Last BM was 2 ays PTA and was loose. She presented to the ED today because her urine was become darker and she was concerned that she was becoming more dehydrated. At ___, labs were notable for: ALT: 813 AP: 596 Tbili: 4.61 Alb: 4.3 AST: 514 TProt: 7.2 ___: Lip: 1050. US showed cholelithiasis without other sonographic evidence of acute cholecystitis as well as dilated intra and extra hepatic bile ducts. She was given zosyn, IVF and transferred to ___ for ERCP. In our ED, initial vs were 98.2 76 131/77 16 100% RA. She was seen by surgery who recommended ERCP consult. ERCP evaluated the pt in the ED and recommended medicine admission for ERCP in the AM. Vitals on transfer were 98.7 70 130/83 16 97%. On arrival to the floor, she is comfortable and has no complains. Denies N/V/abd pain presently. 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 diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria, frequency. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: --HTN --Anxiety/depression Social History: ___ Family History: HTN, mom with cardiac disease Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:98.2 BP:137/87 P:77 R:16 O2:98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfusedno clubbing, cyanosis or edema Skin: no rashes/lesions Neuro: CNs ___ intact, moving all extremities On discharge: VS 98.6, 80, 116/70, 14, 96% on room air Pertinent Results: ___ labs ___: WBC 8.4 HCT 38.0 PLT 299 HCG Neg Na 135 K 3.7 Cl 96 CO2 30 Glu 118 BUN 11 Cr 0.46 Ca ___ Mg 1.92 Alb 4.3 TP 7.2 BILI 4.6 ALP 596 ALT 813 AST 514 Lipase 1050 UA +bili, + nitrite, +leuk esterase STUDIES: ___ RUQ US 1. CHOLELITHIASIS WITHOUT OTHER SONOGRAPHIC EVIDENCE OF ACUTE CHOLECYSTITIS. 2. DILATED INTRA- AND EXTRAHEPATIC BILE DUCTS. PLEASE NOTE THAT A DISTAL DUCT STONE CANNOT BE EXCLUDED. IF THERE IS CONCERN FOR CHOLEDOCHOLITHIASIS, MRCP SHOULD BE OBTAINED. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY Please hold for SBP <100. 2. Atenolol 50 mg PO DAILY Please hold for SBP <100 or HR <50. 3. Paroxetine 30 mg PO DAILY Discharge Medications: 1. Atenolol 50 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Paroxetine 30 mg PO DAILY 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID 6. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: 1. Choledocholithiasis 2. Cholelithiasis 3. Pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ woman with gallstone pancreatitis. REASON FOR THIS EXAMINATION: Please evaluate if patient passed stone. COMPARISON: None available TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 tesla magnet, including dynamic 3D imaging, obtained prior to, during, and after the uneventful intravenous administration of 0.1 mmol/kg (7 cc) of Gadavist gadolinium contrast. Patient also received 2.5 cc of Gadavist gadolinium in 75 cc of water for oral contrast. FINDINGS: Patient is apparently status post ERCP the morning prior to this study, although report is not available at this time. There is persistent moderate diffuse intrahepatic and extrahepatic biliary ductal dilatation, the common bile duct measures 10 mm in diameter. There is diffuse peribiliary enhancement consistent with cholangitis, including enhancement about the intrahepatic and extrahepatic bile ducts as well as the gallbladder wall. In the more inferior common bile duct is a small likely partially obstructing hypointense calculus measuring 6 mm in diameter. 2 smaller filling defects are seen superior and inferior to this lesion, these may represent additional nonobstructing calculi. Smaller filling defects are also seen in the distalmost common bile duct near the ampulla, with note also made of ampullary edema and hyperemia. No evidence of abscess formation. The gallbladder is nondistended but filled with sludge and stones with wall hyperenhancement which may represent secondary or chronic cholecystitis. 6 mm simple appearing cyst in the left hepatic lobe. There is minimal dilatation of the pancreatic duct measuring 4 mm. Mild fat stranding is seen surrounding the pancreatic head. The pancreatic parenchyma appears to have preserved enhancement. Bilateral simple appearing renal cortical cysts measuring up to 8 mm in the right upper pole. Spleen, pancreas, bilateral adrenal glands appear unremarkable. Normal caliber abdominal aorta. No evidence of significant lymphadenopathy. Visualized small and large bowel appear unremarkable. No evidence of ascites. Small fat containing umbilical hernia. IMPRESSION: 1. Persistent moderate intrahepatic and extrahepatic biliary ductal dilatation suggestive of distal CBD obstruction. Multiple common bile duct stones measuring up to 6 mm in the inferior common bile duct, with small stones seen near the ampulla, along with ampullary edema and minimal pancreatic ductal prominence. Cannot exclude tiny stone impacted at the ampulla. Extensive cholelithiasis. 2. Findings suggestive of associated cholangitis with secondary or chronic cholecystitis. Radiology Report INDICATION: History of cholelithiasis and choledocholithiasis and gallstone pancreatitis. Status post laparoscopic cholecystectomy. COMPARISONS: MRCP from ___. FINDINGS: Four fluoroscopic spot views from an intraoperative cholangiogram are submitted for review without the presence of a radiologist. These demonstrate opacification of the common bile duct, common hepatic duct, and cystic duct. The common bile duct and the common hepatic duct appear dilated. There are no filling defects. For further details, please refer to the intraoperative note. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: DIARRHEA Diagnosed with CHOLELITHIASIS NOS, HYPERTENSION NOS temperature: 98.2 heartrate: 76.0 resprate: 16.0 o2sat: 100.0 sbp: 131.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you on this admission. You came to the hospital because you were having abdominal pain, nausea, and dark urine. You were found to have an obstruction of your bile duct. This caused your pancreas to get inflammed. You were treated with IV fluids and pain control. You underwent an ERCP to remove some stones, and then you had your gallbladder removed to ensure the problem wouldn't recur. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: shortness of breath, lightheadedness Major Surgical or Invasive Procedure: + Aortic Valvuloplasty - ___ History of Present Illness: ___ w/h/o critical aortic stenosis, CAD, CHF, presents from assisted living facility with SOB. Yesterday she reports that she had a "weak spell" a/w nausea, diaphoresis, and exertional dyspnea, but no chest pain. Brought to ___ ___ "abnormal vital signs", where EKG showed mild new lateral TWI, negative initial troponin BNP 300. Concerning for decompensating AS vs. unstable angina. Pt's outpt cardiologist had scheduled her for balloon valvuloplasty in ___ contacted cards at ___ regarding transfer w/ concern that procedure may need to be scheduled more urgently. In the ED initial vitals were: 98.7 88 112/56 18 97% RA. Labs were significant for hg 8.7 down from baseline of 10, neg troponin X 1, pro BNP 6143. CXR showed pulmonary edema w/ R pleural effusion. On floor pt is comfortable, oriented, no SOB or acute distress. Her only complaint is poor sleep. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: CAD s/p STEMI ___ with BMS to RCA Hyperlipidemia Hypertension GERD COPD Hypothyroidism h/o rheumatic fever Severe AS s/p balloon angioplasty in ___ Social History: ___ Family History: Brother with rheumatic heart disease, died of MI in ___ mother with MI in ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - 98.6 130-143/41-58 ___ 16 95-96RA GENERAL: NAD, very hard of hearing, AAOx3 HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent nares, MMM, dental plate NECK: supple neck, no JVD CARDIAC: RRR, ___ SEM best heard in LUSB LUNG: mild crackles throughout, greatest in bases, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: trace pitting edema in ___. Moving all extremities well. Ecchymosis and mild edema over dorsum of L hand at site of blood draw NEURO: no focal deficits. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals - 98.4 108-140/40-50 ___ 18 93-98% on RA I/O: ___ NET -600 GENERAL: AAOx3, NAD. HEENT: MMM, dentures in place NECK: supple neck, no JVD CARDIAC: RRR, ___ SEM best heard in LUSB. Pulses not delayed or soft. LUNG: CTAB ___, no accessory muscle use ABDOMEN: nondistended, mildly tender in RLQ, otherwise nontender. EXTREMITIES: no edema in ___. Moving all extremities well. The right femoral artery access site has resolving ecchymosis, non-tender and without induration. Distal dorsalis pedis and posterior tibial pulses are easily palpable and 2+ bilaterally. Feet well perfused, <1 sec cap refill. NEURO: no focal deficits. full strength, normal sensation. Oriented and appropriate SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 06:00PM BLOOD WBC-7.8 RBC-2.73* Hgb-8.7* Hct-26.5* MCV-97 MCH-32.0 MCHC-32.9 RDW-14.3 Plt ___ ___ 06:00PM BLOOD Neuts-78.4* Lymphs-12.7* Monos-7.3 Eos-1.4 Baso-0.2 ___ 10:00AM BLOOD ___ PTT-53.1* ___ ___ 06:00PM BLOOD Glucose-108* UreaN-25* Creat-1.0 Na-137 K-4.8 Cl-105 HCO3-23 AnGap-14 ___ 06:10AM BLOOD Calcium-9.8 Phos-2.9 Mg-1.9 ___ 06:00PM BLOOD CK-MB-4 proBNP-6143* ___ 06:00PM BLOOD cTropnT-<0.01 ___ 10:00AM BLOOD CK-MB-3 cTropnT-<0.01 DISCHARGE LABS: ___ 09:45AM BLOOD WBC-9.6 RBC-3.82* Hgb-11.9* Hct-37.1 MCV-97 MCH-31.2 MCHC-32.2 RDW-14.9 Plt ___ ___ 09:45AM BLOOD Plt ___ ___ 09:45AM BLOOD Glucose-137* UreaN-36* Creat-1.2* Na-141 K-4.9 Cl-105 HCO3-23 AnGap-18 ___ 09:45AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.2 STUDIES: + CXR: Widespread bilateral interstitial opacities are new since the prior exam and consistent with mild interstitial pulmonary edema. A small right pleural effusion is present with bibasilar opacities consistent with atelectasis. No focal consolidation or pneumothorax. The heart size is mildly enlarged and there is calcification of the aortic knob. Right rib deformities are consistent with chronic fractures. Osseous structures are diffusely demineralized with multiple thoracic and lumbar spine compression deformities, of indeterminate age. IMPRESSION: 1. Mild interstitial pulmonary edema with small right pleural effusion. 2. Mild cardiomegaly. 3. Multiple thoracolumbar spine compression deformities of indeterminate age. + EKG: NSR @ 86. Normal axis. Normal intervals. LAE, LVH. + Aortic Valvuloplasty: Assessment & Recommendations 1.Severe aortic stenosis 2.Successful balloon aortic valvuloplasty using a 23 mm Tyskak II balloon 3.Medical therapy + ECHO: Overall left ventricular systolic function is mildly depressed (LVEF= 45%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. The aortic valve VTI = 91 cm. There is severe aortic valve stenosis (valve area <1.0cm2). Trace aortic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Focused study/limited views. Severe aortic stenosis. Mildly depressed global left ventricular systolic function. Compared with the prior study (images reviewed) of ___, the ___ has increased in size from 0.5 cm2 to 0.7 cm2 secondary to an interval percutaneous balloon valvuloplasty. Given the limited nature of the current study a comprehensive comparison of all previously assessed parameters could not be made. + CT Abdomen: There is a large, retroperitoneal hematoma seen originating from the right inguinal region in the vicinity of the patient's known right common femoral artery aneurysm. The retroperitoneal hematoma extends superiorly to the level of the anterior superior iliac spine, and measures approximately 4.4 x 4.0 x 10.6 cm (AP x TRV x CC, 3:60 and 4b:15). The urinary bladder is grossly unremarkable. Bilateral inguinal hernias are noted, fat containing on the right and bowel-containing on the left. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen throughout the visualized thoracolumbar spine. The patient is status post left hip arthroplasty, and right femoral neck ORIF. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Large, right retroperitoneal hematoma extending from the right inguinal region through the iliacus muscle plane up to the anterior superior iliac spine. 2. Extensive colonic diverticulosis. 3. Severe atherosclerotic calcifications of the aorta and its major branches. 4. Bilateral inguinal hernias. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO QMON 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Lisinopril 5 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral daily 13. Multivitamins 1 TAB PO DAILY 14. Acetaminophen 325-650 mg PO Q6H:PRN pain 15. Albuterol Inhaler 2 PUFF IH Q8H:PRN sob Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Albuterol Inhaler 2 PUFF IH Q8H:PRN sob 11. Alendronate Sodium 70 mg PO QMON 12. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral daily 13. Acetaminophen 325-650 mg PO Q6H:PRN pain 14. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Aortic stenosis status post valvuloplasty SECONDARY: Acute Kidney Injury. Retroperitoneal hematoma. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with aortic stenosis, dyspnea // acute process? TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: Multiple prior chest radiographs, most recently of ___. FINDINGS: Widespread bilateral interstitial opacities are new since the prior exam and consistent with mild interstitial pulmonary edema. A small right pleural effusion is present with bibasilar opacities consistent with atelectasis. No focal consolidation or pneumothorax. The heart size is mildly enlarged and there is calcification of the aortic knob. Right rib deformities are consistent with chronic fractures. Osseous structures are diffusely demineralized with multiple thoracic and lumbar spine compression deformities, of indeterminate age. IMPRESSION: 1. Mild interstitial pulmonary edema with small right pleural effusion. 2. Mild cardiomegaly. 3. Multiple thoracolumbar spine compression deformities of indeterminate age. Radiology Report INDICATION: ___ year old woman got valvulplasty yesterday, now with hematoma. // ongoing bleeding. TECHNIQUE: Focused grayscale, color Doppler, and spectral Doppler ultrasound over the right groin was obtained. COMPARISON: None FINDINGS: The right common femoral artery and vein are patent with appropriate arterial and venous waveforms. There is a narrow neck of arterial blood flow extending radially outward from the common femoral artery into a moderate perivascular hematoma. IMPRESSION: Thrombosed right common femoral artery pseudoaneurysm. Minimal residual blood flow visualized in the pseudoaneurysm neck without any flow in the hematoma. Findings discussed with Dr. ___ by Dr. ___ at 8:15 p.m. on ___ Radiology Report EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY INDICATION: ___ year old woman with AS, CAD, CHF, s/p valvuloplasty (___) c/b R psuedoaneurysm. // Pt with known R groin pseudoaneurysm with small amt of leak on previous study. Please eval and repair if leak still present. TECHNIQUE: Focused grayscale, color Doppler, and spectral Doppler ultrasound over the right groin. COMPARISON: Comparison is made to right groin Doppler ultrasound dated ___. FINDINGS: The right common femoral artery and vein are patent and demonstrate appropriate arterial and venous waveforms, respectively. Redemonstrated is a narrow neck of arterial blood flow seen extending radially outward from the right common femoral artery. There is an unchanged 1.7 x 1.3 cm soft tissue hematoma seen adjacent to this pseudoaneurysm, without evidence of internal flow. IMPRESSION: 1. Unchanged narrow neck of arterial blood flow extending radially right CFA. 2. Stable, adjacent 1.7 x 1.3 cm soft tissue hematoma without internal flow. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ year old woman with critical AS s/p valvuloplasty now with peritoneal signs and falling h H/leukocytosis/lower BPS // r/o abdominal bleed/RP 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: 420.0 mGy-cm COMPARISON: Comparison is made to right femoral vascular ultrasound dated ___. FINDINGS: There are small, bilateral, nonhemorrhagic pleural effusions with adjacent atelectasis. Extensive coronary calcifications are noted. The heart is normal in size and there is no evidence of pericardial effusion. ABDOMEN: The examination is limited secondary to the lack of intravenous contrast. Within this limitation, the non-contrast enhanced appearance of the liver, gallbladder, pancreas, spleen, and bilateral adrenal glands are grossly normal. The bilateral kidneys are atrophic. The stomach, small bowel, and large bowel are unremarkable in appearance without dilation or wall thickening. Extensive colonic diverticulosis is noted. There is no overt retroperitoneal lymphadenopathy by CT size criteria. There is no pneumoperitoneum. The aorta and its major branches contain calcifications. PELVIS: There is a large, retroperitoneal hematoma seen originating from the right inguinal region in the vicinity of the patient's known right common femoral artery aneurysm. The retroperitoneal hematoma extends superiorly to the level of the anterior superior iliac spine, and measures approximately 4.4 x 4.0 x 10.6 cm (AP x TRV x CC, 3:60 and 4b:15). The urinary bladder is grossly unremarkable. Bilateral inguinal hernias are noted, fat containing on the right and bowel-containing on the left. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen throughout the visualized thoracolumbar spine. The patient is status post left hip arthroplasty, and right femoral neck ORIF. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Large, right retroperitoneal hematoma extending from the right inguinal region through the iliacus muscle plane up to the anterior superior iliac spine. 2. Extensive colonic diverticulosis. 3. Severe atherosclerotic calcifications of the aorta and its major branches. 4. Bilateral inguinal hernias. NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___ telephone at 12:41 on ___, 1 min after discovery. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with RESPIRATORY ABNORM NEC, CAD UNSPEC VESSEL, NATIVE OR GRAFT temperature: 98.7 heartrate: 88.0 resprate: 18.0 o2sat: 97.0 sbp: 112.0 dbp: 56.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ was a pleasure taking care you during your hospitalization. You were admitted because you were having lightheadedness and shortness of breath with activity that we felt was caused by your aortic stenosis. You were scheduled for a repeat balloon valvuloplasty in ___ but we decided to do it on this admission because of your symptoms. The valvuloplasty was successful but it was complicated by bleeding which caused you to have low blood pressures and your kidneys to be damaged. Your blood pressure, blood counts and kidney function had all improved and were stable by the time your discharge. Your lasix was stopped. You should followup with your cardiologist. We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: ___ Midline placement at the bedside History of Present Illness: ___ w/ampullary carcinoma, CVA with r-sided deficits, htn, afib on coumadin, h/o basal ganglial hemorrhage, and urinary retention who presents with fevers and AMS. Patient recently treated for ESBL E. coli UTI on ___ with Marcrobid and since that time has had increasing confusion. Spiked a temperature to 105.7 at his facility today and was given some Tylenol and sent to ___. On evaluation, patient unable to participate in interview due to delerium. Past Medical History: Hypertension Dyslipidemia Atrial fibrillation, on Coumadin Prostatic hypertrophy Hip replacement ___ Ampullary adenocarcinoma, s/p palliative XRT only GERD Depression Urinary retention Dysphagia CVA w/R hemiparesis Recurrent UTI Social History: ___ Family History: Mother: HTN Physical ___: ADMISSION PHYSICAL EXAM: Vitals: T:97.6 BP:120/59 P:70 R:18 O2:97%ra PAIN: unable to assess, appears comfortable General: nad Lungs: clear anteriorly CV: rrr no m/r/g Abdomen: bowel sounds present, soft, nt/nd Ext: no e/c/c Skin: +sacral decubitus ulcer GU: foley in place Neuro: asleep, arrousable, not oriented. states location as church and year as 1224, R hemiparesis . DISCHARGE PHYSICAL EXAM: VS: AVSS Pain: ___ Gen: NAD CV: RRR, no murmurs Lungs: CTAB/L ant lung fields Abd: soft, NT, ND, NABS, no CVAT Ext: no edema Neuro: AAOx1 only. Fluent speech. Psych: appropriate Pertinent Results: ADMISSION LABS: =================== ___ 11:30PM BLOOD WBC-11.4* RBC-3.61* Hgb-9.6* Hct-30.7* MCV-85 MCH-26.6* MCHC-31.2 RDW-15.0 Plt ___ ___ 11:30PM BLOOD ___ PTT-38.7* ___ ___ 11:30PM BLOOD Glucose-154* UreaN-24* Creat-0.7 Na-140 K-3.6 Cl-103 HCO3-24 AnGap-17 ___ 11:30PM BLOOD ALT-13 AST-13 AlkPhos-209* TotBili-0.4 ___ 11:43PM BLOOD Lactate-2.5* . URINE STUDIES: ================== ___ 02:02AM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:02AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 02:02AM URINE RBC-4* WBC-28* Bacteri-FEW Yeast-NONE Epi-0 . PERTINENT LABS: =================== ___ 07:45AM BLOOD WBC-5.0 RBC-3.33* Hgb-8.6* Hct-29.1* MCV-88 MCH-25.9* MCHC-29.6* RDW-15.4 Plt ___ ___ 06:25AM BLOOD Albumin-2.7* Calcium-8.3* Iron-12* ___ 06:25AM BLOOD calTIBC-118* VitB12-644 Ferritn-943* TRF-91* . INR TREND: ============== ___ 11:30PM BLOOD ___ PTT-38.7* ___ ___ 04:58PM BLOOD ___ ___ 06:55AM BLOOD ___ PTT-45.6* ___ ___ 07:45AM BLOOD ___ ___ 06:40AM BLOOD ___ . MICROBIOLOGY: ================= ___ Blood culture x 1: NGTD, final PENDING ___ Urine culture URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S . IMAGING: ============ ___ CT HEAD IMPRESSION: No acute hemorrhage and no evidence of other acute intracranial abnormalities. . ___ PA/LAT CXR IMPRESSION: No focal consolidation. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. cranberry 405 mg oral daily 2. Vitamin D 50,000 UNIT PO QMONTH 3. Tamsulosin 0.4 mg PO BID 4. Potassium Chloride 10 mEq PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Multivitamins 1 TAB PO DAILY 7. Mirtazapine 7.5 mg PO HS 8. Metoprolol Tartrate 25 mg PO BID 9. Magnesium Oxide 400 mg PO DAILY 10. Levothyroxine Sodium 88 mcg PO DAILY 11. Finasteride 5 mg PO DAILY 12. Docusate Sodium 100 mg PO TID 13. CloniDINE 0.3 mg PO BID 14. BuPROPion 75 mg PO HS 15. Bethanechol 25 mg PO TID 16. Ascorbic Acid ___ mg PO DAILY 17. Amlodipine 7.5 mg PO DAILY 18. Acetaminophen 650 mg PO TID 19. Polyethylene Glycol 17 g PO DAILY 20. Senna 17.2 mg PO HS 21. Bisacodyl ___VERY 3 DAYS 22. ___ MD to order daily dose PO DAILY16 Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO BID 3. Bethanechol 25 mg PO TID 4. Acetaminophen 650 mg PO TID 5. Docusate Sodium 100 mg PO TID 6. Senna 17.2 mg PO HS 7. Potassium Chloride 10 mEq PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Ascorbic Acid ___ mg PO DAILY 10. cranberry 405 mg oral daily 11. Magnesium Oxide 400 mg PO DAILY 12. CloniDINE 0.3 mg PO BID 13. Metoprolol Tartrate 25 mg PO BID 14. Mirtazapine 7.5 mg PO HS 15. Pantoprazole 40 mg PO Q24H 16. BuPROPion 75 mg PO HS 17. Amlodipine 7.5 mg PO DAILY 18. Bisacodyl ___VERY 3 DAYS 19. Polyethylene Glycol 17 g PO DAILY 20. Multivitamins 1 TAB PO DAILY 21. Vitamin D 50,000 UNIT PO QMONTH 22. Warfarin 4 mg PO DAILY16 Duration: 3 Days Needs INR check on ___ to determine dosing 23. ertapenem 1 gram injection every 24 hours Duration: 7 Days RX *ertapenem [Invanz] 1 gram 1 gram iv every 24 hours Disp #*7 Vial Refills:*0 24. Collagenase Ointment 1 Appl TP DAILY 25. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ESBL E. coli UTI Anemia, likely anemia of chronic disease 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 HEAD W/O CONTRAST INDICATION: History: ___ with history of basal ganglia hemorrhage in setting of elevated INR, now presenting with altered mental status and INR of 5.1. Evaluate for hemorrhage. TECHNIQUE: Axial helical MDCT images were obtained through the brain without administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axes and thin section bone algorithm reconstructed images were acquired. DOSE: DLP: 892 mGy-cm COMPARISON: Nonenhanced head CT dated ___ FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect or acute large vascular territory infarction. There is stable encephalomalacia along the lateral margin of the left lentiform nucleus at the site of prior basal ganglia hemorrhage. Periventricular white matter hypodensities are nonspecific but likely represent sequela of chronic small vessel ischemic disease. The ventricles and sulci are normal in size for age. The basal cisterns appear patent. Calcification of the vertebral and internal carotid arteries is noted. No fracture is identified. There is mild mucosal thickening within the visualized portion of the right maxillary sinus. The remaining visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. Soft tissue density in bilateral external auditory canals is compatible with cerumen. IMPRESSION: No acute hemorrhage and no evidence of other acute intracranial abnormalities. Radiology Report INDICATION: Fever and altered mental status. Evaluate for pneumonia. COMPARISON: ___. FINDINGS: Frontal and lateral radiographs of the chest demonstrate stable top normal heart size with mild tortuosity of the thoracic aorta. No focal consolidation, pleural effusion or pneumothorax is present. IMPRESSION: No focal consolidation. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Altered mental status Diagnosed with URIN TRACT INFECTION NOS temperature: 99.2 heartrate: 98.0 resprate: 16.0 o2sat: 97.0 sbp: 149.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

You were sent from your nursing home with confusion and fever, due to inadequately treated UTI. You were given IV antibiotics with good improvement in your symptoms. You will need to complete a course of IV antibiotics via midline IV. Because your Coumadin levels were high, your Coumadin was held and you were given some Vitamin K to reverse the Coumadin. You will need to resume your Coumadin and have your INR monitored. . Please take your medications as listed. . Please see your physicians as listed. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with a PMH notable for metastatic rectal cancer status post laparoscopic abdominoperineal resection and colostomy, chemotherapy, and radiation along with right lower lobe segmentectomy for lung metastases who presents with acute onset of abdominal pain, nausea, and vomiting. Patient recently had a complicated hospitalization from ___ to ___ at ___ after being transferred from ___ due to concerns for SBO. During the hospitalization, she was treated for acute L5-S1 osteomyelitis which was thought to be due to MSSA bacteremia from a likely left foot ulcer source. Patient was also initially conservatively managed for intermittent SBO but ultimately on ___ he was taken to the OR for exploratory laparoscopy, lysis of adhesion, and incision and resection of small bowel. During this admission, he also was started on TPN, which he continued as an outpatient. The patient reports feeling relatively well since discharge and improving. After he follow-up with Dr. ___ started advancing his diet to a non-residual diet. However, he felt that he may have pushed too far, having a cheeseburger and fries yesterday prior, which soon led to nausea and vomiting. The vomiting continued through the night and into this morning, and he subsequently presented to the ___ ED. He reports that his last BM in his colostomy bag was yesterday morning. He has not had any fevers or chills. In the ED his initial vitals were notable for a temp of 99.2, heart rate 105, BP 116/85, oxygen saturation 98% on room air. See exam was notable for a soft abdomen that was descended with a small amount of green soft stool in the ostomy and diffuse tenderness. His lab was notable for an elevated white count of 14.8, H&H of 10.7 and 34.0, normal LFTs, creatinine of 0.9, BUN of 31, and a lactate of 2.8. He had a CT abdomen and pelvis with contrast which showed a small bowel obstruction with a transition point in the right lower quadrant, proximal to the small bowel anastomosis with no bowel wall thickening, pneumatosis, or pneumoperitoneum. Blood cultures were taken. He received 2 L of normal saline, esomeprazole 40 mg IV every 12, Zofran as needed, and Dilaudid 1 mg ×1. Colorectal surgery was consulted, and after reviewing the case, no surgical option were available given the extent of the patient's disease and recommendation was made for admission to home in with conservative management of SBO. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: ONCOLOGICAL HISTORY (per ___ records): ___- first screening colonoscopy (pt with new anemia Hg 12.4) showed a large, ulcerated, three fourths circumferential mass highly suspicious for malignancy in the mid to lower rectum; 2 other small polyps were seen-biopsy showed 2 tubular adenomas and moderately differentiated invasive adenocarcinoma, low-grade in rectal biopsy ___: CT C/A/P showed rectal wall thickening, several perirectal lymph nodes, small pulmonary nodules, possible small pericardial cyst versus 10 mm lung nodule ___: pelvic MRI showed large near circumferential low rectal tumor, with extramural extension contacting the mesorectal fascia, anal sphincter involvement, and multiple mesorectal nodal involvement, imaging stage T3N1MX. ___: concurrent chemoradiotherapy with continuous infusion ___ ___- cycle ___ FOLFOX ___- RLL nodule resected (Dr. ___ and showed adenocarcinoma c/w colon primary ___- cycle ___ FOLFOX; CT chest showed new lung nodules ___- cycle ___ FOLFOX ___- cycle ___ FOLFOX ___ ___ FOLFOX ___- chest CT showed stable RML nodule; 2 add'l nodules detected on last CT not definitely appreciated; no new nodules ___- cycle ___ FOLFOX ___- cycle ___ FOLFOX ___- cycle ___ FOLFOX ___- Cycle ___ FOLFOX ___- CT C/A/P with stable pulmonary nodules, slight decrease in rectal mass ___- Dr. ___ APR, coccygectomy, and placement of fiducials with flap closure of perineum; final pathology showed adenocarcinoma of rectum, low grade, measuring 10.1 x 6.0 x 1.2 cm with tumor perforation. The tumor was staged as yT4bpN0 with total of 14 nodes evaluated (___). The tumor extended to the circumferential margin at orange ink but was negative; adjacent tissue "coccyx" was negative for margins as well (by 21 mm); +LVI; MMR IHC showed intact expression of MLH1, MSH2, MSH6, and PMS2 ___- completed cyberknife therapy to rectal region (Dr. ___ ___- CT chest with RLL opacity- inflammation vs recurrence; reviewed with radiology- favor inflammation/scar tissue ___- CT C/A/P showed possible liver lesion- liver MRI ordered ___ MRI showed ring-enhancing lesions in segment 4A of the liver and a smaller one in segment 3 of the liver concerning for metastatic lesion; spleen was slightly enlarged ___ her biopsy showed a single focus with atypical appearing ductal epithelium, seen in association with abundant chronic inflammation, predominantly passed cells; no diagnostic evidence of malignancy ___- start FOLFIRI- received 1 cycle ___- had multiple hospitalizations at ___ then transferred to ___- initially had diabetic foot infection (resulting in high grade MSSA bacteremia), then intermittent SBO; then had back pain and dx'd with presumed osteomyelitis (despite negative biopsy); eventually went to OR and found to have diffuse peritoneal carcinomatosis; d/c'd ___ he is DNR/DNI PAST MEDICAL/SURGICAL HISTORY: - Type 2 diabetes mellitus - Hypertension - Hypercholesterolemia - Erectile dysfunction - Stasis dermatitis Social History: ___ Family History: No first degree relative with colon cancer. Other relatives with lung cancer. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Patient declined a full physical examination. VITALS: T 98.1, BP 149/88, HR 103, RR 20, O2 Sat 93% 2L NC GENERAL: Alert and in no apparent distress, slightly somnolent appearing EYES: Anicteric ENT: Ears and nose without visible erythema, masses, or trauma CV: Patient declined RESP: Patient declined GI: Abdomen moderately distended and tympanic, diffusely tender and most prominent in the RLQ. Bowel sounds present. Gas is present in the colostomy bag. 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: Appeared irritated and did not wish to converse for a long period DISCHARGE PHYSICAL EXAMINATION: VITALS: 98.0 PO 132 / 72 86 18 99 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, PERRLA, pink conjunctiva, MMM, oropharynx clear Neck: supple CV: RRR, normal S1, S2, no murmurs, rubs, or gallops RESP: CTAB, no wheezes, rales, or ronchi GI: Abdomen soft, nontender, nondistended. Normoactive bowel sounds. Draining stool and gas in colostomy bag. Area surrounding colostomy clean and dry, no erythema or tenderness. No guarding or rebound. Ext: Warm and well perfused, no clubbing, cyanosis, or edema. Pertinent Results: ADMISSION LABORATORY STUDIES ======================================== ___ 01:00PM BLOOD WBC-14.8*# RBC-4.08* Hgb-10.7* Hct-34.0* MCV-83 MCH-26.2 MCHC-31.5* RDW-17.7* RDWSD-51.6* Plt ___ ___ 01:00PM BLOOD Neuts-85.7* Lymphs-2.3* Monos-10.9 Eos-0.1* Baso-0.3 Im ___ AbsNeut-12.68*# AbsLymp-0.34* AbsMono-1.61* AbsEos-0.01* AbsBaso-0.04 ___ 01:00PM BLOOD ___ PTT-28.1 ___ ___ 01:00PM BLOOD Glucose-209* UreaN-31* Creat-0.9 Na-139 K-4.2 Cl-95* HCO3-27 AnGap-17* ___ 01:00PM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.0 Mg-2.0 ___ 01:15PM BLOOD Lactate-2.8* ___ 07:28AM BLOOD freeCa-1.09* DISCHARGE LABORATORY STUDIES ======================================== ___ 05:30AM BLOOD WBC-5.1 RBC-3.16* Hgb-8.4* Hct-26.3* MCV-83 MCH-26.6 MCHC-31.9* RDW-17.1* RDWSD-52.2* Plt ___ ___ 05:30AM BLOOD Plt ___ ___ 05:30AM BLOOD Glucose-100 UreaN-19 Creat-0.6 Na-138 K-4.0 Cl-103 HCO3-21* AnGap-14 ___ 05:30AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0 ___ 06:30AM BLOOD Triglyc-41 MICROBIOLOGY ======================================== BLOOD CULTURES: Pending IMAGING/REPORTS ======================================== CT ABD/PELVIS: 1. Small-bowel obstruction with a transition point in the right lower quadrant, proximal to the small bowel anastomosis. No bowel wall thickening, pneumatosis, or pneumoperitoneum. 2. Small rim enhancing fluid collection within the presacral surgical bed, measuring up to 4.8 cm, significantly decreased in size compared to ___. 3. Increased fat stranding surrounding a moderate-sized periumbilical fat containing hernia, incarcerated fat not excluded. CTA CHEST 1) No evidence of pulmonary embolism or acute pulmonary parenchymal process. 2) Gastric pneumatosis. Extensive portal venous gas in the liver, as well as gas within the splenic and gastroepiploic veins. Findings could reflect emphysematous gastritis or underlying ischemic small bowel given the recent history of small bowel obstruction. 3) 4 mm nodule in the right middle lobe, unchanged compared to outside CT of the chest from ___. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 40 mg PO QPM 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Severe 5. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Nystatin Oral Suspension 15 mL PO QID 8. LORazepam 1 mg PO Q6H:PRN nausea, anxiety 9. Glargine 18 Units Bedtime Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 2. Atorvastatin 40 mg PO QPM 3. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate 4. Glargine 18 Units Bedtime 5. LORazepam 1 mg PO Q6H:PRN nausea, anxiety 6. Nystatin Oral Suspension 15 mL PO QID 7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Severe 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY - recurrent small bowel obstruction SECONDARY - metastatic rectal cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis with IV contrast. INDICATION: ___ with rectal cancer and colostomy here with SBO symptoms. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,031 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: LOWER CHEST: Dependent atelectasis. No focal consolidations. Trace pericardial fluid. No pleural effusion. A venous catheter is seen terminating at the superior cavoatrial junction. 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. A small splenule is seen anteriorly. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. There are multiple dilated fluid-filled loops of small bowel with air-fluid levels. There is a transition point within the right lower quadrant (series 2, image 72), which is proximal to a small bowel anastomosis, also in the right lower quadrant. There is no thickening of the small bowel wall, pneumatosis, or pneumoperitoneum. The colon is normal in appearance with a left lower quadrant colostomy. The appendix is normal. Patient is status post proctectomy. Within the presacral surgical bed, there is a small rim enhancing fluid collection measuring 4.8 x 3.3 cm (series 2, image 83), which has significantly decreased in size compared to the CT dated ___. PELVIS: The urinary bladder and distal ureters are unremarkable. LYMPH NODES AND PERITONEUM: 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: Degenerative changes throughout the lumbar spine a Schmorl's node involving the superior endplate of L3, which is unchanged compared to prior. SOFT TISSUES: A left lower quadrant colostomy is normal in appearance. There is a moderate-sized periumbilical hernia containing fat with surrounding fat stranding, which has slightly increased compared to prior. IMPRESSION: 1. Small-bowel obstruction with a transition point in the right lower quadrant, proximal to the small bowel anastomosis. No bowel wall thickening, pneumatosis, or pneumoperitoneum. 2. Small rim enhancing fluid collection within the presacral surgical bed, measuring up to 4.8 cm, significantly decreased in size compared to ___. 3. Increased fat stranding surrounding a moderate-sized periumbilical fat containing hernia, incarcerated fat not excluded. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with PICC in place, not flushing easily// ?PICC placement TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Right-sided PICC terminates in the low SVC/cavoatrial junction, without evidence of pneumothorax. Linear left base atelectasis is seen without focal consolidation. No pleural effusion or pneumothorax is seen. Cardiac silhouette size is borderline to mildly enlarged. Mediastinal contours are unremarkable. No pulmonary edema is seen. IMPRESSION: Right-sided PICC terminates in the low SVC/cavoatrial junction without evidence of pneumothorax. Mild left base atelectasis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, N/V Diagnosed with Unspecified intestinal obstruction temperature: 99.2 heartrate: 105.0 resprate: 18.0 o2sat: 98.0 sbp: 116.0 dbp: 85.0 level of pain: 10 level of acuity: 2.0

Dear Mr. ___, It was a pleasure caring for you at ___. You were admitted because of your nausea and vomiting, which was secondary to a recurrent small bowel obstruction. Your symptoms improved after advancing your diet very slowly and giving fluids through the IV. It is very important for you to continue advancing your diet very slowly. It is also very important for you to follow up with your physicians as scheduled (see below for your upcoming appointments). 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: Nausea, vomiting and diffuse abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with no significant PMH but a few prior epiodes of abdominal pain who presents with a 2-day history of nausea/vomiting and diffuse abdominal pain. Symptoms started with nausea/vomiting without any clear inciting cause 2 days ago; she denies any recent travel outside of the ___ ___, denies sick contacts, denies consumption of any new or unusual foods, and denies any recent antibiotic use. She has been having watery emesis approximately every 2 hours, non-bloody and non-bilious, although her last emesis was approximately 7 hours prior to time of ACS evaluation. She states that she continues to pass flatus but has not had a bowel movement in 2 days. Her pain is sharp but diffusely distributed and comes in waves. Percocet left over from previous dental procedure provided moderate relief. She denies fevers/chills, denies other symptoms. She states that she has had 3 episodes like this before, all of which spontaneously resolved after 1 day. The first episode was ___ years ago and she has had 2 more over the past ___ years, all characterized by nausea/vomiting and abdominal pain. She has not needed to seek treatment for these episodes until now. Pain is sharp, constant, worsening, diffuse in abdomen but centered mid-abdomen. No appetite. Denies chest pain, dyspnea. Family history is significant for a brother with GI problems never formally diagnosed. Patient has never had a colonoscopy. ACS was consulted for evaluation and management while in ED. ED Course (labs, imaging, interventions, consults): In the ED, patient had an episode of coffee ground emesis. Per report, she admitted drinking baileys everyday in her coffee for the past ___ years. Also admits to using MJ occasionally. She has had this pain for days and has taken some percocet from an old prescription - Initial Vitals/Trigger: T 98.7 HR 85 BP 163/88 O2Sat 100%RA. - EKG: SR @95, NANI, no STE, TW flattening inferior and lateral - Meds: For her nausea she received Zofran 4mg. She also received Ativan and morphine for pain. HAD 1L of fluid in total. Concerned for infection given ileitis (see below), she was started on cipro flagyl per ACS recs - Labs: No leukocytosis, lactate 1.3, nml lytes, neg tropx1, nml coags, neg tox screen - urine: UA and UCx were sent. Few bacteria, moderate blood, trace leukocytes, nitrites positive - CT abd/pelvis: Terminal ileitis. Proximal to the inflamed ileus, the small bowel is dilated and fluid-filled with multiple air-fluid levels conssistent with some degree of SBO or ileus SURGERY RECS: Seen in ED No evidence of indication for acute surgical intervention. Recommend admit to Medicine and ultimately endoscopy. Surgery will follow for present. ___ ___ ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: Denies any PMHx Social History: ___ Family History: CAD in multiple family members Brother with GI problems NOS Physical Exam: Physical exam on admission Vitals- T 98.5 HR 82 BP 120/66 RR 16 O2Sat 98%RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, dry mucous menbrane, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, diffusely tender to palpation but ND, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Physical exam at discharge VS- Tm 100.1 Tc 99.3 60-70s 110-140s/60-70s 18 >96 on RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND, bowel sounds present, no rebound tenderness, no guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- Pupils equal. Rest of neuro exam non-focal Pertinent Results: Labs on admission ------------------- ___ 07:44AM LACTATE-1.3 ___ 06:48AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:48AM URINE BLOOD-MOD NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR ___ 06:48AM URINE RBC-15* WBC-4 BACTERIA-FEW YEAST-NONE EPI-1 ___ 06:48AM URINE MUCOUS-RARE ___ 01:53AM cTropnT-<0.01 ___ 01:46AM GLUCOSE-199* UREA N-26* CREAT-0.8 SODIUM-138 POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-22* ___ 01:46AM ALT(SGPT)-12 AST(SGOT)-26 ALK PHOS-90 TOT BILI-0.5 ___ 01:46AM LIPASE-12 ___ 01:46AM ALBUMIN-4.1 ___ 01:46AM CRP-136.7* ___ 01:46AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:46AM WBC-9.9 RBC-4.87 HGB-15.7 HCT-48.4* MCV-99* MCH-32.2* MCHC-32.4 RDW-12.6 ___ 01:46AM NEUTS-73* BANDS-10* LYMPHS-12* MONOS-5 EOS-0 BASOS-0 ___ MYELOS-0 ___ 01:46AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 01:46AM PLT SMR-HIGH PLT COUNT-446* ___ 01:46AM ___ PTT-27.1 ___ ___ 01:46AM SED RATE-16 Labs at discharge ------------------ ___ 05:50AM BLOOD WBC-6.3# RBC-4.20 Hgb-13.5 Hct-41.9 MCV-100* MCH-32.3* MCHC-32.3 RDW-12.6 Plt ___ ___ 05:50AM BLOOD Plt ___ ___ 05:50AM BLOOD ___ PTT-29.6 ___ ___ 05:50AM BLOOD ___ 05:50AM BLOOD Glucose-102* UreaN-3* Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-29 AnGap-13 ___ 05:50AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.1 Images ---------- CT ABD&Pelvis with contrast 1. Narrowed segment of terminal ileum with wall edema, mucosal hyperemia and prominence of the Vasa recta consistent with terminal ileitis. This could be due to inflammatory bowel disease, infectious or ischemic causes. 2. Just proximal to the inflamed loop of bowel there is a focal narrowing which could reflect peristalsis; however, an underlying stricture is possible. 3. Proximal to the inflamed ileum, the small bowel is dilated and fluid-filled with multiple air-fluid levels consistent with some degree of obstruction or ileus. Microbiology: ___ 7:30 am BLOOD CULTURE Blood Culture, Routine (Preliminary): ANAEROBIC GRAM POSITIVE ROD(S). UNABLE TO IDENTIFY FURTHER. Isolated from only one set in the previous five days. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT 0555. GRAM POSITIVE ROD(S). Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with 4d worsening abdominal painNO_PO contrast // eval for intra-abdominal infection TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous administration of 130cc of Omnipaque. Coronal and sagittal reformations were performed. DOSE: DLP: 286 mGy-cm. COMPARISON: None. FINDINGS: CHEST: The bases of clear. Visualized heart and pericardium are unremarkable ABDOMEN: The liver enhances homogeneously without focal lesion or intrahepatic biliary dilatation. The gallbladder is unremarkable and the portal vein is patent. The pancreas, spleen and adrenal glands are unremarkable. There are multiple hypodensities within the bilateral kidneys, the largest on the right measuring 1.3 cm consistent with a simple cyst. Others are too small to characterize but likely also represent cysts. The kidneys present symmetric nephrograms and excretion of contrast with no focal lesions, stones or hydronephrosis. The small bowel is dilated measuring up to 3.7 cm, fluid-filled and has multiple air-fluid levels. A transition point is noted in the mid pelvis with a focal area of narrowing (2:66). Just distal to this there is a long segment of narrowed terminal ileum with extensive wall edema, mucosal hyper enhancement and prominence of the Vasa recta consistent with terminal ileitis. The ileocecal valve demonstrates fatty deposition within the wall. The appendix is not visualized; however, there is no evidence of appendicitis. There is scattered sigmoid diverticulosis without evidence of diverticulitis. There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. There is a small amount of free fluid tracking along the right pericolic gutter. No free air is identified. The anterior abdominal vasculature demonstrates scattered atherosclerotic calcifications. PELVIS: The urinary bladder is unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. BONES AND SOFT TISSUES: No lytic or sclerotic lesion suspicious for malignancy is present. IMPRESSION: 1. Narrowed segment of terminal ileum with wall edema, mucosal hyperemia and prominence of the Vasa recta consistent with terminal ileitis. This could be due to inflammatory bowel disease, infectious or ischemic causes. 2. Just proximal to the inflamed loop of bowel there is a focal narrowing which could reflect peristalsis; however, an underlying stricture is possible. 3. Proximal to the inflamed ileum, the small bowel is dilated and fluid-filled with multiple air-fluid levels consistent with some degree of obstruction or ileus. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with REG ENTERITIS, SM INTEST temperature: 98.0 heartrate: 118.0 resprate: 24.0 o2sat: 96.0 sbp: 162.0 dbp: 100.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You were admitted on ___ with a 2-day history of nausea/vomiting, diffuse abdominal pain and constipation. In the emergency room, most of your laboratory work-up was negative except for elevated inflammatory markers. You also had a CT scan to look at your abdomen and pelvis, which was concerning for inflammation at the end of your small intestine as well as a partial obstruction of your small intestine. You were evaluated by the surgical service, who thought that there was no surgical concern at that time. On admission to the medicine floor, you had significant abdominal pain and was very dehydrated. You were hydrated with intravenous fluid since drinking made your pain worse. We also started you on two antibiotics named ciprofloxacin and flagyl to decrease the inflammation and improve your symptoms. You were also seen by our gastroenterologists who thought you may be suffering from inflammatory bowel disease given your history. Your symptoms continue to improve over 48 hours and by the ___ day of your stay, you were able to tolerate a regular diet with no abdominal pain or nausea. Also, your blood culture grew some bateria so we switched you antibiotic to cover for the microbes. By the time of discharge, you were able to walk on your own, your pain was significantly improved, you have transitioned successfully to oral pain medication and you have been tolerating a regular diet. We sent some labs as requested by our gastroenterologist in preparation, should you need any treatment in the future based on further analysis as outpatient. We strongly suggested you follow-up with the appointment with the gastroenterologist and on getting a colonoscopy, which you understand is not only important for screening for colon cancer but also may help in making the final diagnosis. Please take all your medications as prescribed. You will be on a steroid which you will be taking every morning. You will also be on oxycodone for pain so avoid driving while on this medication. PLEASE BE SURE TO HAVE YOUR PPD READ ON ___ BY A NURSE OR DOCTOR AT YOUR PRIMARY CARE DOCTOR'S OFFICE. Thank you for choosing the ___. We wish you the very best. Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Diverticular abscess Major Surgical or Invasive Procedure: None History of Present Illness: ___ recently diagnosed with sigmoid diverticultis w/ phlegmon extending to left adnexa in ___ after she presented with LLQ pain. She as admitted for 3 days, and completed a course of augmentin for 10days. Her symptoms improved, until ___, she began having copius vaginal dischage. She went to the ER, a repeat CTAP was done and showed mild improvement. She was discharged with 10day course of levaquin and flagyl. She presents today with LLQ pain that started this afternoon. Denies fevers, chills , nausea, emesis, changes to bowel habits. The pain has since improved since being in the ED. Last colonosocpy ___ that showed pandiverticulosis. Past Medical History: PMH: Peptic Ulcer s/p Billroth II ___ w Dr. ___ Acute necrotizing esophagus, "black esophagus" Diverticulosis GERD Anemia of chronic disease Hyperlipidemia Essential hypertension Gastroesophageal reflux disease PSH Billroth II ___ w Dr. ___ Colonoscopy ___ multiple diverticuli Remote ex-lap LOA for endometriosis Social History: ___ Family History: Significant family hx of breast cancer: sister died of breast cancer and ___ nieces with ___ diagnoses, however, patient negative for mutation; dad with peptic ulcers; and no hx of colon cancer. Physical Exam: --ADMISSION-- Vitals: 98 78 125/67 18 99RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, incisons CDI withut hernia Ext: No ___ edema, ___ warm and well perfused --DISCHARGE-- VS: 99.1, 82, 149/88, 21, 100% RA Gen: well-appearing, NAD, A&O HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding Ext: No ___ edema, ___ warm and well perfused Pertinent Results: --LABS-- ___ 05:20PM BLOOD WBC-9.5 RBC-3.96*# Hgb-11.9*# Hct-35.4*# MCV-90 MCH-30.2 MCHC-33.7 RDW-13.3 Plt ___ ___ 07:00AM BLOOD WBC-8.7 RBC-3.59* Hgb-10.6* Hct-31.2* MCV-87 MCH-29.6 MCHC-33.9 RDW-13.2 Plt ___ ___ 05:20PM BLOOD Glucose-156* UreaN-10 Creat-0.8 Na-136 K-4.0 Cl-100 HCO3-26 AnGap-14 ___ 07:00AM BLOOD Glucose-97 UreaN-8 Creat-0.8 Na-135 K-4.2 Cl-100 HCO3-26 AnGap-13 ___ 07:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7 --IMAGING/STUDIES-- CT ABD/PELV ___ 1. Wall thickening and mild surrounding fat stranding of the mid sigmoid colon compatible with known diverticulitis with associated 3.1 x 2.0 x 1.6 cm pericolonic abscess. No intraperitoneal free air. Extensive pan colonic diverticulosis. 2. Multi lobulated lesion at the left adnexa containing small hypodensities measuring up to 1.2 cm. It is unclear whether this is reactive inflammation from surrounding diverticulitis or involvement of the ovaries/fallopian tubes. Continued followup is recommended following treatment. 3. Compression deformities of the L1 and L2 lumbar vertebral bodies, worse in the L2 level without CT findings to suggest acuity however are of unknown chronicity. Correlate with focal tenderness. 4. Moderate hiatal hernia. Medications on Admission: protonix 40 bid, calcitriol 0.5mcg daily, vitamin D 50, 000U/week, lisinopril 5mg daily, ca, simvistatin 10daily, reglan 10 qhs Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 1,000 mg-62.5 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. Lisinopril 5 mg PO DAILY 3. Calcitriol 0.5 mcg PO DAILY 4. Calcium Carbonate 500 mg PO TID 5. Metoclopramide 10 mg PO QHS 6. Pantoprazole 40 mg PO Q12H 7. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Diverticulitis with pericolonic abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with recurrent diverticulitis now w/ LLQ pain intermittent, pyuria. Evaluate for diverticulitis TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis following the intravenous administration of 130 cc of Omnipaque . Coronal and sagittal reformatted images were also generated for review. DOSE: 448 mGy-cm COMPARISON: CT chest from ___ FINDINGS: LOWER CHEST: The lung bases are clear. Atherosclerotic calcifications are seen in the coronary arteries. There is no pericardial or pleural effusion. LIVER: The liver enhances homogeneously, with no focal lesions or intrahepatic biliary duct dilatation. The gallbladder is unremarkable and the portal vein is patent. PANCREAS: The pancreas does not demonstrate focal lesions or peripancreatic stranding or fluid collection. SPLEEN The spleen is homogeneous and normal in size. ADRENALS: The adrenal glands are unremarkable. KIDNEYS: The kidneys do not show solid or cystic lesions and demonstrate symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation or perinephric abnormalities are present. GI TRACT: There is a moderate hiatal hernia with suture material and surgical clips posterior to the crura of the right hemidiaphragm and the lesser curvature of the stomach, unchanged since prior study. The duodenum and remaining small bowel are within normal limits, without evidence of wall thickening or obstruction. There is wall thickening and mild surrounding fat stranding of the mid sigmoid colon compatible with known diverticulitis. There is a associated 3.1 x 2.0 x 1.6 cm pericolonic abscess (02:59). There is also extensive diverticulosis throughout the entire colon. The appendix is visualized and normal. VASCULAR: The aorta contains moderate atherosclerotic calcifications but is normal in caliber without aneurysmal dilatation. The origins of the celiac axis, SMA, bilateral renal arteries, and ___ are patent. RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph node enlargement. No ascites, free air, or abdominal wall hernias are noted. PELVIC CT: The urinary bladder and distal ureters are unremarkable. No pelvic wall or inguinal lymph node enlargement is seen. There is no pelvic free fluid. There is a multilobuated lesion in the left adnexa with several hypodensities measuring up 1.2 cm. There is no fat plane between the pericolonic abscess and this left adnexal structure. OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is present. There is moderate to severe compression deformity of the L2 vertebral body with associated 4 mm retropulsion into the spinal canal of indeterminate chronicity. There is also mild compression deformity of the superior endplate of L1. Moderate degenerative changes are seen throughout the lower thoracic and lumbar spine. IMPRESSION: 1. Wall thickening and mild surrounding fat stranding of the mid sigmoid colon compatible with known diverticulitis with associated 3.1 x 2.0 x 1.6 cm pericolonic abscess. No intraperitoneal free air. Extensive pan colonic diverticulosis. 2. Multi lobulated lesion at the left adnexa containing small hypodensities measuring up to 1.2 cm. It is unclear whether this is reactive inflammation from surrounding diverticulitis or involvement of the ovaries/fallopian tubes. Continued followup is recommended following treatment. 3. Compression deformities of the L1 and L2 lumbar vertebral bodies, worse in the L2 level without CT findings to suggest acuity however are of unknown chronicity. Correlate with focal tenderness. 4. Moderate hiatal hernia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN LLQ, INTESTINAL ABSCESS temperature: 99.5 heartrate: 80.0 resprate: 18.0 o2sat: 99.0 sbp: 137.0 dbp: 73.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were admitted to ___ for diverticulitis causing a small intra-abdominal abscess. You were treated with antibiotics. You are being discharged on antibiotics to complete a 3-week course. After that, you will have a repeat CT scan and follow up with Dr. ___ in clinic. Please read and follow the following instructions for discharge. General Discharge Instructions: -Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Take Augmentin for a total 3-week antibiotic course (___). -Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 3000 mg in one day. -Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Headache, blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ old right-handed man with a history of asthma, prior smoking history, and family history of stroke who presents with acute-onset, persistent symptoms of unsteadiness lasting all day as well as progressive headache, blurry vision, and intermittent sensory loss. He was last in his normal state of health at 7AM this morning as he was getting ready for work. He had the acute onset of dizziness, which he describes as "lightheadedness" but seems to be more instability rather than near syncope. He had difficulty donning his uniform, and nearly fell into a chair while trying to do so. Sitting down he felt somewhat better, though not back to normal. However, he was able to go to work. However, around 1330 ___ he began to develop headache and worsening instability. At ___ he started to notice blurry vision. It initially improved but then returned with worsening headache. At 1630 he felt numbness and tingling in his left leg below the knee. He talked to his daughter and told her he wanted to go home, but they encouraged him to go to the emergency department. When they met him here, they noticed that he was walking and holding on to the walls, which is not typical for him. Upon presentation to the ED, his initial NIHSS was 0. He was given fluids and a CT/CTA was ordered. This scan showed a new R PCA infarct, largely in the medial occipital lobe; as well as occlusion of the right carotid artery. Regarding his headache, these are quite unusual for him as he does not usually get headches. Otherwise, he denies diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, paresthesias. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. Jehad a severe cold about a month ago which has resolved. 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: -Asthma -Conjunctivitis -Bladder stones -s/p TURP Social History: ___ Family History: Mother died at age ___ of catastrophic stroke. Two maternal aunts with obesity and stroke. No family history of headache, heart disease. Physical Exam: General: Overweight man, sitting up in bed, joking in NAD. HEENT: NC/AT, no scleral icterus, mucus membranes are moist. Supraorbital pulses palpable bilaterally, could not determine whether there was reversal of flow. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Normal work of breathing. Vesicular breath sounds bilaterally, no wheezes or crackles appreciated. Cardiac: S1/S2 appreciated, RRR, no M/R/G. Abdomen: Obese, soft, nontender, nondistended. Extremities: No lower extremity edema Skin: Rash on right thumb. No other rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Speaks ___ fluently and some ___. Jocular, able to relate history without difficulty but somewhat vague. Language is fluent and intact to repetition, naming of high and low frequency objects, comprehension or cross-body commands. Normal prosody. 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: PERRL 4 to 2mm, both directly and consensually; brisk bilaterally. Left homonymous hemianopsia. III, IV, VI: EOMI without nystagmus. There are hypometric saccades most prominent on leftward gaze. V: Facial sensation intact to light touch, pinprick 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, and is equal ___ strength bilaterally as evidenced by tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE WrFl FFl FE IO IP Quad Ham TA ___ L ___ 4+ 4+ ___ ___ 5 5 5 5 R ___ ___ ___ ___ 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 3 2 R 2 2 2 3 2 - Plantar response was flexor bilaterally. -Sensory: No deficits to light touch, pinprick in upper and lower extremities. Proprioception intact in great toes bilaterally. No extinction to DSS. -Coordination: Subtle left intention tremor, no dysdiadochokinesia noted. Dysmetria on L FNF and HKS, normal on right. -Gait: Good initiation. Slightly wide-based, normal stride and arm swing. Could not walk in tandem. Romberg absent. ###DISCHARGE EXAM### Patient continues to have L sided dysmetria and L homymous hemianopsia. His gait was stable and independent. Pertinent Results: ___ 02:50PM BLOOD cTropnT-<0.01 ___ 02:50PM BLOOD Triglyc-116 HDL-51 CHOL/HD-2.8 LDLcalc-68 ___ 02:50PM BLOOD %HbA1c-5.8 eAG-120 ___ 02:50PM BLOOD CRP-6.5* ___ 02:50PM BLOOD TSH-1.5 ___ Head CTA 1. Focal hypodensity with loss of gray-white differentiation in the right posterior cerebral artery distribution involving the right occipital lobe, right inferior medial temporal lobe, compatible with an evolving acute infarct. 2. Hypodensity of the right thalamus is identified, which may represent prominent perivascular space versus sequela of lacunar infarct. 3. Complete occlusion of the right common carotid artery just distal to the bifurcation with a tapering configuration, potentially secondary to dissection. 4. Otherwise, unremarkable CTA of the head and neck. ___ Brain MRI/A 1. Study is moderately degraded by motion. 2. Redemonstration of known right PCA distribution infarcts with evidence of hemorrhagic transformation, as described. 3. Redemonstration of complete occlusion of right common and cervical internal carotid arteries, with flow noted within right supraclinoid internal carotid artery and distal branches. 4. Within limits of study, no definite focal dissection identified of right common or cervical internal carotid artery. 5. Paranasal sinus disease as described. ___ NCHCT 1. Hemorrhagic transformation of right temporal occipital infarct wild new since the CT of ___ is unchanged from the MRI of ___. The area of infarct appears stable in size. ___ Echo The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 70%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. 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 no pericardial effusion. ___ CXR 1. Bilateral lower lung interstitial abnormality is of indeterminate chronicity, but new since ___. If the patient has clinical evidence pointing to a specific pulmonary problem, consider chest CT for further evaluation. 2. No focal consolidation concerning for pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Disposition: Home Discharge Diagnosis: -Right PCA territory stroke -R ICA occluded from common carotid to intracranial portion where it reconstitutes - unknown chronocity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: History: ___ with HA, lightheadedness, L eye visual changes // ? stroke or other abnormality 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 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP = 21.8 mGy-cm. 3) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 31.9 mGy (Head) DLP = 1,258.3 mGy-cm. Total DLP (Head) = 2,177 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is a focal hypodensity in the right occipital lobe extending into the inferior right temporal lobe on image 4: ___ with loss of gray-white differentiation in keeping with an evolving acute infarct in the right posterior cerebral artery distribution. Also seen is a focal hypodensity in the right thalamus on image 4:16. There is no evidence of no evidence of hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is mild mucosal thickening in the floor of bilateral maxillary sinuses. The remaining visualized paranasal sinuses and mastoid air cells are clear. . The visualized portion of the orbits are unremarkable. There are multiple periapical lucencies surrounding the maxillary and mandibular teeth with a large lucency in the anterior hard palate surrounding the right maxillary incisors. CTA HEAD: There is absence of contrast opacification of the right internal carotid artery along its entire course up to the level of carotid terminus where there is contrast opacification likely secondary to retrograde flow from the anterior communicating artery and ophthalmic artery. The remaining vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. Incidentally seen is hypoplastic right vertebral artery terminating into posterior inferior cerebellar artery. Also seen is hypoplastic left posterior communicating artery. CTA NECK: There is a 3 vessel aortic arch. There is complete occlusion of the right common carotid artery just distal to the bifurcation with a tapering configuration. There is absence of contrast opacification of the right common and internal carotid artery along its entire course up to the carotid terminus. The left carotid artery demonstrates minimal atherosclerotic calcification at its bifurcation without any stenosis by NASCET criteria. Bilateral vertebral arteries appear unremarkable. OTHER: There is dependent atelectasis in bilateral upper also seen is minimal paraseptal emphysema in right lung apex and mild centrilobular emphysema in visualized lung parenchyma. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Focal hypodensity with loss of gray-white differentiation in the right posterior cerebral artery distribution involving the right occipital lobe, right inferior medial temporal lobe, compatible with an evolving acute infarct. 2. Hypodensity of the right thalamus is identified, which may represent prominent perivascular space versus sequela of lacunar infarct. 3. Complete occlusion of the right common carotid artery just distal to the bifurcation with a tapering configuration, potentially secondary to dissection. 4. Otherwise, unremarkable CTA of the head and neck. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with stroke. Evaluate for acute cardiopulmonary process. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs of ___ and ___. FINDINGS: Compared with the prior radiograph, lung volumes remain low with bronchovascular crowding. New bilateral lower lung interstitial abnormality is equivocal and of indeterminate chronicity. There is no focal consolidation or pneumothorax. IMPRESSION: 1. Bilateral lower lung interstitial abnormality is of indeterminate chronicity, but new since ___. If the patient has clinical evidence pointing to a specific pulmonary problem, consider chest CT for further evaluation. 2. No focal consolidation concerning for pneumonia. RECOMMENDATION(S): If the patient has clinical evidence pointing to a specific pulmonary problem, consider chest CT for further evaluation. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with history of asthma, prior smoker, family history of stroke, with stroke and right ICA occlusion and right PCA distribution acute to subacute infarcts. Evaluate extent of infarct and for right carotid artery dissection. TECHNIQUE: Three dimensional time of flight MR arteriography was performed through the brain with maximum intensity projection reconstructions. Dynamic MRA of the neck was performed during administration of 16 mL of Multihance intravenous contrast. Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient echo and diffusion technique. Three dimensional maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. The examination was performed using a 1.5T MRI. COMPARISON: ___ head and neck CTA. FINDINGS: Study is moderately degraded by motion. MRI BRAIN: Areas of slow diffusion are identified in the right posterior medial temporal and right occipital lobe, as well as right thalamus. There are matched FLAIR hyperintensities and areas of increased susceptibility. There is no evidence of masses or midline shift. The ventricles and sulci are normal in caliber and configuration. Bilateral maxillary sinus and ethmoid air cell mucosal thickening is present. MRA BRAIN: Complete occlusion of right common carotid artery from the origin up to the level of carotid terminus is again demonstrated. The right ophthalmic artery remains patent. The remaining anterior and posterior circulation are patent. A patent right posterior communicating artery is noted. Left PCOM origin probable infundibulum is again noted (see 4 01:10, 4: 77 on current study and 651:11 on the prior exam). The left vertebral artery is dominant. MRA NECK: Hypoplastic right vertebral artery terminates into posterior inferior cerebellar artery. Left posterior communicating artery is hypoplastic. The left common, internal and external carotid arteries appear normal. There is no evidence of left internal carotid artery stenosis by NASCET criteria. The origins of bilateral vertebral, the left common carotid, and subclavian arteries are grossly patent. Again is noted complete occlusion of the left common carotid and cervical internal carotid artery. The right common carotid artery origin is not visualized. Within limits of examination, no definite dissection is identified. IMPRESSION: 1. Study is moderately degraded by motion. 2. Redemonstration of known right PCA distribution infarcts with evidence of hemorrhagic transformation, as described. 3. Redemonstration of complete occlusion of right common and cervical internal carotid arteries, with flow noted within right supraclinoid internal carotid artery and distal branches. 4. Within limits of study, no definite focal dissection identified of right common or cervical internal carotid artery. 5. Paranasal sinus disease as described. NOTIFICATION: The impression ___ were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:00 ___, 2 hrs after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with stroke, hemorrhagic conversion // assess size of bleed for stability TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.2 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: ___ contrast head MR ___ head and neck CTA FINDINGS: There is area of increased density (03:18) in the posterior right temporal and right occipital region compared to before, consistent with hemorrhagic transformation which is unchanged from the previous MRI of ___. Surrounding area of hypodensity appear stable in size and consistent with infarct. Right thalamic infarct is also stable. The ventricles and sulci are stable 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. Hemorrhagic transformation of right temporal occipital infarct wild new since the CT of ___ is unchanged from the MRI of ___. The area of infarct appears stable in size. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with large PCA infarct with hemorrhagic conversion who now has a fever // infiltrate? infiltrate? IMPRESSION: Comparison to ___. The lung volumes have increased, likely reflecting improved ventilation. Minimal left basilar atelectasis. Mild elongation of the descending aorta. No pneumonia, no pulmonary edema, no pleural effusions. Gender: M Race: HISPANIC/LATINO - CUBAN Arrive by WALK IN Chief complaint: Headache, Visual changes, Presyncope Diagnosed with Headache temperature: 99.0 heartrate: 87.0 resprate: 16.0 o2sat: 100.0 sbp: 161.0 dbp: 95.0 level of pain: 3 level of acuity: 1.0

Dear Mr. ___, You were hospitalized due to symptoms of unsteady walking and visual changes 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: Prior smoking We are changing your medications as follows: Take aspirin 81mg daily Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology 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: ___ aspiration of perirectal abscess History of Present Illness: ___ woman with crohn's disease with recent hospitalization for SBO with perforation, complicated by intraabdominal abscesses requiring drainage procedures and placement of wound VAC and post-operative pulmonary embolism, who presents with a abdominal pain. She notes the pain started six days ago and is associated with nausea/vomiting. Pain is in LUQ, is ___. She has been unable to keep fluids food or fluids down as a result. She notes that her emesis has appeared to look like food content with associated fever and chills. She denies blood in her stool or melena. She has had increased watery consistency of ostomy output. Denies slowing of output concerning for obstruction. She notes that her symptoms are most consistent with prior episodes of c. diff colitis. ___ has had multiple hospitalizations over the fall. With one hospitalization over a month long that was complicated by SBO with perforation requiring ex-lap, SBR, revision of ileostomy, then drainage of intraabdominal abscess. Course complicated by pulmonary embolism and has been on anticoagulation since. Her course was also complicated by bacteremia with need for antibiotics. In the ED, initial vital signs were: Temp 97.7, HR 108, BP 95/72, RR 18, 100% RA - Labs were notable for: WBC 11.3, Hg 7.9, platelets 818. Na 136, K 3.8, Cl 99, bicarb 21, BUN 5 Cr, 1.0, lipase 222 with normal lactate. Past Medical History: Crohn's disease c/b rectovaginal fistula erythema nodosum pyoderma gangrenosum LLE fracture H. pylori C. diff. DVT associated with surgery (completed 6 month of coumadin) depression PSH: - Lap diverting ileostomy (___) - Excision of fistulous track and primary repair of vaginal canal (___) - Lap left hemicolectomy, proctectomy and excision of anus w/ end-colostomy, takedown of ileostomy - Completion colectomy w/ end ileostomy (___) - Revision ileostomy ___ - Revision of ileostomy and debridement and drainage of abscess cavity (___) - Exploratory laparotomy, end ileostomy revision (___) - LLE fixation of fracture - Transvaginal revision of levatorplasty (release of mid vaginal band) (___) - Exploratory laparoscopy and resection and revision of end ileostomy (___) - Exploratory laparotomy, revision of ileostomy with extraperitonealization of the ileostomy (___) Social History: ___ Family History: Mother and cousin with Crohn's disease. No family history of colorectal cancer. Mother with hypertension. Father with heart disease. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS - 98.1, 104/65, 73, 18, 100RA GENERAL - chronically ill appearing young woman, uncomfortable, dry heaving HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, dry MM NECK - supple CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - normal bowel sounds, soft, tender in LUQ, non-distended, ostomy in RLQ, pink color, liquid stool. Wound vac in place. No erythema or purulence noted. EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - A&Ox3, CN II-XII grossly normal, gross motor function intact PSYCHIATRIC - listen & responds to questions appropriately, pleasant PHYSICAL EXAM on DISCHARGE: Vitals: T 99.2/98.2 BP 94-117/58-82 HR ___ RR 18 SatO2 >98%/RA General: Appears to be uncomfortable, in NAD. HEENT: PERLA, moist mucous membranes CV: RRR, normal S1 + S2, m/r/g. Lungs: CTAB Abdomen: Healing midline scar consistent with laparotomy incision, has two sites of exudative drainage on morning of discharge. Ostomy draining loose dark green stool without frank blood. Remains tender to palpation in the LUQ/left flank. Today complains of mild tenderness to palpation in the right abdomen as well. Soft, non-distended. No rebound or guarding. GU: Deferred. Ext: Warm, well-perfused. No clubbing, cyanosis, edema. Skin: No rashes, lesions, or cyanosis. Pertinent Results: LABS on ADMISSION: ___ 12:15PM BLOOD WBC-11.3* RBC-3.42* Hgb-7.9* Hct-26.0* MCV-76* MCH-23.1* MCHC-30.4* RDW-18.2* RDWSD-50.0* Plt ___ ___ 12:15PM BLOOD Neuts-83.6* Lymphs-8.1* Monos-7.0 Eos-0.4* Baso-0.5 Im ___ AbsNeut-9.46* AbsLymp-0.92* AbsMono-0.79 AbsEos-0.04 AbsBaso-0.06 ___ 12:15PM BLOOD ___ PTT-48.8* ___ ___ 12:15PM BLOOD Plt ___ ___ 12:15PM BLOOD Glucose-93 UreaN-5* Creat-1.0 Na-136 K-3.8 Cl-99 HCO3-21* AnGap-20 ___ 12:15PM BLOOD ALT-12 AST-19 AlkPhos-127* TotBili-0.2 ___ 12:15PM BLOOD Lipase-222* ___ 12:15PM BLOOD Albumin-3.6 ___ 06:51AM BLOOD Calcium-9.4 Phos-5.3*# Mg-1.5* ___ 12:15PM BLOOD HCG-<5 ___ 12:15PM BLOOD CRP-113.9* ___ 12:24PM BLOOD Lactate-1.2 LABS on DISCHARGE: ___ 06:50AM BLOOD WBC-7.3 RBC-3.61* Hgb-8.2* Hct-27.6* MCV-77* MCH-22.7* MCHC-29.7* RDW-17.3* RDWSD-48.6* Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD ___ PTT-43.5* ___ ___ 06:50AM BLOOD Glucose-84 UreaN-3* Creat-0.8 Na-135 K-3.8 Cl-95* HCO3-30 AnGap-14 ___ 06:50AM BLOOD ALT-7 AST-18 AlkPhos-108* TotBili-0.2 ___ 06:50AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.6 PERTINENT STUDIES/IMAGING: - CT abd with contrast (___): 1. Enhancing perirectal fluid collection appears minimally increased in size from the prior examination in ___ and shows adjacent fat stranding. 2. Overall size of perihepatic, and perisplenic fluid collections are decreased from ___. Mild small bowel mucosal hyper enhancement as well asenhancement within the mesentery and omentum also appears minimally decreasedfrom the prior examination. 3. No free air in the abdomen or pelvis. - KUB (___): No evidence of free air. Several dilated small bowel loops, may represent obstruction or focal ileus. CT can be performed for further evaluation if clinically indicated. - CXR (___): No acute cardiopulmonary abnormalities - PELVIS U.S., TRANSVAGINAL (___): Pelvic fluid collection consistent with abscess. No evidence of ovarian torsion. - CT interventional procedure (___): Limited preprocedure images demonstrate a presacral collection, as seen on recent CT. Successful CT-guided aspiration the presacral collection. Samples was sent for microbiology evaluation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Citalopram 40 mg PO DAILY 3. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 4. Lactobacillus acidophilus ___ colonies ORAL DAILY 5. Ondansetron 4 mg PO Q8H:PRN nausea 6. OxycoDONE (Immediate Release) ___ mg PO Q4-6H PRN pain 7. Pantoprazole 40 mg PO Q24H 8. Promethazine 12.5 mg PO Q6H:PRN nausea 9. Warfarin 3 mg PO 3X/WEEK (___) 10. Warfarin 2 mg PO 4X/WEEK (___) 11. Xeljanz (tofacitinib) 5 mg oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Pantoprazole 40 mg PO Q24H 3. Xeljanz (tofacitinib) 5 mg oral DAILY 4. Citalopram 40 mg PO DAILY 5. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 6. Lactobacillus acidophilus ___ colonies ORAL DAILY 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. OxycoDONE (Immediate Release) ___ mg PO Q4-6H PRN pain 9. Promethazine 12.5 mg PO Q6H:PRN nausea 10. Warfarin 3 mg PO 3X/WEEK (___) 11. Warfarin 2 mg PO 4X/WEEK (___) 12. Outpatient Lab Work ___ (DOB ___ ICD Code ___.40 Please draw INR on ___ and fax results to ___, MD to ___ 13. OxycoDONE (Immediate Release) ___ mg PO Q4-6H:PRN pain RX *oxycodone 10 mg ___ tablet(s) by mouth Q4-6H:PRN Disp #*21 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pancreatitis Perirectal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: ___ with abd pain+PO contrast // hernia, infection, sbo? 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) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP = 13.2 mGy-cm. 2) Spiral Acquisition 4.8 s, 52.5 cm; CTDIvol = 7.7 mGy (Body) DLP = 404.6 mGy-cm. Total DLP (Body) = 418 mGy-cm. COMPARISON: ___ CT FINDINGS: LOWER CHEST: There is minimal atelectasis at the lung bases. The visualized heart and pericardium is within normal limits. HEPATOBILIARY: The liver is normal in size and attenuation. There is no biliary ductal dilatation. The portal vein is patent. At 1.5 cm hypodensity in segment 4A is unchanged from the prior exam (02:20). The gallbladder is within normal limits SPLEEN: The spleen is normal in size and enhancement. PANCREAS: The pancreas shows normal enhancement. There is no pancreatic duct dilatation or peripancreatic fat stranding. ADRENALS: The adrenal glands are unremarkable bilaterally. URINARY: The kidneys display symmetric nephrograms with no evidence of hydronephrosis or mass lesion in either kidney. The ureters are symmetrical in their course to the bladder. GASTROINTESTINAL: The stomach is within normal limits. The patient is status post colectomy and right lower quadrant ileostomy. Similar to prior exams, there is mild mucosal hyper enhancement and subtle wall thickening of the small bowel, which appears minimally decreased from the prior examination on ___. The small bowel is normal in caliber and there is no evidence of small bowel obstruction. A right perihepatic collection measures approximately 3.8 x 0.7 cm and is decreased in size from the prior examination when it measured approximately 4.6 x 0.8 cm (___:12). A small subhepatic rim enhancing fluid collection is essentially resolved with only minimal residual soft tissue density remaining. A small perisplenic collection is also minimally decreased from the prior examination (02:27). A 3.8 x 3.0 cm deep pelvic fluid collection appears increased from the prior examination when it measured 3.5 x 2.8 cm. There is adjacent fat stranding surrounding this collection. Mild inflammation of the mesentery and omentum persists but appears slightly decreased from the prior examination in ___. There is no free air in the abdomen or pelvis. LYMPH NODES: Scattered prominent but not pathologically enlarged mesenteric lymph nodes are re- demonstrated. There is no pelvic or inguinal adenopathy. VASCULAR: The abdominal aorta is normal in caliber without evidence of aneurysmal dilatation or atherosclerotic disease. PELVIS: The bladder is within normal limits. The reproductive organs are within normal limits. BONES AND SOFT TISSUES: A right lower quadrant ileostomy is demonstrated. A 13 mm hypodense collection at the level of the umbilicus may represent a small postoperative seroma, consistent with recent procedure. No suspicious osseous lesions are identified. IMPRESSION: 1. Enhancing pelvic fluid collection appears minimally increased in size from the prior examination in ___ and shows adjacent fat stranding. 2. Overall size of perihepatic, and perisplenic fluid collections are decreased from ___. Mild small bowel mucosal hyper enhancement as well as enhancement within the mesentery and omentum also appears minimally decreased from the prior examination. 3. No free air in the abdomen or pelvis. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ yo woman with chronic Crohn's disease s/p multiple intra-abdominal surgeries, recurrent hospitalizations for obstructions and ostomy revisions, DVT (on Coumadin), and cdiff. She is now p/w 1 week of nausea, vomiting, LUQ pain, and PO intolerance. We are investigating potential infectious etiologies with Cdiff assay (now returned negative), stool cultures, norovirus, rotavirus, and CXR. // Is there radiologic evidence of acute intrathoraic processs suggestion of infection? TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Cardiomediastinal contours are normal. The lungs are clear. There is no pneumothorax or pleural effusion. S-shaped scoliosis is again noted. IMPRESSION: No acute cardiopulmonary abnormalities Radiology Report INDICATION: ___ woman with Crohn's disease with recent hospitalization for SBO with perforation, complicated by intraabdominal abscesses requiring drainage procedures and placement of wound VAC and post-operative pulmonary embolism, who presents with a abdominal pain. // assess for perforation, obstruction TECHNIQUE: Supine and upright views of the abdomen. COMPARISON: CT abdomen pelvis on ___. FINDINGS: No evidence of free intraperitoneal air. Patient is status post colectomy. There are several loops of dilated small bowel in the abdomen. No air-fluid levels. IMPRESSION: No evidence of free air. Several dilated small bowel loops, may represent obstruction or focal ileus. CT can be performed for further evaluation if clinically indicated. Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ woman with Crohn's disease with recent hospitalization for SBO with perforation, complicated by intraabdominal abscesses requiring drainage procedures and placement of wound VAC and post-operative pulmonary embolism, who presents with a abdominal pain. // New onset RLQ/Right pelvic pain; patient has no appendix; eval ovarian cyst/torsion TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: CT ___ FINDINGS: The uterus is normal and measures 3.7 x 2.5 x 8.0 cm cm. The endometrium is homogenous and measures 2 mm. The ovaries are normal with a dominant follicle seen in the right ovary which measures 2.9 x 1.9 x 2.7 cm. The left ovary measures 2.1 x 1.3 x 1.8 cm. Both ovaries show normal arterial and venous flow patterns. A complex fluid collection is seen in the left hemipelvis corresponding to the known abscess as demonstrated on recent CT scan. IMPRESSION: Pelvic fluid collection consistent with abscess. No evidence of ovarian torsion. . Radiology Report INDICATION: ___ year old woman with Crohn's and recent SBO with perf, now with recurrent abdominal pain and a slowly enlarging pelvic collection. // request for aspiration of collection and culture. COMPARISON: CT abdomen pelvis ___. PROCEDURE: CT-guided drainage of presacral collection. OPERATORS: Dr. ___ resident and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a prone position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. Based on the CT findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 5 ___ ___ was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle, and more fluid was then aspirated. Approximately 9 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. Limited postprocedure fluoroscopic images shows interval decrease in size of fluid collection. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: DLP: 179 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 20 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited preprocedure images demonstrate a presacral collection, as seen on recent CT. IMPRESSION: Successful CT-guided aspiration the presacral collection. Samples was sent for microbiology evaluation. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, N/V Diagnosed with Unspecified abdominal pain temperature: 97.7 heartrate: 108.0 resprate: 18.0 o2sat: 100.0 sbp: 95.0 dbp: 72.0 level of pain: 6 level of acuity: 2.0

Dear ___, It was a pleasure taking care of you at ___. You were admitted because you had worsening abdominal pain for several days associated with nausea and vomiting, with difficulty being able to eat food and liquids, and decreased ostomy output. You were evaluated by the GI and colorectal services. Imaging did not reveal any perforation (as had occurred in the past), and we monitored you for any signs of obstruction or blockage. It was found on the CT image that you had a perirectal abscess, and per colorectal surgery, interventional radiology aspirated the fluid (culture pending). After the procedure, you had a fever, and we gave you IV antibiotics (cefepime and flagyl) to treat for a suspected infection. However, there was lower suspicion for infection at this point, and we discontinued the antibiotics. You will be discharged on your home oxycodone (Immediate Release) ___ mg PO Q4-6H PRN pain for a total of 21 pills. Please see your PCP on ___ to obtain refills. For your midline incision with two areas of yellow drainage: place wet gauze and let dry, and change dressing daily. Please follow up with your PCP on ___ at 9:30 AM. We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Glucocorticoids,Systemic Classifier / Leukine / Prochlorperazine Attending: ___. Chief Complaint: Neurologic changes over past week Major Surgical or Invasive Procedure: Stereotactic biopsy of the left frontal lesion ___ History of Present Illness: Mr ___ is a ___ year old male with metastatic melanoma to the lungs, brain, and left lower extremity who recently initiated PD-1 (nivolumab, ipilimumab) 12 weeks ago presenting with 1 week of neurologic changes. His wife notes over the past week he has been increasingly confused, with increasing anxiety and depressive symptoms; he has been weak and fatigued. No lateralized motor deficits, but he has overall had difficulties with balance. He was scheduled to get an MRI brain in a few weeks as part of the study, however the MRI was moved up several days on account of these worsening neurologic symptoms. On the MRI he was found to have an increasing left frontal lobe lesion (5 mm -> 3 cm) associated with brain edema, along with an increase in the 2 right frontal lobe lesions also associated with edema. Of note, per his family, although he has had prior brain metastases, he has never been on significant stretches of steroids for edema. This is his first episode of brain edema according to his wife. He has also never had seizures; 2 days prior to this admission, his wife did notice that he had some tremors that lasted a few minutes but no loss of consciousness. He also has had improvement in his leg pain (site of melanoma metastases) since initiating PD-1 12 weeks ago. He's attempted to decrease his pain medications given this improvement (does continue on a 100 mcg fentanyl patch changed every 72 hours) but quit dilaudid 3 days ago (was taking ___ pills per day) cold ___. Following the brain MRI today, he developed nausea and one episode of emesis. Usually, he experiences nausea during/after an MRI and takes lorazepam to mitigate these symptoms. Review of systems is negative for chest pain, chest pressure, shortness of breath, abdominal pain, diarrhea, dysuria. He is frequently constipated secondary to his pain medications; he is chronically taking stool softeners. He is admitted given his worsening brain lesions, edema, and likely consequent neurologic symptoms. In the ED, he received 10 mg of decadron and zofran. Past Medical History: ONCOLOGIC HISTORY: Mr. ___ underwent an excisional biopsy of a 6.2 mm thick, ___ Level IV, broadly ulcerated melanoma on his right shoulder in ___. Wide local excision showed tumor within 0.1 mm of the edge, a satellite nodule, and 25 mitoses per HPF. Sentinel node biopsy showed evidence of melanoma in 1 of 2 lymph nodes. He underwent complete node dissection with residual melanoma being identified in the soft tissue of the axilla, but no melanoma was found in 15 lymph nodes. -- ___ to ___, received adjuvant interferon, and then stopped due to fatigue. He was then noted to have a right axillary mass, FNA confirmed recurrent melanoma. CT scan revealed 2 nodules in the right axilla, but no clear evidence of distant metastases. There was uptake in the right glenoid, most consistent with a rotator cuff injury. -- ___ had excision of the right axillary nodules: Pathology showed 3 soft tissue deposits of melanoma within the dermis, resected with clean margins. He had postoperative radiation therapy, 5100 cGy in 17 fractions over 3 weeks in Western ___. -- in ___ started on adjuvant GM-CSF. After 4 doses, he developed erythema & leg swelling. -- in ___ PET-CT showed a lung nodule. Brain MRI then showed a metastatic lesion in the left parietal lobe s/p SRS ___. -- in ___ received ___ cycle of high dose IL-2; course was c/b shock, toxic encephalopathy, & myocarditis. During his ___ cycle of ___, he developed tongue swelling after the ___ day of the ___ week. Given concern for airway compromise, he did not receive any additional doses. -- in ___, 4 week scans showed stability of lung nodules. Scans done again in ___ showed stable lung disease, no new brain lesions. He seen in our clinic in ___ and last in ___ at which time scans were again stable. - ___, MRI revealed a tiny 3 x 3 lesion in the right frontal lobe adjacent to the surface of the brain, which was new. - ___ underwent stereotactic radiation with Dr. ___. He states that after the radiation, he had a significant frontal headache, which has improved, but recurs with any coughing. - ___ MRI head was unchanged right frontal 4 x 4 mm enhancing lesion, consistent with a stable metastasis. No new lesions. -- ___, he had significantly worsening headaches and MRI findings concerning for recurrent leptomeningeal disease. At that time, he underwent lumbar puncture with negative cytology. Of note, opening pressure was 14 cm of water. However, despite negative cytology, given his severe symptoms, we discussed starting ___ and contacted his primary oncologist, Dr. ___. However symptoms resolved and ___ not started. -- ___: There was a concern for leptomeningeal disease given his pressure dependent headaches; however, these have resolved and followup imaging was stable enough to support him pursuing wedge resection of the nodule that was growing in his left lower lobe. This was performed by Dr. ___ on ___ by laparoscopic thoracotomy. This was performed near home and we have not received the pathology report, though it is highly likely melanoma. -- ___ - resection of recurrent disease in the LLL, RUL and mediastinum -- internal fixation of the left femur on ___, and -- completion of external beam radiotherapy at ___ as of ___, -- status post CyberKnife radiosurgery to left frontal (2mm) and right parietal (2mm) metastases both to ___ cGy at 76% isodose line -- ___ : Signed consent for ___ ___, sequential protocol of ipilimumab and PD-1 antibody, started on ___. Social History: ___ Family History: Mother: brain tumor Sister died in ___ from pancreatitis Physical Exam: On Admission VS: 97.9, 130/80, 80, 18, 99% RA Gen: Caucasian male, latent speech, confused, but cooperative to exam Neurologic: No gross motor or sensory deficits. Cerebellar testing WNL. Cognitively impaired, with latent, inappropriate responses. No lateralized sensory or motor signs. Cardiac: Nl s1/s2 no appreciable murmurs Pulm: clear bilaterally Abd: soft and nontender; small hematoma noted in left lower quadrant (biopsy site from ___ years ago, still unhealed); melanoma associated lesion in left upper quadrant, nodular, 5 cm in diameter, erythematous and ragged Ext: no edema or rashes noted On Discharge Gen: Very pleasant, lying in bed, in NAD, latent speech, but cooperative to exam Neurologic: Oriented to self, place, and date. No gross motor or sensory deficits. No lateralized sensory or motor signs. Cardiac: Nl s1/s2 no appreciable murmurs Pulm: clear bilaterally Abd: soft and nontender; small hematoma noted in left lower quadrant (biopsy site from ___ years ago, still unhealed); Ext: No edema or rashes noted Pertinent Results: ADMISSION LABS ___ 03:00PM GLUCOSE-102* UREA N-9 CREAT-0.6 SODIUM-141 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-15 ___ 03:00PM ALT(SGPT)-7 AST(SGOT)-15 ALK PHOS-135* TOT BILI-0.3 ___ 03:00PM WBC-9.3 RBC-5.28 HGB-14.6 HCT-43.6 MCV-83 MCH-27.7 MCHC-33.6 RDW-15.0 ___ 03:04PM ___ PTT-27.9 ___ DISCHARGE LABS ___ 07:30AM BLOOD WBC-12.9* RBC-5.49 Hgb-15.4 Hct-45.7 MCV-83 MCH-28.0 MCHC-33.7 RDW-15.7* Plt ___ ___ 08:25AM BLOOD Neuts-90.2* Lymphs-5.4* Monos-3.9 Eos-0.6 Baso-0.1 ___ 07:30AM BLOOD Glucose-97 UreaN-15 Creat-0.7 Na-137 K-4.0 Cl-100 HCO3-28 AnGap-13 ___ 07:30AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.3 MRI with contrast ___ IMPRESSION: Considerable increase in size in the left frontal lobe subcortical lesion measuring now 3 cm compared to 5 mm on the previous study with a thick rim of enhancement and intrinsic restricted diffusion likely secondary to melanin pigments or blood products. The previously seen two right frontal lobe lesions also now have increased in size and measure approximately 6 mm compared to punctate enhancement on the previous study with mild surrounding edema. No midline shift is seen, and there is no hydrocephalus. Findings were added to the critical communication dashboard for communication with the referring physician. CT Torso with contrast ___ 1. Progression of retroperitoneal lymphadenopathy. 2. New metastases in the ileocecal valve and left diaphragmatic crura are suspacted . 3. Enlarging subcutaneous metastases. Please see concurrent CT chest report regarding supradiaphragmatic metastasis. 4. Nonspecific trace pelvic free fluid. ___ EEG This is an abnormal EEG due to the presence of a variable and disorganized background with bursts of generalized slowing. This pattern is consistent with a mild to moderate encephalopathy of toxic, metabolic, or anoxic etiology. No evidence of ongoing or potential seizure activity was seen during this recording. Date of Procedure: ___ SURGICAL PATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: 1. Brain, core biopsy: Reactive brain and necrotic tissue, see note There is no evidence of malignancy. 2. Brain core biopsy: Reactive brain and necrotic tissue. There is no evidence of malignancy. 3. Brain core biopsy: Reactive brain and necrotic tissue. There is no evidence of malignancy. Note: No evidence of malignant melanoma. Cells interspersed in necrotic debris are positive for LCA and CD68 and negative for Melan-A and HMB4S. S100 labels surrounding gliotic brain tissue. Medications on Admission: amitriptyline 20 mg qhs fentanyl [Duragesic] 100 mcg/hr Transderm Patch q72 hrs Dilaudid 2 mg tablet q4 hrs PRN pain lorazepam 0.5 mg tablet PRN sulindac 150 mg tablet q12 hrs aspirin 81 mg chewable tablet daily docusate sodium 100 mg capsule ___ capsules daily One-A-Day Men's 0.4 mg-600 mcg tablet 1 Tablet(s) by mouth once a day Metamucil Oral Powder TID Senokot 8.6 mg tablet BID Discharge Medications: 1. Amitriptyline 10 mg PO HS 2. Docusate Sodium 100 mg PO BID 3. Fentanyl Patch 100 mcg/h TP Q72H 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Post-Op pain 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Senna 2 TAB PO HS:PRN constipation 7. Aspirin 81 mg PO DAILY 8. One-A-Day Mens (multivit with min-FA-lycopene) 0.4-600 mg-mcg Oral daily 9. Psyllium 1 PKT PO TID 10. Sulindac 150 mg PO BID 11. Famotidine 20 mg PO BID:PRN epigastric pain RX *famotidine [___] 20 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 12. Calcium Carbonate 500 mg PO TID RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0 13. LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 14. Vitamin D 800 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 15. Dexamethasone 4 mg PO Q8H Tapered dose - DOWN RX *dexamethasone 4 mg 1 tablet(s) by mouth three times daily Disp #*60 Tablet Refills:*0 16. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule,delayed ___ by mouth daily Disp #*30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Metastatic melanoma Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: MRI of the brain. CLINICAL INFORMATION: Patient with metastatic melanoma, for re-evaluation of CNS disease prior to therapy. TECHNIQUE: T1 sagittal, axial and FLAIR T2 susceptibility and diffusion axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal images acquired following the administration of gadolinium. Comparison was made with the previous MRI of ___. FINDINGS: The previously seen small lesion in the left frontal lobe has considerably increased in size. It now demonstrates significantly increased surrounding edema and a thick rim of enhancement and now measures approximately 3 cm in size compared to 5 mm on the previous study. There is now restricted diffusion seen within this rim-enhancing lesion with T1 hyperintensity which could be secondary to melanin pigments or secondary to blood products. The previously noted lesions in the right frontal lobe also have increased in size and now measure approximately 6 mm in size compared with a punctate enhancement seen on the previous study. Mild increase in surrounding edema to these lesions is also seen. There is no other definite area of abnormal enhancement seen within the supra- or infratentorial brain. There is no midline shift or hydrocephalus identified. IMPRESSION: Considerable increase in size in the left frontal lobe subcortical lesion measuring now 3 cm compared to 5 mm on the previous study with a thick rim of enhancement and intrinsic restricted diffusion likely secondary to melanin pigments or blood products. The previously seen two right frontal lobe lesions also now have increased in size and measure approximately 6 mm compared to punctate enhancement on the previous study with mild surrounding edema. No midline shift is seen, and there is no hydrocephalus. Findings were added to the critical communication dashboard for communication with the referring physician. Radiology Report HISTORY: Melanoma with lung and brain metastases, pre-operative. FINDINGS: In comparison with the study of ___, there are several suggested nodular opacifications on the left, both of which overlie ribs, which could possibly represent areas of metastatic disease. No evidence of acute focal pneumonia or vascular congestion. There is blunting of the left costophrenic angle. Mild atelectatic changes are seen in the retrocardiac region. Radiology Report HISTORY: A ___ male with left frontal lesion TECHNIQUE: Contiguous axial multi detector images were obtained after administration of intravenous contrast. Bone algorithm reconstructed images were acquired. DLP 958 mGy-cm. CTDI 58mGy. COMPARISON: MR head with and without contrast ___. FINDINGS: Re- demonstration of a left frontal ring-enhancing well-defined lesion with associated vasogenic edema and mild compression of the left lateral ventricle. No shift of normally midline structures. Cisterns are patent. No evidence of new hemorrhage or infarction. The bones are unremarkable. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Visualized vessels are patent. IMPRESSION: No interval change in the appearance of the left frontal lesion demonstrated on MR 3 days ago. No evidence of new lesions, hemorrhage, or infarction. Radiology Report HISTORY: ___ male with brain mass status post stereotactic biopsy. COMPARISON: Contrast enhanced head CT 4 hr prior to current study. Technique : TECHNIQUE: Contiguous axial multi detector images were obtained through the brain without administration of intravenous contrast. DLP 891 mGy-cm. CTDI 53 mGy. FINDINGS: Re- demonstration of left frontal lesion with surrounding stable appearing vasogenic edema. The patient is status post left frontal craniotomy without evidence of pneumocephalus. No hemorrhage or new infarction identified. Stable mild effacement of adjacent sulci without shift of midline structures. Post surgical craniotomy site noted. The remainder of the bones are unremarkable. The paranasal sinuses, mastoid air cells, middle ear cavities remain clear. IMPRESSION: No interval change status post left frontal craniotomy and biopsy. No hemorrhage identified. Radiology Report INDICATION: Metastatic melanoma. New chest and abdominal cutaneous nodules. Evaluation for disease progression. TECHNIQUE: MDCT images were obtained of the abdomen and pelvis in conjunction with the chest. Coronal and sagittal reformations were prepared. DLP: ___ mGy-cm. Three-minute delayed images of the abdomen were also acquired. COMPARISON: ___. CT ABDOMEN: There is a new 4.5 x 2.2 cm mass in the crura of the left hemidiaphragm (2:60). Enlarging subcutaneous masses including those adjacent to the left pectoral muscle and between the right sixth and seventh ribs are described in a separate report. Focal hypodensity along the falciform ligament is likely fatty deposition. The liver otherwise enhances homogeneously. The hepatic and portal veins are patent. The gallbladder, pancreas, spleen, and adrenals are normal. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or mass. The stomach is normal. Retroperitoneal lymphadenopathy has progressed considerably from ___ (300B:30). There is no portacaval or mesenteric lymphadenopathy. Small amount of free fluid is noted in the rectovesicular space (2:117). There is no free intraperitoneal air. CT PELVIS: Focal nodularity of one of the lips of the ileocecal valve is not seen on prior CT and suspicious for metastasis, measuring 2.8 x 2.7 cm (2:106). The sigmoid colon is redundant, but there is no evidence of volvulus. The rectum is normal. The urinary bladder is distended but otherwise unremarkable. The seminal vesicles and prostate are normal. There is no pelvic lymphadenopathy. Subcutaneous nodule in the left lower quadrant now measures 2.6 x 2.5 cm, previously 1.6 x 1.5 cm (2:100). 50 mm right inguinal lymph node is not present on prior CT and is suspicious for metastasis (2:126). OSSEOUS STRUCTURES: There is no lytic or blastic lesion suspicious for metastasis. The intramedullary rod is noted in the left proximal femur. IMPRESSION: 1. Progression of retroperitoneal lymphadenopathy. 2. New metastases in the ileocecal valve and left diaphragmatic crura are suspacted . 3. Enlarging subcutaneous metastases. Please see concurrent CT chest report regarding supradiaphragmatic metastasis. 4. Nonspecific trace pelvic free fluid. Radiology Report INDICATION: Metastatic melanoma. Evaluation of tumor burden prior to next cycle of chemotherapy. TECHNIQUE: MDCT images of the chest were obtained in conjunction with imaging of the abdomen and pelvis after administration of oral and intravenous contrast. Coronal and sagittal reformations as well as axial MIPs were prepared. COMPARISON: ___. FINDINGS: Numerous pulmonary nodules have developed since ___. The largest is in the left upper lobe and measures 15 x 11 mm (2:24). Numerous other nodules are all worrisome for metastasis (2:9, 13, 18, 20, 24, 32, 34, 37, 41). A large left axillary, hilar lymph node is also new, measuring 3.9 x 2.7 cm (2:13). Several chest wall metastases, the left mass adjacent to the inferior margin of the left pectoralis major has enlarged to 3.2 x 2.7 cm, previously 11 mm (2:43). More inferiorly the mass between the anterior sixth and seventh ribs now measures 4.5 x 3.4 cm, previously 2.4 x 2.3 cm (2:52). More superiorly in the chest wall is a new 7-mm nodule (2:14). The 11-mm nodule between the right posterior ninth and tenth ribs is enlarged, and seen retrospectively (2:49). Post-surgical changes from prior right upper lobe wedge resection are noted. There is no focal consolidation or pleural effusion. The airways are patent to the subsegmental level. The heart and great vessels are normal. There are no pathologically enlarged mediastinal or hilar lymph nodes by size criteria. OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for metastasis. IMPRESSION: 1. Diffuse pulmonary and chest wall metastases as described above, representing marked progression from ___. 2. Please correlate with report of CT abdomen and pelvis regarding subdiaphragmatic metastases. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: VOMITING,NAUSEA Diagnosed with NAUSEA WITH VOMITING, SEC MAL NEO BRAIN/SPINE temperature: 98.0 heartrate: 72.0 resprate: 16.0 o2sat: 99.0 sbp: 125.0 dbp: 71.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, You came to the hospital because of confusion and worsening mental status. This is secondary to advanced melanoma. You had a brain biopsy which revealed the tumor's response to treatment with surrounding swelling. You were started on steroids to decrease the swelling in your brain, and on seizure medication called keppra for possible seizure activity. You will not continue on your current treatment for the melanoma, but will be started on a new medication (a BRAF inhibitor). This will arrive in the mail. Please follow up with your outpatient oncologists as below regarding further management of your melanoma. Thank you for allowing us to take part in your care, 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 and facial droop Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is an ___ yo man with CAD, DM2, sCHF (EF <40%), afib, and CKD, recently found to have a cerebellar mass (likely metastatic lung primary), s/p VP shunt placement on ___ and undergoing WBXRT, who presents today with worsening slurred speech over the last one week and a left sided facial droop. Per report, the patient's sons have reported that he has been less attentive and less ambulatory over the last one week, with increasingly slurred speech and gradually worsening facial drooping. . He was initially diagnosed with the cerebellar mass on ___, when he presented to ___ with several weeks of unsteady gait. Brain CT there showed the right cerebellar mass, and CXR showed a left lingular mass and left hilar fullness. CT Torso showed peripheral LUL mass with left hilar and mediastinal LAD. He was transferred to ___, and brain MRI ___ showed the right cerebellar mass with surrouding edema. He was started on steroids. The neurosurgery service did not recommend surgical intervention. Lung bx ___ showed poorly differentiated carcinoma. Since that time, he has had issues with gait unsteadiness. On ___ he underwent elective VP shunt placement, with an uncomplicated OR course, and post-op head CT stable without new hemorrhage. Exam was intact, and the pt was discarged on ___. His Coumadin had been on hold due to bleeding risk, while he continued in atrial fibrillation. In the ___, he was called as a code stroke upon presentation with an NIHSS of 9, for a gaze preference (left, although able to fully ___ sclera on the right), right sided facial droop, right pronator drift and subtle weakness in an upper motor neuron pattern, right leg drift, limb ataxia, and dysarthria. Additional findings include his overall inattentiveness, apathy, paucity of speech, and perseveration. Labs were unremarkable except BUN 56 and Cr 1.6, and positive UA (22 WBCs, few bacteria). Neurology felt that a new acute stroke was unlikely, and that his symptoms were more likely due to increasing edema around the right cerebellar mass. Seizure and GBS were thought unlikely. On head CT there appeared to be a slight increase in the size of his ventricles, so a shunt study was performed and Neurosurgery was made aware, with a plan to evaluate the integrity of the shunt and adjust as necessary. ROS: Unable to be adequately assess as pt is inattentive with poor communication. Denies all other symptoms. Past Medical History: PAST ONCOLOGIC HISTORY: ___ Ataxia ___ Brain CT showed right cerebellar mass ___ Chest x ray showed a left lingular mass ___ CT Torso showed left upper lobe mass ___ Brain MRI showed right cerebellar mass ___ Lung biopsy preliminary report shows poorly differentiated carcinoma OTHER PAST MEDICAL HISTORY: - Coronary artery disease - Diabetes mellitus with peripheral neuropathy, no retinopathy - Atrial fibrillation (off coumadin due to high bleeding risk) - Nonischemic cardiomyopathy w/ sCHF EF <40% - Hypertension - Peripheral vascular disease - Osteomyelitis of right foot - Right great toe amputation - Cataracts - Chronic kidney disease, stage IV - Asbestosis Social History: ___ Family History: No known oncologic disease. Physical Exam: Physical Exam on Admission: VS: Temp 96.8F, BP 120/66, HR 69, R 20, SaO2 100% RA General: elderly man in NAD, lying comfortably in bed HEENT: PERRL/EOMI, sclerae anicteric, MMM, OP clear Neck: supple, no LAD or JVD, no nuchal rigidity Lungs: CTA bilat, no r/rh/wh Heart: RRR, nl S1-S2, no MRG Abdomen: +BS, soft/NT/ND, no HSM Extrem: WWP, no c/c/e Skin: no rashes or lesions . Physical Exam on Discharge: VS: Tm/c 98.8 BP 130/68 HR 85 R 20 SaO2 94% RA General: elderly man in NAD, lying comfortably in bed, somewhat sleepy but easily arousable HEENT: PERRL/EOMI, sclerae anicteric, MM dry, OP clear Neck: supple, no LAD or JVD, no nuchal rigidity Lungs: CTA bilat, no r/rh/wh Heart: RRR, nl S1-S2, no MRG Abdomen: +BS, soft/NT/ND, no HSM Extrem: WWP, no c/c/e, cogwheel rigidity on R>L Skin: no rashes or lesions Neuro: -oriented to self, place, birthdate when prompted with 3 choices, not date, perseverates -CN: EOMI, PERRL, some neglect on left, V intact, left sided facial droop sparing the forehead, SCM intact ___, tongue protrudes midline -Motor: ___ in ___ -finger to nose intact -sensation grossly intact throughout Pertinent Results: Labs on Admission: . ___ 12:10PM WBC-10.3 RBC-4.17* HGB-12.7* HCT-36.7* MCV-88 MCH-30.4 MCHC-34.6 RDW-13.9 ___ 12:10PM PLT COUNT-176 ___ 12:10PM ___ PTT-26.7 ___ ___ 12:26PM GLUCOSE-155* NA+-137 K+-4.5 CL--100 TCO2-26 ___ 12:10PM UREA N-56* ___ 12:10PM CREAT-1.6* ___ 04:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM ___ 04:30PM URINE RBC-3* WBC-22* BACTERIA-FEW YEAST-MOD EPI-1 . Imaging . Head CT (12:17pm): Again seen is a 2.3 x 2.0 cm cystic lesion in the right cerebellar peduncle with mass effect on the adjacent fourth ventricle and surrounding edema, unchanged from the prior exam from today. Ventricles continued to be moderately dilated with prominent temporal horns and a right frontal approach ventriculostomy catheter terminating in the frontal horn. There is no area of hemorrhage identified or new mass lesion. IMPRESSION: Unchanged exam compared to the study performed earlier today at 8:54 a.m. No evidence of hemorrhage. . Head CT (8:54am): Again a cystic lesion identified in the right middle cerebellar peduncle with mass effect on the adjacent fourth ventricle. The lesion measures approximately 2.5 cm compared to 2.2 cm on the previous study. The surrounding edema and the mass effect is not significantly changed. The ventricles are moderately dilated with prominent temporal horns, not significantly changed. Shunt catheter is seen from the right frontal region extending to the anterior horn, unchanged. IMPRESSION: Unchanged appearance of the ventricular size. Although the cystic lesion in the right middle cerebellar peduncle appears slightly larger, the surrounding edema and the associated mass effect is not significantly changed. No hemorrhage seen. . Shunt Study: The course of the ventriculoperitoneal shunt arising from the right side of the brain and coursing along the right neck, chest, and epigastric region appears intact. Its tip terminates along the left lateral mid abdomen. There is again a large lung nodule projecting over the left lower lung. Calcified pleural plaques are present. There are moderate degenerative changes of the thoracolumbar spine. Bony demineralization is suspected. IMPRESSION: Intact course of ventriculoperitoneal shunt. . Reports . EEG ___: This is an abnormal EEG because of diffuse background slowing and bursts of generalized slowing. These findings are indicative of a mild to moderate diffuse encephalopathy, which is etiologically non specific. There were no epileptiform features. Of note, the cardiac rhythm strip demonstrated an irregularly irregular rhythm with occasional wide complex ectopic beats. . Labs on Discharge: ___ 09:00AM BLOOD WBC-7.1 RBC-4.33* Hgb-12.9* Hct-39.3* MCV-91 MCH-29.8 MCHC-32.8 RDW-14.2 Plt ___ ___ 09:00AM BLOOD Neuts-82.7* Lymphs-11.9* Monos-5.2 Eos-0.2 Baso-0.1 ___ 07:05AM BLOOD ___ PTT-26.8 ___ ___ 09:00AM BLOOD Glucose-310* UreaN-56* Creat-1.5* Na-142 K-4.7 Cl-104 HCO3-29 AnGap-14 ___ 07:05AM BLOOD ALT-23 AST-14 AlkPhos-121 TotBili-0.6 ___ 09:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2 Medications on Admission: - famotidine 20mg PO BID - docusate 100mg PO BID - senna 8.6mg PO BID - oxycodone-acetaminophen ___ tabs PO Q6hrs PRN pain - acetaminophen 325-650mg PO Q6hrs PRN pain - atorvastatin 80mg daily - digoxin 125mcg PO daily - carvedilol 3.125mg PO BID - dexamethasone 4mg PO Q8hrs - 70/30 insulin Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 5. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain, fever: Do not exceed 4000mg acetaminophen over any 24-hour period. . 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 2 days: last day is ___. 11. dexamethasone 6 mg Tablet Sig: One (1) Tablet PO twice a day. 12. insulin aspart 100 unit/mL Solution Sig: per sliding scale units Subcutaneous QACHS: Please give insulin per sliding scale depending on fingerstick blood glucose readings. 13. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous QAM. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Cerebellar mass Carcinoma of the lung Urinary tract infection . Secondary: Diabetes Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAM: CT head. CLINICAL INFORMATION: Patient with VP shunt, for further evaluation to assess interval change. TECHNIQUE: Axial images of the head were obtained without contrast. Comparison was made with the CT of ___ and MRI of ___. FINDINGS: Again a cystic lesion identified in the right middle cerebellar peduncle with mass effect on the adjacent fourth ventricle. The lesion measures approximately 2.5 cm compared to 2.2 cm on the previous study. The surrounding edema and the mass effect is not significantly changed. The ventricles are moderately dilated with prominent temporal horns, not significantly changed. Shunt catheter is seen from the right frontal region extending to the anterior horn, unchanged. IMPRESSION: Unchanged appearance of the ventricular size. Although the cystic lesion in the right middle cerebellar peduncle appears slightly larger, the surrounding edema and the associated mass effect is not significantly changed. No hemorrhage seen. Radiology Report CLINICAL HISTORY: ___ man with left facial droop and right-sided weakness. Evaluate for CVA. COMPARISON: Multiple priors, most recently from ___, approximately 4 hours prior to this exam. TECHNIQUE: Non-contrast head CT. FINDINGS: Again seen is a 2.3 x 2.0 cm cystic lesion in the right cerebellar peduncle with mass effect on the adjacent fourth ventricle and surrounding edema, unchanged from the prior exam from today. Ventricles continued to be moderately dilated with prominent temporal horns and a right frontal approach ventriculostomy catheter terminating in the frontal horn. There is no area of hemorrhage identified or new mass lesion. IMPRESSION: Unchanged exam compared to the study performed earlier today at 8:54 a.m. No evidence of hemorrhage. Radiology Report SHUNT SERIES HISTORY: Ventriculoperitoneal shunt. COMPARISONS: None aside from CT interventional procedure-related imaging from ___. This provides a comparison for a portion of the chest based on the scout film. TECHNIQUE: Shunt series. FINDINGS: The course of the ventriculoperitoneal shunt arising from the right side of the brain and coursing along the right neck, chest, and epigastric region appears intact. Its tip terminates along the left lateral mid abdomen. There is again a large lung nodule projecting over the left lower lung. Calcified pleural plaques are present. There are moderate degenerative changes of the thoracolumbar spine. Bony demineralization is suspected. IMPRESSION: Intact course of ventriculoperitoneal shunt. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R/O CVA Diagnosed with BRAIN CONDITION NOS, FACIAL WEAKNESS, VENTRICULAR SHUNT STATUS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dear Mr. ___, . You were admitted to the hospital with left sided facial droop and slurring of your words. A CAT scan of your head was done which showed that the mass in your head was stable to minimally larger in size. You also had imaging of your shunt which was in proper position and not kinked. An EEG was done which showed that you did NOT have any seizure activity. The cause of your left facial droop and slurred speech was thought to be secondary to swelling in your brain. We treated you for this with steroids. We also started you on Keppra, a medicine to prevent seizures. Of note, you also had a urinary tract infection which we treated with antibiotics. . We have made the following changes to your medications: -START Keppra 500mg twice daily -CHANGE Dexamethasone to 6mg PO bid -START Cefpodoxime 200mg daily, last day on ___ . On discharge, please follow up with Dr. ___ Dr. ___ ___ Dr. ___ as scheduled below. . It was a pleasure taking care of you, we wish you all the best.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Losartan Attending: ___. Chief Complaint: ACUTE LEUKEMIA Major Surgical or Invasive Procedure: None History of Present Illness: ___ with no PMH apart from h/o acute leukemia diagnosed in the past week, now admitted for chemotherapy. . She has experienced 1 month of nightsweats and fatigue plus dry cough x 1 week (cough now resolved). No fever, no N/V/C. Describes poor appetite and 6 lb weight loss over several weeks. At initial eval, PCP found leukopenia on screening labs. Referred to hematologist who performed BM bx ___ - preliminary BM bx results showed acute leukemia concerning for AML. . Patient presented to the ___ ED for admission to the ___ service. . In the ED, initial VS T99.6 HR 136 BP123/67 RR18 99/RA. While in the ED she triggered for tachycardia, which improved to HR ___ greatly after 2L NS IVF. Labs remarkable for WBC 0.7, HCT 33.1, platelets 174, 19% PMNs, 77% lymphs, 2% monos, 1% eosinophils. . On the floor, she feels well except for 1 month mouth dryness and bilateral eye redness/swelling. Tried eyedrops per ophthalmology recommendation (beta blocker eyedrops, prescription unknown) without no improvement. . ROS: As per HPI. Full 12-system ROS negative including GI/GU issues, CP, palpitations, SOB, abd pain. Past Medical History: HTN Social History: ___ Family History: 2 children, ___ and ___. One brother died ___ age ___. Father DM and CAD, mother CVA. Physical Exam: ADMISSION PHYSICAL EXAM: VS 96.3 106/64 92 18 98/RA GENERAL - well developed younger than stated ago, NAD AOX3 HEENT - MM dry no oral lesions no cervical LAD PERRL EOMI injected conjunctiva/sclera, and periorbital erythema and swelling CARDIAC - RRR nl S1 S2 no murmur PULM - CTAB no r/r/w ___ - soft nt nd +BS no organomegaly EXTREM - no edema PSYCH - mood and affect appropriate HEME/LYMPH - no LAD SKIN - minimally raised red rash >1 cm diameter lesions, on back and posterior L leg, non-pruritic . Discharge PE: VS 99 122/72 101 (80s-100s) 97%RA GENERAL - NAD, very well appearing HEENT - MMM, no oral lesions no LAD CARDIAC - RRR nl S1 S2 no murmur PULM - CTAB no r/r/w ___ - soft nt nd +BS no organomegaly EXTREM - RUE without edema, but with continued palpable clot medial upper arm PSYCH - mood and affect appropriate HEME/LYMPH - no LAD, few bruises but no bleeding. SKIN - b/l thigh plaques are much improved ACCESS: Peripheral, intact. Pertinent Results: ADMISSION LABS ___ 10:45AM BLOOD WBC-0.7* RBC-3.50* Hgb-10.9* Hct-33.1* MCV-95 MCH-31.1 MCHC-32.9 RDW-13.5 Plt Ct-74* ___ 10:45AM BLOOD Neuts-19* Bands-0 Lymphs-77* Monos-2 Eos-1 Baso-0 ___ Metas-1* Myelos-0 ___ 12:08PM BLOOD ___ PTT-26.0 ___ ___ 12:08PM BLOOD ___ ___ 10:45AM BLOOD Glucose-165* UreaN-23* Creat-1.1 Na-135 K-4.3 Cl-100 HCO3-23 AnGap-16 ___ 10:45AM BLOOD ALT-25 AST-25 LD(LDH)-238 AlkPhos-42 TotBili-0.7 ___ 10:45AM BLOOD Albumin-3.2* Calcium-8.9 Phos-2.2* UricAcd-3.7 ___ 11:16AM BLOOD Lactate-3.1* . . PATHOLOGY . OSH thigh punch biopsy: 1.Perivascular and predominantly superficial dermal neutrophilic infiltrate with leukocytoclasis and red blood extravasation consistent with acute neutrophilic vasculitis (see comment). 2.Atypical dermal mononuclear cell infiltrate . ___ KARYOTYPE: 46,XX[20] INTERPRETATION: No cytogenetic aberrations were identified in 20 metaphases analyzed from this unstimulated specimen. This normal result does not exclude a neoplastic proliferation. . ___ BM BIOPSY PRELIM: Poorly differentiated acute myelogenous leukemia . IMAGING . ___ CXR FINDINGS: PA and lateral views of the chest. The cardiac, mediastinal, and hilar contours are normal. The lungs are clear. Heart size is top normal. Pleural surfaces are normal. No evidence of pneumonia. No pleural effusions or pneumothorax. No evidence of pulmonary edema. IMPRESSION: No evidence of pneumonia. No acute cardiopulmonary process. . DISCHARGE LABS Micro: Blood cultures negative ___ x2 . ___ 05:33AM BLOOD WBC-0.9* RBC-2.83* Hgb-8.6* Hct-24.0* MCV-85 MCH-30.4 MCHC-35.9* RDW-15.0 Plt Ct-34* ___ 05:33AM BLOOD Neuts-22.2* Bands-0 Lymphs-68.8* Monos-7.2 Eos-1.2 Baso-0.5 ___ 05:33AM BLOOD ___ PTT-26.8 ___ ___ 05:41AM BLOOD ___ 05:33AM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-135 K-4.2 Cl-101 HCO3-29 AnGap-9 ___ 05:33AM BLOOD ALT-18 AST-13 LD(LDH)-143 AlkPhos-57 TotBili-0.7 ___ 05:33AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.2 Medications on Admission: Lisinopril (dose unknown) Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 2. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: acute myeloid leukemia left upper extremity deep vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Acute leukemia. Question of pneumonia. COMPARISON: None available. FINDINGS: PA and lateral views of the chest. The cardiac, mediastinal, and hilar contours are normal. The lungs are clear. Heart size is top normal. Pleural surfaces are normal. No evidence of pneumonia. No pleural effusions or pneumothorax. No evidence of pulmonary edema. IMPRESSION: No evidence of pneumonia. No acute cardiopulmonary process. Radiology Report INDICATION: New PICC line placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient has received a right-sided PICC line. The course of the line is unremarkable, the tip of the line projects over the mid SVC. There is no evidence of complications, notably no pneumothorax. Otherwise, the radiograph is unchanged, except for a newly appeared atelectatic opacity at the level of the left hilus, that should receive attention at subsequent followups. Radiology Report CLINICAL HISTORY: ___ woman with AML and right upper extremity PICC, now with right arm swelling. COMPARISON: None. FINDINGS: The right subclavian shows some decrease in phasicity of flow. A right PICC is seen within the basilic vein and through the subclavian vein. Around the PICC, there is hypoechoic material without compressibility representing clot; flow is not seen in most of the basilic vein indicating the clot is occlusive. The clot also extends into the axillary vein, where it is also occlusive, and into the medial brachial vein, which has some flow within it and is not occlusive. There may be thrombus around the PICC within the right subclavian vein but there is clear flow in the right subclavian vein with good variability inidcating no occlusion here or more centrally. IMPRESSION: 1. Occlusive thrombis in the right basicilic and axillary veins, surrounding the PICC. Non-occlusive thrombus within the medial brachial vein.Possible thrombus extending into the right subclavian vein around the PICC, which would be non-occlusive if present. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: WEAKNESS, NEW LEUKEMIA SENT FOR ADMIT Diagnosed with OTHER MALAISE AND FATIGUE, ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION temperature: 99.6 heartrate: 136.0 resprate: 18.0 o2sat: 99.0 sbp: 123.0 dbp: 67.0 level of pain: 3 level of acuity: 1.0

Mrs. ___, ___ were admitted to the hospital for treatment of your leukemia with chemotherapy. ___ developed a blood clot of your right upper arm, likely due to the IV line that was used to infuse your medication. This line was removed, and ___ were treated with a blood thinner until your platelets (the cells that help your body form clots) dropped to a low level. . ___ were kept in the hospital until your white blood cells (the cells that fight infection) recovered from the chemotherapy treatment. . We have made the following changes to your medications: -START fluconazole (to prevent infection) -START levofloxacin (to prevent infection) -START Acyclovir (to prevent infection) -STOP lisinopril until instructed to do so by your outpatient doctors.

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx of glaucoma, ? dementia, COPD, Rheumatoid arthritis, DVT/PE, who presents after being confused about his PCP ___. Pt reports that yesterday AM, he was notified that he had an appointment for the next day. He took a nap, woke up in the afternoon, but thought it was the next morning, and proceeded to go to ___ for his PCP ___. At ___, given that he was confused, he was told to go to the ED. He was then admitted for concern for poor self care. A community nurse helps patient fills his medication box. He lives alone as his wife is currently sick and is at nursing home. He walks with a cane. Reports having good appetite. Per previous note with community resource nurse: Pt takes the bus or a taxi to ___ ___ and/or social activities: such as visiting his wife in the nursing home. He does not have a lifeline. He says if he does not feel well, he knocks on his neighbor's door and asks for help. Pt was asked what he would do if he was alone, not able to get OOB to ask for help. ___ did not know. Past Medical History: Seropositive rheumatoid arthritis Latent TB Hepatitis B, continues on lamivudine Diabetes COPD continues the inhaler therapy Medication compliance issues Social History: ___ Family History: No h/o autoimmune disease, denies family history of DVT/PE Physical Exam: ADMISSION PHYSICAL EXAM ========================== Vital Signs: 98.1 142/71 61 18 98% RA General: Alert, oriented, no acute distress HEENT: Erythematous sclera. EOMI. Clear oropharynx. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM ============================ Vital Signs: 98.9 120-137/57-71 59-68 ___ 93-98% RA General: Alert, oriented, no acute distress HEENT: Erythematous sclera. EOMI. No tonsillar exudates. Neck: No cervical lymphadenopathy CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding. Umblilical hernia, non-tender, reducible. 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. Pertinent Results: ADMISSION LABS =================== ___ 01:22AM BLOOD WBC-5.9 RBC-4.23* Hgb-11.8* Hct-38.1* MCV-90 MCH-27.9 MCHC-31.0* RDW-13.8 RDWSD-44.9 Plt ___ ___ 01:22AM BLOOD Neuts-60.4 ___ Monos-7.4 Eos-2.4 Baso-0.8 Im ___ AbsNeut-3.59 AbsLymp-1.69 AbsMono-0.44 AbsEos-0.14 AbsBaso-0.05 ___ 01:22AM BLOOD Glucose-123* UreaN-13 Creat-1.0 Na-139 K-5.0 Cl-96 HCO3-31 AnGap-17 ___ 01:22AM BLOOD ALT-7 AST-14 AlkPhos-70 TotBili-0.4 ___ 01:22AM BLOOD Albumin-3.9 ___ 01:22AM BLOOD VitB12-230* Folate->20 ___ 01:22AM BLOOD ___ METHYLMALONIC ACID (___): 543 H Normal range: 87-318 nmol/L **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: REACTIVE. Reference Range: Non-Reactive. QUANTITATIVE RPR (Final ___: REACTIVE AT A TITER OF 1:4. DISCHARGE LABS ================== ___ 12:51PM BLOOD WBC-5.8 RBC-4.46* Hgb-12.6* Hct-40.5 MCV-91 MCH-28.3 MCHC-31.1* RDW-13.9 RDWSD-45.8 Plt ___ ___ 12:51PM BLOOD Neuts-61.7 ___ Monos-9.1 Eos-3.1 Baso-0.9 Im ___ AbsNeut-3.59 AbsLymp-1.44 AbsMono-0.53 AbsEos-0.18 AbsBaso-0.05 ___ 12:51PM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-137 K-4.9 Cl-99 HCO3-29 AnGap-14 ___ 12:51PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2 MICRO: R/O Beta Strep Group A (Pending) ___: URINE culture (___): No growth CXR (___) Mild interstitial edema. Left basilar opacity may reflect atelectasis though infection can be considered in the appropriate clinical setting. Radiology Report INDICATION: ___ male with confusion. Evaluate for infectious process. TECHNIQUE: PA and lateral chest radiographs were obtained. COMPARISON: Chest radiograph from ___. FINDINGS: There is mild interstitial edema, and the heart is normal in size. A left basilar opacity may reflect atelectasis versus pneumonia. There is no pleural effusion or pneumothorax. IMPRESSION: Mild interstitial edema. Left basilar opacity may reflect atelectasis though infection can be considered in the appropriate clinical setting. Gender: M Race: BLACK/CARIBBEAN ISLAND Arrive by UNKNOWN Chief complaint: Confusion, Eye redness Diagnosed with Altered mental status, unspecified temperature: 99.7 heartrate: 78.0 resprate: 18.0 o2sat: 99.0 sbp: 155.0 dbp: 78.0 level of pain: 3 level of acuity: 3.0

Dear Mr. ___, It was a pleasure caring for you Why you were admitted? - You were admitted because there was concern about your safety at home. What we did for you? - Physical therapy evaluated you and recommended that you go to a rehab facility, but unfortunately due to financial constraints, this could not be rearranged. It was determined that it was safest for you to be discharged to your sister's house. What you should do when you go home? - Continue taking all your medications as prescribed and go to the appointments that we have arranged. We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___ ___ Complaint: Left leg and ankle pain Major Surgical or Invasive Procedure: Left tibia external fixator History of Present Illness: The patient is a ___ male who slipped on wet rocks and fell, worked up at OSH and found to have left ankle fracture, then transferred to ___. He was in his usual state of health, was walking, slipped on some wet gravel with inversion injury and then fell over with immediate pain and inability to ambulate. He was found to have comminuted distal tibia/fibula fracture with intra-articular extension. He was admitted to the orthopaedic team and treated with external fixator on ___. Past Medical History: HTN GERD Social History: ___ Family History: NC Physical Exam: DISCHARGE PHYSICAL EXAM General: Alert and oriented, NAD, AVSS Cardio: RRR Resp: breathing unlabored Left lower extremity: External fixator in place, pin sites wrapped in dry gauze with mild staining, wiggles toes, SILT superficial peroneal, deep peroneal, saphenous, tibial, sural distributions, ___ pulses, foot warm and well-perfused Radiology Report INDICATION: ___ with pilon L ankle fracture, status post reduction. COMPARISON: Prior exam performed earlier today from outside hospital. FINDINGS: AP, lateral, oblique views of the left ankle were provided. There has been interval reduction attempt with no significant change in alignment. Comminuted fractures through the distal tibia and fibula are unchanged. Overlying plaster splint is in place. IMPRESSION: Distal tibia and fibula fractures in unchanged overall alignment. Radiology Report INDICATION: Status post trauma with distal tibia and fibular fractures. Evaluate preoperatively. TECHNIQUE: MDCT images were obtained through the left ankle without the administration of IV contrast. Sagittal and coronal reformatted images were obtained and reviewed. DOSE: Total DLP: 440.44 mGy-cm. COMPARISON: Ankle radiographs from ___. FINDINGS: There is a markedly comminuted oblique fracture of the distal tibia with intra-articular extension. The dominant distal fracture fragment is displaced anteromedially. The fragments are overriding by approximately 1 cm. The intra-articular portion of the fracture has two major components. First, there is a nondisplaced fracture through the posterior portion of the joint. Second, there is an anteromedial fragment that is displaced anteriorly by 1.2 cm. This is creating a small focal articular surface gap. There are two tiny bone fragments adjacent to the medial malleolus, suggesting an avulsion injury. The remainder of the medial malleolus is intact. There is also a markedly comminuted fracture of the distal fibula with intra-articular extension. There is one fracture above the syndesmosis with the distal fragments displaced anteromedially, similar to the tibial fracture. Below the syndesmosis, the lateral malleolus is split into two dominant fracture fragments. There is an anterior fragment and a posterior fragment which are distracted by approximately 1.4 cm. Additionally, there are several smaller bone fragments, including an elongated horizontally oriented fracture fragment at the level of the distal fibula which extends to within 4 mm of the skin (400 be, 92). Additionally, there is a small 9 mm fragment in between the dominant anterior and posterior fragments of the lateral malleolus at the level of the tibio-talar joint. No other fracture is identified. No evidence of entrapment of the extensor, peroneal, or flexor tendons. There is edema in the surrounding soft tissues, most marked along the lateral aspect of the joint. There is no subcutaneous gas or evidence of a foreign body. There is no large focal fluid collection or hematoma. IMPRESSION: Markedly comminuted displaced intra-articular fractures of the distal tibia and fibula, as described above. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) LEFT INDICATION: LEFT TIB FX.ORIF IMPRESSION: Multiple images from the operating room shows placement of extensive fixation device about the comminuted fracture of the distal tibia. Further information can be gathered from the operative report. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: L Ankle pain, FX Diagnosed with FX TIBIA W FIBULA NOS-CL, UNSPECIFIED FALL temperature: 97.5 heartrate: 56.0 resprate: 14.0 o2sat: 100.0 sbp: 135.0 dbp: 70.0 level of pain: 3 level of acuity: 3.0

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming. - Keep the pin sites on your external fixator clean and dry. - Keep wound sites wrapped with dry gauze if draining - No dressing is needed if wound is not draining. - Keep your leg elevated on 2 pillows as much as possible to prevent swelling. ACTIVITY AND WEIGHT BEARING: - Activity as tolerated - Left lower extremity: Non weight bearing, elevate on 2 pillows as much as possible until follow up with surgeon to prevent swelling.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Aspirin / Avandia / spironolactone / amiodarone Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with heart failure w/ preserved ejection fraction, PAH, AF, DM, hypothyroidism, p/w ___ year old female with chief complaint of dyspnea and hypoxemia. 2L o2 at home, sats 92% at baseline presenting with dyspnea and hypoxia. Reportedly, over the past 10 days, she has had worsening dyspnea, hypoxemia (down to 85%). She uses O2 at home. She reports shortness of breath, even with small activities and bending over to look down at her feet. She was seen on ___ and was noted to have an unchanged weight with mild R-sided chest pain, baseline O2 sat at rest, but with sats that dropped to the ___ when she was taken off her O2 (usually she is in the ___ off O2). No lightheadedness, headache, f/c, n/v/d, myalgias. Although medication compliance has been an issue in the past, she reports taking her torsemide every day. In the ED, initial vitals were: 96.8 F, BP 150/70s, HR ___, RR 20, 96% on 2 L NC. Past Medical History: Type 2 Diabetes HTN Hyperlipidemia Sick sinus syndrome s/p atrial pacemaker implantation Paroxysmal atrial fibrillation Iron deficiency anemia Chronic diastolic heart failure with home O2 requirement Osteoporosis GERD w/ paraesophageal hernia Osteoarthritis/Back Pain OSA supposed to be on CPAP s/p CCY Social History: ___ Family History: Says her mother and father had 'heart problems', unclear on specifics. Denies h/o cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: not yet taken on the floor General: Alert, oriented, no acute distress, on 2 L O2 HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. Unable to appreciate JVP. no LAD CV: Regular rate and rhythm. Normal S1+S2, soft systolic murmur at the RUSB Lungs: Decreased breath sounds with crackles b/l Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, 1+ pitting edema to the mid shins Neuro: ___ strength upper/lower extremities, grossly normal sensation, normal gait DISHCARGE PHYSICAL EXAM Vitals: 98.3 92-127/52-71 69-70 95% 3L NC I/O= 300/650 (8hr's) 1240/1650 (24hrs) Weight: 71.4 <- 71.2 kg <- 70.8 <-71.3 kg Weight on admission: 71.3 kg Weight in ___ - 164 lb - 74.4kg Telemetry: unremarkable. General: Chronically ill appearing female in NAD HEENT: MM dry, face symmetrical Lungs: scattered crackles CV: Regular rate and rhythm. Normal S1+S2, soft systolic murmur at the RUSB. JVP 6-8 cm Abdomen: soft nd nt Ext: wwp no peripheral edema Pertinent Results: ADMISSION LABS ------------- ___ 08:00PM WBC-9.7 RBC-4.16 HGB-12.0 HCT-37.9 MCV-91 MCH-28.8 MCHC-31.7* RDW-14.6 RDWSD-48.7* ___ 08:00PM proBNP-3154* ___ 08:00PM cTropnT-<0.01 ___ 07:30AM ALT(SGPT)-12 AST(SGOT)-12 LD(LDH)-188 ALK PHOS-141* TOT BILI-0.5 IMPORTANT STUDIES: -------------------- CT CHEST W/O ___ 1. Diffuse ground-glass pulmonary opacities with smooth interlobular septal thickening likely represents pulmonary edema in the setting of cardiomegaly. Although less likely, this could alternatively be related to infectious or inflammatory process. 2. Stable large hiatal hernia. 3. Increase in number of mediastinal lymph nodes. These are not enlarged by CT size criteria and demonstrate ___ years of stability, and may represent a low grade lymphoproliferative process. 4. Interval increase in size of cystic lesion within the pancreatic body measuring up to 2.5 cm. Further evaluation with MRI may be helpful if desired. 5. No significant change in right adrenal adenoma and left adrenal myelolipoma. 6. A 15 x 30 mm left thyroid nodule, for which further evaluation with nonemergent thyroid ultrasound is recommended. TTE ___ The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>60%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size is normal with mild global free wall hypokinesis. 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. There is no mitral valve prolapse. Moderate to severe [3+] tricuspid regurgitation is seen accounting for shadowing from the right ventricular pacer lead. There is at least 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 no pericardial effusion. IMPRESSION: Hypertensive heart disease. Increased PCWP. Mildly hypokinetic right ventricle with moderate to severe tricuspid regurgitation (intrinsic RV function will be decreased) and at least moderate pulmonary hypertension. Compared with the prior study (images reviewed) of ___ the findings are similar. DISCHARGE LABS ------------- ___ 05:10AM BLOOD WBC-8.2 RBC-3.73* Hgb-10.8* Hct-34.1 MCV-91 MCH-29.0 MCHC-31.7* RDW-13.9 RDWSD-46.5* Plt ___ ___ 05:10AM BLOOD Glucose-201* UreaN-66* Creat-1.6* Na-138 K-4.2 Cl-98 HCO3-30 AnGap-14 ___ 05:10AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1 ___ 08:00PM BLOOD TSH-4.8* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. diclofenac sodium 1 % topical DAILY PRN 2. Torsemide 60 mg PO DAILY 3. Levothyroxine Sodium 25 mcg PO DAILY 4. Apixaban 2.5 mg PO BID 5. Losartan Potassium 25 mg PO BID 6. Sertraline 50 mg PO DAILY 7. Pravastatin 40 mg PO QPM 8. Ketoconazole Shampoo 1 Appl TP ASDIR 9. Januvia (SITagliptin) 25 mg oral DAILY 10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 11. GlipiZIDE XL 5 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Metoprolol Succinate XL 150 mg PO BID 14. Felodipine 5 mg PO DAILY 15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 18. nystatin 100,000 unit/gram topical DAILY:PRN 19. Acetaminophen 1000 mg PO Q8H 20. Vitamin D ___ UNIT PO DAILY 21. lutein 20 mg oral BID 22. Magnesium Oxide 400 mg PO QPM 23. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 2. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 3. Acetaminophen 1000 mg PO Q8H 4. Apixaban 2.5 mg PO BID 5. diclofenac sodium 1 ? topical DAILY PRN pain 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. GlipiZIDE XL 5 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Januvia (SITagliptin) 25 mg oral DAILY 10. Ketoconazole Shampoo 1 Appl TP ASDIR 11. Levothyroxine Sodium 25 mcg PO DAILY 12. lutein 20 mg oral BID 13. Magnesium Oxide 400 mg PO QPM 14. nystatin 100,000 unit/gram topical DAILY:PRN 15. Omeprazole 20 mg PO DAILY 16. Pravastatin 40 mg PO QPM 17. Sertraline 50 mg PO DAILY 18. Torsemide 60 mg PO DAILY RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*3 19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 20. Vitamin D ___ UNIT PO DAILY 21. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 22.Home oxygen ICD-10 code: ___.0 Pulmonary Hypertension Home Oxygen: 4L Nasal Cannula with rest and exercise SpO2 with ambulation on 3L: 88% SpO2 seated on 3L NC: 95% Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: =========== Acute Diastolic heart failure exacerbation Acute on chronic hypoxemic respiratory failure Severe pulmonary 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: CT chest without contrast. INDICATION: ___ year old woman with worsening shortness of breath of unclear etiology, new findings on CXR// e/o aspiration or restrictive lung disease TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Chest radiograph from ___, CT chest from ___ CT chest from ___. FINDINGS: HEART AND VASCULATURE: A left-sided pacer device is present with leads in the right atrium and right ventricle. The thoracic aorta is normal in caliber. The heart is enlarged. No pericardial effusion. The great vessels are within normal limits based on an unenhanced scan. No pericardial effusion is seen. A 15 x 30 mm hypoattenuating nodule is present in the left thyroid lobe. AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy. There are prominent right upper paratracheal lymph nodes, although not enlarged by CT size criteria, these have increased in number in comparison to the prior CT from ___. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There are diffuse ground-glass opacities with smooth interlobular septal thickening, which likely represent edema or less likely infection. This is similar in appearance to the prior CT chest from ___. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the unenhanced upper abdomen demonstrates a 2.8 x 1.3 mass in the medial limb of the right adrenal gland with an internal attenuation of 2 ___ (2:42) and is compatible with adrenal adenoma. The left adrenal gland shows a 4.5 x 3.2 cm heterogeneous mass with macroscopic fat component compatible with myelolipoma, unchanged from ___. Large hiatal hernia is present. Partially visualized cystic lesion within the pancreatic body measuring 2.2 x 2.6 cm, slightly increased in size in comparison to ___. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. Moderate to severe multilevel degenerative changes of the visualized spine, including persistent severe thoracic kyphosis. IMPRESSION: 1. Diffuse ground-glass pulmonary opacities with smooth interlobular septal thickening likely represents pulmonary edema in the setting of cardiomegaly. Although less likely, this could alternatively be related to infectious or inflammatory process. 2. Stable large hiatal hernia. 3. Increase in number of mediastinal lymph nodes. These are not enlarged by CT size criteria and demonstrate ___ years of stability, and may represent a low grade lymphoproliferative process. 4. Interval increase in size of cystic lesion within the pancreatic body measuring up to 2.5 cm. Further evaluation with MRI may be helpful if desired. 5. No significant change in right adrenal adenoma and left adrenal myelolipoma. 6. A 15 x 30 mm left thyroid nodule, for which further evaluation with nonemergent thyroid ultrasound is recommended. Gender: F Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: Dyspnea, Hypoxia Diagnosed with Dyspnea, unspecified temperature: 96.8 heartrate: 70.0 resprate: 20.0 o2sat: 96.0 sbp: 157.0 dbp: 78.0 level of pain: 0 level of acuity: 3.0

Ms. ___, Why were you admitted to the hospital? - you were admitted for worsening shortness of breath and low oxygen in your blood, especially with walking around. What was done for you in the hospital? - we gave you medications to take fluid off of your lungs. - We changed your medications as your blood pressure was low. - We decreased your beta blocker to help your heart pump better. - We increased your home oxygen level to 4L What should you do when you go home? - Wear your Oxygen at home all the time. - Take all your medications as prescribed that are listed on your medication sheet. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. - Please seek medical attention if you develop any chest pain, worsening shortness of breath, swelling in your legs or any other symptoms that concern you It was a pleasure taking care of you! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Shellfish Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: =============== Admission labs =============== ___ 06:20PM BLOOD WBC-5.2 RBC-3.69* Hgb-10.4* Hct-33.3* MCV-90 MCH-28.2 MCHC-31.2* RDW-14.7 RDWSD-48.5* Plt ___ ___ 06:20PM BLOOD Neuts-69.0 Lymphs-16.2* Monos-11.5 Eos-2.1 Baso-0.8 Im ___ AbsNeut-3.59 AbsLymp-0.84* AbsMono-0.60 AbsEos-0.11 AbsBaso-0.04 ___ 06:20PM BLOOD ___ PTT-31.1 ___ ___ 06:20PM BLOOD Glucose-93 UreaN-18 Creat-1.0 Na-141 K-4.5 Cl-104 HCO3-28 AnGap-9* ___ 06:20PM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2 =============== Pertinent labs =============== ___ 06:30AM BLOOD TSH-3.1 ___ 06:30AM BLOOD Cortsol-16.3 ___ 06:20PM BLOOD cTropnT-<0.01 ___ 06:20PM BLOOD CK(CPK)-232 =============== Discharge labs =============== ___ 05:40AM BLOOD WBC-6.1 RBC-4.10* Hgb-11.7* Hct-36.4* MCV-89 MCH-28.5 MCHC-32.1 RDW-14.9 RDWSD-48.3* Plt ___ ___ 05:40AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-138 K-5.0 Cl-99 HCO3-24 AnGap-15 ___ 05:40AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.4 =============== Studies =============== Carotid US ___: IMPRESSION: Right ICA <40% stenosis. Left ICA <40% stenosis. TTE ___: CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The inferior vena cava diameter is normal. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is a small area of regional left ventricular systolic dysfunction with severe hypokinesis/akinesis/dyskinesis of the distal ventricle/apex. The baasal inferior wall is hypokinetic (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%. Left ventricular cardiac index is low normal (2.0-2.5 L/min/m2). There is no left ventricular outflow tract gradient at rest or with Valsalva. No ventricular septal defect is seen. 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. 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 mild [1+] aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with coronary artery disease (LAD and ? RCA distribution). Compared with the prior TTE (images reviewed) of ___ , global left ventricular systolic function slightly less vigorous. Basal inferior wall now hypokinetic. CT head w/o contrast ___: IMPRESSION: 1. No significant change in the subarachnoid hemorrhage involving the perimesencephalic cisterns, superior cerebellar sulci and left sylvian fissure, as above. No new or expanding intracranial hemorrhage. CTA head/neck ___: 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. 3. Unchanged acute nondisplaced fracture of the left transverse process of T1. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. ECG ___: Sinus rhythm. 1st degree AV block. Old anterior infarct. CT torso w/ contrast ___: IMPRESSION: 1. Acute, nondisplaced fracture of the left transverse process of the T1 vertebra. 2. Type 3 left AC joint separation, better evaluated on the same day radiograph. 3. Mild interstitial pulmonary edema. CT head w/o contrast ___: 1. Small volume subarachnoid hemorrhage as described most conspicuous in the quadrigeminal cistern. 2. No acute fracture. CT c-spine w/o contrast ___: IMPRESSION: 1. No acute cervical spine fracture or change in alignment. 2. Acute nondisplaced fracture involving the left transverse process of T1. 3. Multilevel degenerative changes appear similar to prior. CXR ___: IMPRESSION: 1. Interstitial pulmonary edema. 2. Probable type 3 left AC joint separation. Please refer to report from same day left shoulder radiograph for further details. Shoulder x-ray ___: Findings are concerning for type 3 left AC joint separation. Soft tissue swelling overlying the left AC joint. =============== Microbiology =============== URINE CULTURE (Final ___: < 10,000 CFU/mL. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pantoprazole 20 mg PO Q12H 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Gabapentin 600 mg PO QHS 4. rOPINIRole 8 mg PO BID 5. Clopidogrel 75 mg PO DAILY 6. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY 7. Carbidopa-Levodopa CR (___) 1 TAB PO QHS 8. FLUoxetine 20 mg PO DAILY 9. Atorvastatin 80 mg PO QPM 10. isradipine 2.5 mg oral DAILY 11. Aspirin 81 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Lidocaine 5% Patch 1 PTCH TD QAM pain RX *lidocaine [Lidoderm] 5 % 1 patch qAM Disp #*14 Patch Refills:*0 3. Carbidopa-Levodopa (___) 1.5 TAB PO 5X/DAY 4. Carbidopa-Levodopa CR (___) 1 TAB PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. rOPINIRole 4 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. FLUoxetine 20 mg PO DAILY 10. HELD- Clopidogrel 75 mg PO DAILY This medication was held. Do not restart Clopidogrel until ___ and then restart this medication 11. HELD- Gabapentin 600 mg PO QHS This medication was held. Do not restart Gabapentin until you see your primary care doctor Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid hemorrhage Type 3 left AC joint separation Nondisplaced left transverse process of the T1 vertebra Severe orthostatic hypotension Syncope Recurrent falls ___ disease Discharge Condition: ***Left upper extremity in sling, weight-bearing as tolerated.*** Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with PD w/ syncopal episode, fell down stairs w/ HS and LOC, found to have SAH, T1 process fx and L AC joint dislocation // Please evaluate vasculature 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 6.0 s, 0.5 cm; CTDIvol = 29.9 mGy (Body) DLP = 15.0 mGy-cm. 2) Spiral Acquisition 5.3 s, 41.9 cm; CTDIvol = 15.3 mGy (Body) DLP = 639.8 mGy-cm. Total DLP (Body) = 655 mGy-cm. COMPARISON: CT Head ___, CT cervical spine ___. FINDINGS: CTA HEAD: There is atheromatous calcification of the carotid siphons bilaterally. The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm. There is a fetal origin of both posterior cerebral arteries. The dural venous sinuses are patent. CTA NECK: Bilateral carotid and vertebral artery origins are patent. There is atheromatous calcification at the bifurcation of the right common carotid artery and the proximal aspect of the left internal carotid artery, just distal to the bifurcation of the left common carotid artery. There is no evidence of internal carotid stenosis by NASCET criteria. The carotidandvertebral arteries and their major branches otherwise appear normal with no evidence of stenosis or occlusion. OTHER: There is mild interlobular septal thickening in the lung apices, more marked on the right side, which may be secondary to a degree of mild pulmonary congestion. The visualized portion of the lungs are otherwise clear. There is an 11 mm hypodense nodule in the superior aspect of the right lobe of thyroid gland, and an 11 mm hypodense nodule in the inferior aspect of the left lobe of the thyroid gland. There is no lymphadenopathy by CT size criteria. Note is again made of the acute nondisplaced fracture of the left transverse process of T1. The unchanged appearance of the bone cyst within the dens. Cervical spondylosis, most marked at the craniocervical junction and at C6-C7 level. There is marked degenerative change of the sternoclavicular joints bilaterally. 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. 3. Unchanged acute nondisplaced fracture of the left transverse process of T1. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with tSAH, new episode of presyncope // eval interval change in tSAH 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 1003.42 mGy-cm COMPARISON: Multiple priors most recently CT head from ___ FINDINGS: The subarachnoid hemorrhage in the perimesencephalic cisterns, superior cerebellar sulci and left sylvian fissure appears stable. No new or expanding areas of intracranial hemorrhage. There is no evidence of recent territorial infarction, edema,or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical white matter hypodensities are nonspecific, but likely reflect the sequela of chronic microvascular infarction. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal. Dense atherosclerotic calcifications of the cavernous carotid arteries. IMPRESSION: 1. No significant change in the subarachnoid hemorrhage involving the perimesencephalic cisterns, superior cerebellar sulci and left sylvian fissure, as above. No new or expanding intracranial hemorrhage. Radiology Report EXAMINATION: Carotid Artery ultrasound INDICATION: ___ year old man with syncopal episode // occlusion? TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: There is mild heterogenous atherosclerotic plaque in the right carotid artery. Segment: PSV (cm/s) / EDV (cm/s) ---------------------------------------------- CCA ___: 73.3 cm/s / 21.7 cm/s CCA Distal: 78.3 cm/s / 17 cm/s ICA ___: 96.8 cm/s / 24.6 cm/s ICA Mid: 62.6 cm/s / 17.6 cm/s ICA Distal: 57.9 cm/s / 22.4 cm/s ECA: 57.2 cm/s Vertebral: 43.5 cm/s ICA/CCA Ratio: 1.24 The right vertebral artery flow is antegrade with a normal spectral waveform. LEFT: There is mild heterogenous atherosclerotic plaque in the left carotid artery. Segment: PSV (cm/s) / EDV (cm/s) ---------------------------------------------- CCA ___: 87.8 cm/s / 24.3 cm/s CCA Distal: 76 cm/s / 25.9 cm/s ICA ___: 68 cm/s / 18 cm/s ICA Mid: 59.6 cm/s / 23.8 cm/s ICA Distal: 54.9 cm/s / 23.5 cm/s ECA: 54.1 cm/s Vertebral: 38 cm/s ICA/CCA Ratio: 0.89 The left vertebral artery flow is antegrade with a normal spectral waveform. IMPRESSION: Right ICA <40% stenosis. Left ICA <40% stenosis. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: s/p Fall, Syncope Diagnosed with Traum subrac hem w LOC of unsp duration, init, Fall (on) (from) other stairs and steps, initial encounter temperature: 97.6 heartrate: 68.0 resprate: 16.0 o2sat: 96.0 sbp: 132.0 dbp: 88.0 level of pain: 5 level of acuity: 2.0

Dear Mr. ___, WHY WAS I IN THE HOSPITAL? ========================== You were admitted to ___ after you fell and hit your head. WHAT HAPPENED TO ME IN THE HOSPITAL? ==================================== You had imaging done here which showed you sustained a bleed in your head, and broke a part of the bone in your spine but this fracture is stable and will heal on its own. You also sustained a left acromioclavicular joint (shoulder) separation. The orthopedic team saw you and recommend conservative management with a sling. You were seen by the neurosurgery team for your head bleed and you do not need any surgical intervention. You were also noted to have low blood pressures especially when standing, which can lead to dizziness and cause falls. Your medications were adjusted to help prevent further falls. It was recommend that you go to rehab to work on your strength, but you refused this. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================= Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Please take your blood pressure any time you feel lightheaded or if you get headaches. Please wear your abdominal binder and stockings any time you are out of bed. Stand up slowly any time you get up. If you feel lightheaded, sit or lay down immediately. Please do NOT drive until you are cleared by your doctors. It was a pleasure caring for you, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine / fentanyl Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ Esophagoduodenoscopy (EGD) History of Present Illness: ___ year old female with history with history gallstone pancreatitis s/p ccy, and recent admission at ___ for pancreatitis p/w epigastric pain. Patient was recently admitted to ___ in ___ with bloating, nausea, emesis, epigastric abdominal pain radiating to the back. She was treated conservatively for acute pancreatitis with ivfs and pain control. Her lipase was in the ___ w/ normal LFTs. No imaging was done at that time. She tolerated clears and was discharged home with outpatient ERCP follow up for ___. Since discharge, she did well requiring only a few days of po zofran/dilaudid. 1 night prior to admission, she developed severe bloating. The next morning, she ate breakfast, and experienced burning epigastric pain, ___, radiating to the back, and associated w/ nausea. She subsequently ate toast, which exacerbated the pain. Reports pain is similar to prior episode of pancreatitis. Denies emesis, fevers, chills. No changes in bowel habits. She had one glass of wine and a cocktail two nights prior to admission. She also denies hematuria, dysuria, GERD, bloody/black stools, pain elsewhere. She was seen by her PCP today, who recommended she go to the ED for reevaluation and ERCP. Of note, she has had an ERCP in ___ for similar pain, was told that there was sludge, but does not recall what interventions if any were done. In the ED, VS: T 97.0, HR 93, BP 136/85, RR 18, O2 100%. Labs: ALT 19, AST 23, AP 58, Tbili 0.5, Lip 75, WBC 8.1, Cr 0.6. She received dilaudid 1mg iv x2, zofran 4mg iv x1, and GI cocktail. Most Recent Vitals: 98.2 83 127/79 17 100% Lines & Drains: 20g RFA Currently, she complains of ___ pain. ROS: 12 point review of system is otherwise negative. Past Medical History: BREAST IMPLANTS FIBROADENOMA- LT BREAST REMOVED HERPES SIMPLEX TYPE 1 POS ANTIBODY KIDNEY STONES THROACIC AORTIC GRAFT- D/T SCREW PUNCTURE, COMPL OF SPINE SURG- THYROID NODULE-RIGHT THYROID NODULE COLD INDUCED ASTHMA ALOPECIA DERMATOGRAPHIA ACUTE PANCREATITIS H/O CCY H/O SCOLIOSIS- MULTIPLE SURGERIES IN PAST Social History: ___ Family History: Mother has HTN Father has HLD, melanoma Grandfather w/ early cad Physical Exam: VS: T 99.8 BP 130/83 HR 86 RR 18 O2 99% RA Gen: NAD, c/o pain HEENT: OP clear, moist mm, sclera anicteric Neck: Supple, no LAD CV: RR, no murmurs/rubs/gallops Pulm: CTAB, no wheezes/rhonchi/rales Abd: Three well-healed, old surgical scars noted across the abdomen. Soft, TTP at epigastric area, mild intentional guarding, no rebound tenderness, neg psoas and rovsing's sign GU: No CVAT Ext: WWP, no edema Pertinent Results: ___ 08:34PM GLUCOSE-97 UREA N-9 CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12 ___ 08:34PM ALT(SGPT)-19 AST(SGOT)-23 ALK PHOS-58 TOT BILI-0.5 ___ 08:34PM LIPASE-75* ___ 08:34PM WBC-8.1 RBC-4.57 HGB-15.7 HCT-45.1 MCV-99* MCH-34.3* MCHC-34.7 RDW-12.4 ___ 08:34PM NEUTS-68.9 ___ MONOS-4.6 EOS-0.7 BASOS-0.4 ___ 08:34PM PLT COUNT-347 OSH records -- EUS report from ___ at ___: dilated CBD 11.5mm, no sludge or stones, normal ampulla, mild pancr parencymal abn (hypoechoic strands) and dil pancr side ducts ___ EGD -- Normal mucosa in the esophagus There was mild erythema in the antrum. Cold forceps biopsies were performed for histology. Normal mucosa was noted. Random cold forceps biopsies were performed for histology. Otherwise normal EGD to third part of the duodenum. ___ MRCP -- Preliminary Report IMPRESSION: 1. Prior cholecystectomy. There is evidence of common bile duct dilatation without obstruction or mass lesion. The possibility of sphincter of Oddi dysfunction cannot be excluded. 2. There is a left upper pole renal cyst measuring 1.4 cm. It could not be assessed adequately due to the susceptibility artifact from the metallic hardware within the patient's spine. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 2. aluminum chloride *NF* 20 % Topical qhs 3. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection as directed 4. Minocycline 100 mg PO Q12H 5. traZODONE 25 mg PO HS:PRN sleep 6. Ibuprofen 400 mg PO Frequency is Unknown 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 2. traZODONE 25 mg PO HS:PRN sleep 3. aluminum chloride *NF* 20 % Topical qhs 4. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection as directed 5. Minocycline 100 mg PO Q12H 6. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Abdominal pain of unclear cause Antral (stomach) erythema -- biopsies pending Insomnia Mild intermittent asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ woman with epigastric abdominal pain, nausea, history of prior abdominal/back surgeries, rule out obstruction. COMPARISON: None available. TECHNIQUE: AP upright and supine radiographs of the abdomen and pelvis show gas within the stomach to the splenic flexure than the sigmoid colon. There is also fecal loading of the right colon. The abdominal gas pattern is normal with no signs of obstruction. No pneumatosis or free air. Extensive hardware is seen within the lumbar spine. IMPRESSION: Normal bowel gas pattern with no evidence of obstruction. Radiology Report INDICATION: ___ woman with recurrent epigastric pain of unclear etiology, history of CBD dilatation in the past, labs not consistent with biliary obstruction or pancreatitis. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet including dynamic 3D imaging, obtained prior to, during, and after the intravenous administration of 5 mL of Gadavist. In addition, 2.5 mL of oral Gadavist was administered to the patient. COMPARISON: None. FINDINGS: The study is limited by susceptibility artifact from the metallic hardware within the patient's spine. The patient has had a previous cholecystectomy. There is dilatation of the common bile duct, maximally measuring 1.4 cm. It tapers gradually as it enters into the ampulla. There is no intrahepatic biliary ductal dilatation. There is also aberrant biliary ductal anatomy (normal variant) with insertion of the right posterior duct into the left bile duct. The pancreas is unremarkable with no enhancing lesions. The main pancreatic duct is normal in size. Within the left renal interpolar region, there is a cystic structure which measures 1.4 cm seen on the HASTE images but cannot be evaluated post contrast due to the susceptibility artifact from the hardware. The liver demonstrates normal homogenous enhancement and no focal lesions identified. The spleen, pancreas, right kidney, and adrenals are unremarkable. The right adrenal is difficult to assess due to susceptibility artifact. The visualized large and small bowel are unremarkable. There is no suspicious lymphadenopathy. There is no ascites. IMPRESSION: 1. Prior cholecystectomy. There is evidence of common bile duct dilatation without obstruction or mass lesion. The possibility of sphincter of Oddi dysfunction cannot be excluded. 2. There is a left upper pole renal cyst measuring 1.4 cm. It could not be assessed adequately due to the susceptibility artifact from the metallic hardware within the patient's spine. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: MIDEPIGASTRIC PAIN Diagnosed with ACUTE PANCREATITIS temperature: 97.0 heartrate: 93.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 85.0 level of pain: 6 level of acuity: 3.0

You were admitted with severe abdominal pain. Because of this, you had an endoscopy (EGD) performed, which showed some redness (erythema) in the bottom part of your stomach (antrum) and biopsies were taken. The Gastroenterologists that did this procedure also recommended an MRI of your abdomen (MRCP) which showed a dilated common bile duct and some aberrant bile ducts. These findings are non-specific. The Gastroenterologists will review this study more closely and contact you with a follow-up plan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: bee venom (honey bee) Attending: ___. Chief Complaint: Left intertrochanteric hip fracture Major Surgical or Invasive Procedure: ORIF left intertrochanteric hip fracture History of Present Illness: ___ female past medical history of psoriatic arthritis, presents as a transfer from ___, with a left intertrochanteric femur fracture after a fall while getting up from the toilet. On exam the patient is closed neurovascularly intact with left lower extremity which is externally rotated and shortened. X-rays demonstrate a comminuted left inner troches femur fracture. Past Medical History: GEN: NAD, A&O CV: no cardiac distress PULM: breathing comfortably on room air EXT: LLE Dressing c/d/i Sensation intact s/s/spn/dpn/t Fires ___, wwp Family History: Noncontributory Physical Exam: GEN: NAD, A&O CV: no cardiac distress PULM: breathing comfortably on room air EXT: LLE Dressing on and intact and clean Sensation intact s/s/spn/dpn/t Fires ___, +DP pulse, wwp Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 500 mg PO DAILY 2. Cyanocobalamin 250 mcg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Citalopram 40 mg PO DAILY 5. Magnesium Oxide 140 mg PO DAILY 6. Tretinoin 0.025% Cream 1 Appl TP QHS 7. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 8. Losartan Potassium 50 mg PO DAILY 9. amLODIPine 5 mg PO DAILY 10. Gabapentin 300 mg PO TID 11. Simvastatin 20 mg PO QPM 12. Alendronate Sodium 70 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin (Prophylaxis) 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC dailyl Disp #*28 Syringe Refills:*0 5. Oxybutynin 5 mg PO TID 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: pacu v floor RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 8. Senna 8.6 mg PO BID:PRN Constipation - First Line 9. amLODIPine 5 mg PO DAILY 10. Calcium Carbonate 500 mg PO DAILY 11. Citalopram 40 mg PO DAILY 12. Cyanocobalamin 250 mcg PO DAILY 13. Gabapentin 300 mg PO TID 14. Losartan Potassium 50 mg PO DAILY 15. Magnesium Oxide 140 mg PO DAILY 16. Simvastatin 20 mg PO QPM 17. Tretinoin 0.025% Cream 1 Appl TP QHS 18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 19. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left intertrochanteric hip fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: FEMUR (AP AND LAT) LEFT INDICATION: ___ woman with left hip fracture. TECHNIQUE: 18 fluoroscopic views performed without a radiologist present. COMPARISON: Left hip radiograph ___. FINDINGS: 18 intraoperative images were acquired without a radiologist present. Images show steps related to placement of an intramedullary rod with gamma nail fixation about an intertrochanteric left hip fracture. Total fluoroscopic time 235.6 seconds. IMPRESSION: Intraoperative images were obtained during open reduction internal fixation of a intertrochanteric left hip fracture. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman reintubated post-op, CXR for verification of tube placement // re-intubated, eval for ETT placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There are low bilateral lung volumes with new bibasilar atelectasis. No pleural effusion or pneumothorax. The tip of the endotracheal tube projects 2.6 cm from the carina. The size of the cardiac silhouette is enlarged but not significantly changed. There are degenerative changes of both shoulders. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Hip fracture, s/p Fall Diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall on same level, unspecified, initial encounter temperature: 99.4 heartrate: 78.0 resprate: 17.0 o2sat: 94.0 sbp: 132.0 dbp: 67.0 level of pain: 4 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: -Weightbearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per ___ regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. 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. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. 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 Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: Weightbearing as tolerated left lower extremity Treatments Frequency: Surgical dressing to remain in place. It may be changed as needed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: Bilateral Lower Extremity Swelling, Hypertensive Urgency Major Surgical or Invasive Procedure: n/a History of Present Illness: Mr. ___ is a ___ year old male, with past history ESRD ___ DM Type I, s/p kidney/pancreas (bladder drained at ___, ___ transplant in ___, with recent bladder to enteric drain scheduled and undergone ___, CAD, OSA with severe pulmonary HTN, paroxysmal atrial fibrillation on amiodarone (not currently on anticoagulation), who is presenting with concern for new acute heart failure with lower extremity edema. Patient was recently hospitalized in ___, with scheduled conversion from pancreas transplant with bladder drain to enteric drainage. Patient post-operatively felt like he "blew up", and hospital course was complicated with new ascites and concern for pancreatic leak from his surgery, and underwent ex-lap with revision with improvement. His hospital course was also complicated with atrial fibrillation for which he was briefly on amiodarone for, no anticoagulation, pulmonary edema and worsened hypertension. He was hospitalized for about 1 week, and started to have improvement and then was discharged on nifedipine for hypertension. At home, patient then felt orthostatic, with SBPs in the 100s, for which he was started on florinef intermittently and discontinued on any diuretic and anti-hypertensive. During that course, patient underwent cardiac workup given new pulmonary edema with TTE showing normal LV systolic function, with mild concentric LVH, ___ dilated, RA moderately dilated, and mild MR. ___ 1.5 weeks ago, found to have new lower extremity swelling. Patient lost about 20 lbs after his surgery about 195 lbs from 215 lbs, and currently weigh about 210 lbs at home. Further, over the past two weeks patient has noted increased sinus congestion. He has finished two different courses of antibiotics, and was taking Flonase, and afrin x 3 days, and no relief, and feels that there is a blockage on the left nostril. He originally thought this was ___ to some irritation from an NG tube that was placed during that hospitalization, and has an ENT follow up appointment this week. Notably, patient has a known diagnosis of severe pulmonary HTN from likely obstructive sleep apnea, but does not use CPAP at home. He also underwent a cardiac catheterization earlier in ___ which showed mild distal RCA disease 40-50%, culprit vessel circumflex (mid disease 50-60%) and ___ OM. ___ and distal LAD showed ___ stenosis and distal 50% stenosis, Cx revealed moderate calcification and moderate disease, LAD moderate calcification and mild luminal disease. After this surgery, he was found to have systolics in the 160s-170s. In the ED, initial vitals were 0 98.3 74 193/84 18 96% RA Labs were notable for WBC 7.7, Hgb 10.9, Hct 34.4, Platetet 406. MCV 99. BNP 9780. TSH: Pending. Sodium 136, Potassium 5.2, Chloride 101, Bicarb 23, BUN 12, Creatinine 0.9. Glucose 110. ___ 11.2, PTT 27.3, INR 1. Imaging: CXR: Pulmonary Edema. Patient was given: ___ 16:05 IV Furosemide 20 mg ___ 16:05 PO/NG Labetalol 200 mg ___ 16:05 PO/NG Magnesium Oxide 800 mg Decision was made to admit for new volume overload. Transfer vitals were: 0 61 174/60 19 94% RA Upon arrival to the floor, patient reports feeling ok. He feels that his left nostril is blocked, and his lower extremity edema is starting to improve. 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: type 1 diabetes hypertension hyperlipidemia a history of gangrene in the right toe s/p surgical intervention BPH sleep apnea Social History: ___ Family History: His mother is alive and well in her ___. He has four children, all relatively healthy, although his older daughter has a clotting disorder. Physical Exam: Admission physical exam: ========================= VS: See OMR. Weight: admit wt: 210 lbs I/O: Not recorded. General: Pleasant, well appearing, no acute distress. HEENT: Normocephalic, atraumatic. No scleral icterus. PERRL. EOMI. There is mild JVD. There is erythema of bilateral turbinates without frank mucous. Neck: supple, no cervical lymphadenopathy appreciated. CV: RRR, S1, S2. Mild systolic murmur heard at left sternal border Lungs: Mild crackles at the bases, no wheezing. Abdomen: Soft, mildly distended. Scar across well healed. Lower Extremities: 3+ ___ edema. Soft, no asymmetry. pulses intact, warm. NEUROLOGIC: ___, CN II-XII grossly normal, normal sensation, with strength ___ throughout. Discharge physical exam: ======================== VS: 97.4 PO 178 / 72 5318 98 RA Weight: admit wt: 210 lbs ->207lb General: Pleasant, well appearing, no acute distress. HEENT: No scleral icterus. EOMI. JVD <10cm. There is erythema of bilateral turbinates without frank mucous. Neck: supple, no cervical lymphadenopathy appreciated. CV: RRR, S1, S2. Mild systolic murmur heard at left sternal border Lungs: decreased at right base, otherwise CTAB Abdomen: Soft, mildly distended. Scar across well healed Lower Extremities: no cyanosis, clubbing, edema NEUROLOGIC: ___. Pertinent Results: Admission labs: =============== ___ 01:45PM BLOOD WBC-7.7 RBC-3.47* Hgb-10.9* Hct-34.4* MCV-99* MCH-31.4 MCHC-31.7* RDW-15.4 RDWSD-55.8* Plt ___ ___ 01:45PM BLOOD Glucose-110* UreaN-12 Creat-0.9 Na-136 K-5.2* Cl-101 HCO3-23 AnGap-17 ___ 01:45PM BLOOD ALT-12 AST-36 AlkPhos-94 Amylase-40 TotBili-0.4 ___ 01:45PM BLOOD CK-MB-2 proBNP-9780* ___ 01:45PM BLOOD Albumin-3.4* Calcium-9.2 Phos-2.7 Mg-1.7 Pertinent labs: =============== ___ 05:05AM BLOOD Amylase-32 ___ 05:01AM BLOOD Amylase-34 ___ 01:45PM BLOOD Lipase-48 ___ 05:05AM BLOOD Lipase-40 ___ 05:01AM BLOOD Lipase-44 ___ 01:45PM BLOOD CK-MB-2 proBNP-9780* ___ 01:45PM BLOOD cTropnT-<0.01 ___ 09:20PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 01:45PM BLOOD TSH-1.6 ___ 05:01AM BLOOD tacroFK-5.0 ___ 05:05AM BLOOD tacroFK-6.3 Discharge labs: =============== ___ 05:01AM BLOOD WBC-5.4 RBC-2.94* Hgb-9.2* Hct-29.6* MCV-101* MCH-31.3 MCHC-31.1* RDW-15.5 RDWSD-57.1* Plt ___ ___ 05:01AM BLOOD Plt ___ ___ 05:01AM BLOOD Glucose-106* UreaN-15 Creat-1.1 Na-140 K-4.3 Cl-103 HCO3-27 AnGap-14 ___ 05:01AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9 Diagnostics: ============ ___ CXR PA and lateral views of the chest provided. Interstitial pulmonary edema is noted with hilar congestion. Background COPD is again noted. No large effusion is seen. Difficult to exclude a subtle pneumonia. Cardiomediastinal silhouette is unchanged. Bony structures are intact. IMPRESSION: COPD with superimposed pulmonary edema. ___ Renal ultrasound The left transplant kidney measures 10.7 cm. The transplant renal morphology is unremarkable. Specifically, the cortex is of normal thickness and echogenicity, pyramids are unremarkable, there is no urothelial thickening, and renal sinus fat is unremarkable. There is no hydronephrosis and no perinephric fluid collection. Trace fluid is seen around the transplant, as on prior. The resistive index of intrarenal arteries are again noted to be elevated measuring in the ___. The main renal artery shows antegrade flow, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 135 cm/sec. Please note that there is diminished diastolic flow in the main renal artery as well. Vascularity is visualized throughout transplant. The transplant renal vein is patent and shows antegrade flow. IMPRESSION: Continually elevated resistive indices. No hydronephrosis or significant perinephric fluid collection is identified. ___ CT Sinus/mandible/maxilla 1. No change in paranasal sinus disease compared to ___, as detailed above. Demineralized cribriform plates and uncinate processes indicate chronic inflammation. No evidence for fluid levels. 2. Unchanged polypoid soft tissue density in the left naris. A polyp is not excluded. ___ EHCO The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the entire inferior wall and basal to mid inferolateral wall. The remaining segments contract normally (LVEF = 45-50 %). The estimated cardiac index is normal (>=2.5L/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 aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with dilated cavity and regional left ventricular systolic dysfunction c/w CAD. Elevated PCWP. Normal right ventricular cavity size and systolic function. Minimal aortic stenosis. Mild mitral regurgitation. At least moderate pulmonary artery systolic hypertension. Micro: ====== None Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Azathioprine 100 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. PredniSONE 5 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Vitamin B Complex 1 CAP PO DAILY 7. Senna 8.6 mg PO BID:PRN constipation 8. Ondansetron 4 mg PO Q8H:PRN n/v 9. Tacrolimus 3 mg PO Q12H Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H Duration: 3 Weeks RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*40 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Carvedilol 3.125 mg PO ONCE:PRN as instructed by your doctor Duration: 7 Days RX *carvedilol 3.125 mg 1 tablet(s) by mouth as instructed by your doctor only for high blood pressures Disp #*7 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily as needed Disp #*60 Capsule Refills:*0 6. Fluticasone Propionate NASAL 2 SPRY NU BID RX *fluticasone 50 mcg/actuation 2 spry in twice a day Disp #*60 Spray Refills:*0 7. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Oxymetazoline 2 SPRY NU TID Duration: 3 Days RX *oxymetazoline 0.05 % 2 spry in three times a day Disp #*6 Spray Refills:*0 9. Sodium Chloride Nasal ___ SPRY NU TID RX *sodium chloride [Saline Nose] 0.65 % ___ spry in daily Disp #*60 Spray Refills:*0 10. Azathioprine 100 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 40 mg PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN n/v 14. PredniSONE 5 mg PO DAILY 15. Senna 8.6 mg PO BID:PRN constipation 16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 17. Tacrolimus 3 mg PO Q12H 18. Vitamin B Complex 1 CAP PO DAILY 19.Outpatient Lab Work ICD-10: ___.8 Please draw by ___ Please draw chem-10 panel Fax results to ___, MD, ___ Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute CHF exacerbation with preserved EF (45-50%) Hypertension Chronic sinusitis Secondary diagnosis: S/p kidney/pancreas transplant 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 dyspnea// eval for edema, effusion, infiltrate COMPARISON: ___ FINDINGS: PA and lateral views of the chest provided. Interstitial pulmonary edema is noted with hilar congestion. Background COPD is again noted. No large effusion is seen. Difficult to exclude a subtle pneumonia. Cardiomediastinal silhouette is unchanged. Bony structures are intact. IMPRESSION: COPD with superimposed pulmonary edema. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. LEFT INDICATION: ___ year old man with renal transplant, worsening HTN and volume overload// please eval with dopplers TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Transplant renal ultrasound ___ FINDINGS: The left transplant kidney measures 10.7 cm. The transplant renal morphology is unremarkable. Specifically, the cortex is of normal thickness and echogenicity, pyramids are unremarkable, there is no urothelial thickening, and renal sinus fat is unremarkable. There is no hydronephrosis and no perinephric fluid collection. Trace fluid is seen around the transplant, as on prior. The resistive index of intrarenal arteries are again noted to be elevated measuring in the ___. The main renal artery shows antegrade flow, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 135 cm/sec. Please note that there is diminished diastolic flow in the main renal artery as well. Vascularity is visualized throughout transplant. The transplant renal vein is patent and shows antegrade flow. IMPRESSION: Continually elevated resistive indices. No hydronephrosis or significant perinephric fluid collection is identified. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: ___ year old man with with chronic sinusitis. TECHNIQUE: Axial images were acquired through the paranasal sinuses. Bone and soft tissue reconstructed images were generated. Coronal and sagittal reformatted images were then produced. DOSE: Acquisition sequence: 1) Spiral Acquisition 1.8 s, 14.2 cm; CTDIvol = 26.8 mGy (Head) DLP = 381.1 mGy-cm. Total DLP (Head) = 381 mGy-cm. COMPARISON: CT sinus from ___. FINDINGS: Again seen is moderate polypoid mucosal thickening of the bilateral maxillary sinuses, left worse than right, not significantly changed from prior exam from ___. There is persistent complete opacification of the left ostiomeatal unit and persistent narrowing of the right ostiomeatal infundibulum by mucosal thickening. Bilateral uncinate processes appear demineralized. Again seen is near complete opacification of the left anterior ethmoid air cells, extending into the frontoethmoidal recess. There is moderate right anterior ethmoid air cell mucosal thickening extending into the frontoethmoidal recess. Remaining frontal sinuses are well-aerated. These findings are unchanged. There is unchanged mild mucosal thickening in the left sphenoid sinus and left greater than right posterior ethmoid air cells. The lamina papyracea appear intact bilaterally. Bilateral cribriform plates are demineralized. The nasal septum is mildly deviated to the left inferiorly, as seen previously. There is unchanged soft tissue density in the left naris, and a polyp cannot be excluded. The maxillary alveolar ridge is not fully imaged, limiting assessment for periapical lucencies, though none were seen on the recent ___ CT. Middle ear cavities and partially visualized mastoid air cells are well aerated. The orbits are unremarkable. This exam is not technically optimized for evaluation of the partially included brain parenchyma. No concerning abnormalities are seen on limited assessment. Periventricular white matter hypodensities are again seen, nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. IMPRESSION: 1. No change in paranasal sinus disease compared to ___, as detailed above. Demineralized cribriform plates and uncinate processes indicate chronic inflammation. No evidence for fluid levels. 2. Unchanged polypoid soft tissue density in the left naris. A polyp is not excluded. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Leg swelling Diagnosed with Heart failure, unspecified temperature: 98.3 heartrate: 74.0 resprate: 18.0 o2sat: 96.0 sbp: 193.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, ___ were admitted to the hospital because of shortness of breath and increased swelling in your legs. This was thought to be due to a heart failure exacerbation. Your cardiac ultrasound showed mildly depressed cardiac function with structural changes due to underlying coronary artery disease. However, ___ did not have an acute coronary event or heart attack. ___ were given IV medications to remove extra fluid and improved after a couple of days. Your blood pressure was high. ___ were started on a new medication: amlodipine. Tomorrow morning, afternoon and night, please check your blood pressure. If your blood pressure is above 170, please call your transplant doctor immediately for further instructions. We will write ___ for a few tabs of carvedilol for ___ to take only if your doctor instructs ___ to. ___ have symptoms like lightheadedness, chest pain, trouble breathing, or experience new swelling in your legs, please call your doctor as well. ___ were evaluated by our ear, nose and throat doctors. ___ will need to take Augmentin for a total of 3 weeks. Please continue using the nasal sprays and Netipot. Your kidney function remained stable, as showed by a renal ultrasound. Please follow up with your doctors below as listed. 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; hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: ___ F PMHx COPD metastatic lung adenoca (new dx during recent hospitalization, d/cd ___, plan to start carboplatin/pemetrexed tomorrow, on home 3L NC) p/w worsening dyspnea. Pt reports that her breathing has been worse over the past week and she has developed a productive cough, no hemoptysis, for the past 3 days. She has had productive cough off and on for the past several weeks History of COPD. States she has not noticed wheezing or fever at home. NO fevers/sore throat. no sick contacts. No lower extremity swelling or weight gain. No chest pain or palpitations. Of note she was discharged ___ after admission for acute hypoxic respiratory failure due to metastatic lung adenocarcinoma (new finding) and ___ also COPD exacerbation and CAP. She has known COPD. PE was ruled out. TTE normal. AFB stains done and negative x4 (TB exposure when younger w h/o positive PPDs)> Flex bronch IP for dx ___, cytology showing adenocarcinoma. Staging imaging showed adenopathy of abdomen c/f mets and bony mets confirmed by bone scan. MRI brain negative for mets. She was treated with 5 days of levoflox for possible CAP and 5 days of prednisone for COPD exacerbation. She is followed by atrius oncology and had plans for outpatient follow up. She was discharged on 3L NC supplemental O2. Also given IM b12 before discharged and started on folic acid anticipating chemo. Hosp course c/b hyponatremia/SIADH which resolved with 2L fluid restriction. She also had pan-S pseudomonas on urine culture but got 5d levoflox as above and given no dysuria or symptoms this specimen was felt to be contaminated. She also had hypomagnesemia requiring supplementation. Past Medical History: Hypertension Hyperlipidemia Asthma COPD--recently on 3L oxygen at baseline. Primary open-angle glaucoma Diabetes Angina - stress echo without signs of ischemia s/p hysterectomy ___ s/p C-section ___ s/p appendectomy ___ s/p tonsillectomy ___ Social History: ___ Family History: Mother- stomach cancer, died at age ___ Maternal aunt with breast cancer at age ___. Grandfather and cousin with lung cancer. Physical Exam: Admission Physical: VITAL SIGNS: T 98.9 154/62 109 95%6L NC General: mildly tachypneic but speaks in full sentences and appears reasonably comfortable, amicable and making jokes HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: scattered wheezes, coarse breath sounds throughout GI: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Oriented x3. Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar, and Achilles tendons, toes are down bilaterally; gait is normal, coordination is intact. Discharge Physical: VS: T98.4 BP 112/60 HR 100 RR 18 96% on 4L GEN: lying in bed in NAD. HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTA with good air entry, faint exp wheeze (prior to Advair) Abd: BS+, soft, NT, no rebound/guarding, no HSM. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: AOx3, CNs II-XII grossly intact. Pertinent Results: ADMISSION/IMPORTANT LABS: ___ 03:15PM BLOOD WBC-15.9* RBC-3.56* Hgb-8.8* Hct-28.2* MCV-79* MCH-24.7* MCHC-31.2* RDW-15.6* RDWSD-45.0 Plt ___ ___ 03:15PM BLOOD Neuts-88.2* Lymphs-3.7* Monos-6.5 Eos-0.8* Baso-0.2 Im ___ AbsNeut-13.99* AbsLymp-0.59* AbsMono-1.03* AbsEos-0.12 AbsBaso-0.03 ___ 03:15PM BLOOD Glucose-147* UreaN-6 Creat-0.5 Na-134 K-4.4 Cl-88* HCO3-38* AnGap-12 ___ 03:31PM BLOOD Lactate-1.5 LABS AT DISCHARGE: ----------------- ___ 07:11AM BLOOD WBC-9.6 RBC-3.37* Hgb-8.5* Hct-26.8* MCV-80* MCH-25.2* MCHC-31.7* RDW-15.7* RDWSD-45.2 Plt ___ ___ 07:11AM BLOOD Glucose-125* UreaN-7 Creat-0.4 Na-131* K-4.1 Cl-92* HCO3-31 AnGap-12 IMAGING/OTHER STUDIES: CTA Chest ___ 1. No evidence of pulmonary embolism or acute aortic pathology. 2. Significant interval worsening of widespread metastatic disease including innumerable parenchymal nodules and lymphangitic carcinomatosis. 3. Widespread mediastinal, hilar, retrocrural, and paraesophageal lymphadenopathy. Enlargement of gastrohepatic lymph node. 4. Osseous metastatic disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Docusate Sodium 200 mg PO BID 3. Ferrous Sulfate 325 mg PO DAILY 4. Hydrochlorothiazide 50 mg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Montelukast 10 mg PO DAILY 7. Simvastatin 10 mg PO QPM 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 10. Acetaminophen 650 mg PO Q8H:PRN pain, fever 11. Bisacodyl 10 mg PO DAILY:PRN Constipation 12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 13. Senna 17.2 mg PO BID 14. Albuterol Inhaler ___ PUFF IH Q4H:PRN shorntess of breath 15. Aspirin 81 mg PO DAILY 16. Calcium Carbonate 650 mg PO DAILY 17. GlipiZIDE 5 mg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Ipratropium Bromide MDI 2 PUFF IH QID 20. Magnesium Oxide 280 mg PO DAILY 21. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain, fever 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN Constipation 5. Docusate Sodium 200 mg PO BID 6. Ferrous Sulfate 325 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 8. FoLIC Acid 1 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Lisinopril 10 mg PO DAILY 11. Montelukast 10 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain or respiratory distress RX *oxycodone 5 mg one to two tablet(s) by mouth every four hours Disp #*60 Tablet Refills:*0 14. Fentanyl Patch 12 mcg/h TD Q72H apply patch every three days. RX *fentanyl [Duragesic] 12 mcg/hour apply one patch every three days Disp #*10 Patch Refills:*0 15. Albuterol Inhaler ___ PUFF IH Q4H:PRN shorntess of breath 16. Calcium Carbonate 650 mg PO DAILY 17. Hydrochlorothiazide 50 mg PO DAILY 18. Ipratropium Bromide MDI 2 PUFF IH QID 19. Magnesium Oxide 280 mg PO DAILY 20. Simvastatin 10 mg PO QPM 21. Senna 17.2 mg PO BID 22. Prochlorperazine 10 mg PO Q6H:PRN nausea RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by mouth every six hours Disp #*14 Tablet Refills:*0 23. Lorazepam 0.5 mg PO Q6H:PRN pain RX *lorazepam [Ativan] 0.5 mg 1 by mouth every six hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: primary: non small cell lung cancer; COPD exacerbation. secondary: type 2 diabetes; hypertension 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: History: ___ with DOE // R/O acute process TECHNIQUE: Chest PA and lateral COMPARISON: Comparison is made with chest radiographs from ___ and CT chest from ___. FINDINGS: Interval increase in interstitial markings left lung, which may reflect progression of widespread disseminated metastasis or possibly concurrent infection in left lung. The previously seen pneumonia in the right lung has improved in the interval but has not completely resolved. There is a small right pleural effusion. No left pleural effusion. There is no pneumothorax. Cardiomediastinal silhouette is unremarkable. IMPRESSION: 1. Interval increase in interstitial markings in the left lung, suggestive of progressing widespread disseminated metastases or possibly concurrent infection. 2. Previously seen pneumonia in the right lung has improved in the interval, but still substantial. 3. Small right pleural effusion. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with new lung adenoca w/DOE and worsening O2 requirement // 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: Total DLP (Body) = 219 mGy-cm. COMPARISON: None 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: Extensive mediastinal and bilateral hilar lymphadenopathy is again noted, including prevascular lymph node conglomerate measuring 2.3 x 1.2 cm and sub carinal lymphadenopathy measuring 2.7 x 1.5 cm. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Since the prior examination, there has been significant interval worsening of widespread metastases in both the form of discrete nodules and bronchovascular lymphangitic spread. There is diffuse peribronchial wall thickening. Bilaterally, slightly worse on the right. Nodular interlobular septal thickening is noted diffusely. The largest parenchymal consolidation is in the posterior right lower lobe (2:83), significantly increased since the prior study. BASE OF NECK: There is a 1.3 cm hypodense nodule left thyroid lobe, unchanged (2:6). ABDOMEN: Extensive retrocrural and paraesophageal lymphadenopathy is again noted. There has been interval enlargement, specifically of a gastrohepatic lymph node currently measuring 2.2 x 2.4 cm (2:108), previously 1.6 x 1.5 cm. There are several small, subcentimeter incompletely characterized hyper enhancing foci in the liver. BONES: Mixed sclerotic and lytic foci in the T5 and T9 vertebral bodies are compatible with previously described widespread osseous metastatic disease. Other predominantly sclerotic foci are also noted in the T10 and T12 vertebral bodies and right scapular tip (02:49). IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic pathology. 2. Significant interval worsening of widespread metastatic disease including innumerable parenchymal nodules and lymphangitic carcinomatosis. 3. Widespread mediastinal, hilar, retrocrural, and paraesophageal lymphadenopathy. Enlargement of gastrohepatic lymph node. 4. Osseous metastatic disease. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea on exertion Diagnosed with Dyspnea, unspecified, Hypoxemia temperature: 97.6 heartrate: 116.0 resprate: 18.0 o2sat: 93.0 sbp: 133.0 dbp: 55.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at the ___ ___. You were admitted to the hospital because your breathing worsened and you were noted to require more supplemental oxygen. These symptoms are related to your underlying lung cancer and COPD. You had a CAT scan of the lungs, which did not show a clot or an infection. You received your first round of chemotherapy on ___ and part of this treatment included high dose steroids which also treated your COPD. In addition, you received routine nebulizer treatments and an antibiotic azithromycin. Because of the steroids and your underlying diabetes, you required insulin shots to control your blood sugar. In the last few days of your hospital stay, you did not require any insulin. You should hold off on resuming your glyburide until you see Dr. ___ in a week. However, you should check you blood sugars every morning and evening, keep a record of them and take with you to your appointment with Dr. ___. Please call his office earlier if you have blood sugars >200. You will discharged on medications for pain and medicines to take as needed for nausea. Please follow up with all scheduled appointments (see below) and continue taking all medications as prescribed. If you develop any of the danger signs listed below, it is important that you talk with your healthcare providers or go the emergency room immediately. 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: s/p fall Major Surgical or Invasive Procedure: 1. Left hip ORIF History of Present Illness: ___ w/ PMHx metastatic pancreatic cancer (lung, liver mets) on chemotherapy presenting s/p fall this morning when his feet felt weak. He has baseline bilateral neuropathy in the lower extremities which he feels contributed to the fall. No lightheadedness, chest pain, shortness of breath, abd pain, diarrhea, vomiting, or presyncopal component to the fall. Fell directly onto his left side without HS or LOC. Since then he has been having pain directly over his left hip. Denies numbness, weakness, or tingling. For the past ___ days the patient has been having intermittent spiking fevers, worsening fatigue, malaise, and decreased PO intake, and is undergoing infectious workup with outpatient providers, without ___ source yet found. Of note, bilirubin was noted to be rising suggestive potentially of the palliative biliary stents as etiology. Past Medical History: Metastatic pancreatic CA Laparoscopic CCY Social History: ___ Family History: No relevant family history. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Afebrile, BP 110s-120s/60s-70s, HR ___, SPO2 96% on RA General: AOx3, answering questions appropriately. HEENT: Mild scleral icterus. Neck: Supple. CV: RRR, nl S1/S2, no m/r/g. Lungs: CTAB, no w/w/r. Abdomen: Soft, nontender, nondistended. +BS. GU: Foley in place with clear yellow urine. Ext: WWP. TTP over left hip. No ecchymoses. Neuro: CN2-12 intact. Strength and sensation grossly intact and symmetric. DISCHARGE PHYSICAL EXAM: Vital Signs: 98.2 138 / 80 84 18 98 RA General: Appears fatigued, alert and oriented though slow in responding to questions HEENT: NC/AT. Lungs: diminished bilaterally, no adventitial sounds heard. CV: Distant, RRR, S1, S2. No extra sounds. GI: nontender, guarding or peritoneal signs. Mildly distended. BS present but diminished Extremities: warm and well perfused, wearing compression stockings. No Lower extremity edema bilaterally. Hip surgical wound c/d/I. Pertinent Results: ADMISSION LABS: ___ 01:25PM BLOOD WBC-12.7*# RBC-3.62* Hgb-10.5* Hct-33.6* MCV-93 MCH-29.0 MCHC-31.3* RDW-16.8* RDWSD-56.4* Plt Ct-70* ___ 01:25PM BLOOD Neuts-77* Bands-0 Lymphs-11* Monos-7 Eos-3 Baso-1 Atyps-1* ___ Myelos-0 NRBC-1* AbsNeut-9.78* AbsLymp-1.52 AbsMono-0.89* AbsEos-0.38 AbsBaso-0.13* ___ 01:25PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ ___ 01:37PM BLOOD ___ PTT-28.0 ___ ___ 01:25PM BLOOD Glucose-143* UreaN-6 Creat-0.8 Na-135 K-3.8 Cl-99 HCO3-24 AnGap-16 ___ 04:22AM BLOOD ALT-22 AST-19 AlkPhos-177* TotBili-1.6* ___ 04:22AM BLOOD Lipase-22 ___ 04:55AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.7 ___ 01:37PM BLOOD Lactate-1.8 ___ 04:47PM URINE Color- Appear-Clear Sp ___ ___ 04:47PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG ___ 04:47PM URINE RBC-7* WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 Microbiology: Urine cultures and blood cultures with no growth. Hyponatremia workup: ___ 06:40AM BLOOD Cortsol-12.3 ___ 10:54AM URINE Hours-RANDOM Creat-91 Na-172 DISCHARGE LABS: ___ 06:23AM BLOOD WBC-15.6* RBC-2.85* Hgb-8.2* Hct-26.5* MCV-93 MCH-28.8 MCHC-30.9* RDW-16.5* RDWSD-55.3* Plt ___ ___ 06:23AM BLOOD ___ PTT-75.5* ___ ___ 06:23AM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-133 K-3.8 Cl-96 HCO3-26 AnGap-15 ___ 06:23AM BLOOD ALT-24 AST-29 LD(LDH)-328* AlkPhos-217* TotBili-0.9 ___ 06:23AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.8 Mg-2.0 Imaging: ___ femur xray: FINDINGS: Re- demonstrated is a nondisplaced left mid cervical femoral neck fracture. No dislocation is identified. Remainder of the left femur demonstrates no additional fractures, and no focal lytic or sclerotic osseous abnormality is identified. Moderate degenerative changes of the left femoral acetabular joint with joint space narrowing, subchondral sclerosis and osteophyte formation is noted. Well-circumscribed ovoid calcification lateral to the left greater trochanter likely reflects heterotopic ossification. Imaged aspect of the left knee demonstrates severe tricompartmental degenerative changes with marked joint space narrowing, subchondral sclerosis, and large osteophytes. Small joint effusion is noted. Spiral tacks are seen in the left pelvis compatible with prior herniorrhaphy. Minimal vascular calcifications are seen. IMPRESSION: Nondisplaced left mid cervical femoral neck fracture. No dislocation. ___ CT torso: IMPRESSION: 1. Mildly displaced and angulated acute left subcapital femoral neck fracture. 2. Interval progression of known metastatic pancreatic cancer with growth in the pancreatic head mass and loss of fat plane between the mass and the adjacent proximal duodenum, persistent contact with multiple peripancreatic vessels as above, growth in peripancreatic lymphadenopathy, increased size and number of hepatic metastases, and a new left lower lobe pulmonary nodule, likely a metastasis. 3. No specific CT evidence for intra-abdominal infection or abscess. 4. Unchanged position of the common bile duct stent with pneumobilia confirming stent patency, although there is a small amount of debris within the common bile duct stent. 5. No pneumonia. ___ CT c-spine: IMPRESSION: 1. Overall similar alignment to the prior CT with multiple levels of mild anterolisthesis and retrolisthesis as above. 2. No evidence of acute cervical spine fracture. 3. Severe multilevel degenerative changes as above with multiple levels of severe narrowing of the central canal and and bilateral severe neural foraminal narrowing, most pronounced at C5-6 and C6-7. These degenerative changes predisposes the patient to cord injury in the setting of minimal trauma. Consider MRI for further assessment of cord injury if there are neurological symptoms referable to a specific level. EKG ___ Sinus tachycardia. Low precordial lead voltage. Diffuse non-specific repolarization abnormalities. Compared to the previous tracing of ___ the heart rate is increased. CT Sinus ___ 1. No evidence of mandible fracture. 2. Mild asymmetric widening of the left temporal mandibular joint space relative to the right could suggest subluxation without evidence of frank dislocation. 3. Missing right mandibular first molar. 4. Paranasal sinus disease as above with probable active sinusitis. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate 2. LORazepam 1 mg PO Q4-6H PRN nausea, insomnia, anxiety 3. Omeprazole 40 mg PO DAILY 4. PredniSONE 20 mg PO DAILY 5. Prochlorperazine 10 mg PO BID:PRN nausea 6. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H 7. Fexofenadine 60 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*0 2. Phosphorus 500 mg PO DAILY RX *sod phos di, mono-K phos mono [Phospha 250 Neutral] 250 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 4. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [Senexon] 8.6 mg 1 tablet by mouth daily Disp #*30 Tablet Refills:*0 5. PredniSONE 60 mg PO DAILY Duration: 5 Days RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*6 Tablet Refills:*0 6. Fexofenadine 60 mg PO BID 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate 8. LORazepam 1 mg PO Q4-6H PRN nausea, insomnia, anxiety 9. Omeprazole 40 mg PO DAILY 10. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H 11. Prochlorperazine 10 mg PO BID:PRN nausea 12.Rolling Walker Diagnosis: Malignant neoplasm of pancreas, unspecified Prognosis: Good Length of need: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Left femoral neck fracture 2. Hypophosphatemia SECONDARY DIAGNOSIS: 1. Metastatic Pancreatic Cancer 2. Hyponatremia 3. Dehydration 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 SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS INDICATION: ___ man with metastatic pancreatic cancer presented to outside hospital after fall to face, broken left hip, febrile, concern for infection preceding trauma. Evaluate for jaw dislocation/fracture. TECHNIQUE: Helically-acquired multidetector CT axial images were obtained through the maxillofacial bones and mandible. Intravenous contrast was not administered. Axial images reconstructed with soft tissue and bone algorithm to display images with 1.25 mm slice. Coronal and sagittal reformations were also constructed. All produced images were evaluated in production of this report. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.0 s, 23.3 cm; CTDIvol = 25.9 mGy (Head) DLP = 603.3 mGy-cm. Total DLP (Head) = 603 mGy-cm. COMPARISON: Head CT from an outside facility dated ___, earlier on the same day at 10:10 and uploaded onto PACs. CTA head and neck dated ___. FINDINGS: SOFT TISSUES: There is no stranding, fluid collection, hematoma, or other soft tissue abnormality. 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. Asymmetric mild widening of the left relative to the right temporal mandibular joint space may suggest subluxation, but there is no evidence of frank dislocation. The temporomandibular joints are without significant degenerative change. DENTITION: Dental hardware creates streak artifact limiting detailed evaluation of surrounding structures including adjacent teeth. No evidence of dental fractures.A right mandibular molar tooth is not present (series 2, image 116). SINUSES: The paranasal sinuses are intact. The left frontal sinus is underpneumatized. Some of the bilateral ethmoidal air cells are partially or completely opacified with a right posterior ethmoidal air cell containing aerosolized secretions suggesting component of active sinusitis. Polypoid mucosal thickening in the bilateral maxillary sinuses is mild. Mucosal thickening in the right sphenoid sinus is minimal. The left sphenoid sinus is essentially clear. The ostiomeatal units are patent. The mastoid air cells and middle ear cavities are clear. NOSE: There is no nasal bone fracture. Nasopharyngeal soft tissues are unremarkable. There is no nasal septal hematoma. 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. Allowing for imaging technique optimized for the face, the limited included portion of the brain is grossly unremarkable. Please refer to the dedicated cervical spine report from the same day for description of findings in the cervical spine. IMPRESSION: 1. No evidence of mandible fracture. 2. Mild asymmetric widening of the left temporal mandibular joint space relative to the right could suggest subluxation without evidence of frank dislocation. 3. Missing right mandibular first molar. 4. Paranasal sinus disease as above with probable active sinusitis. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ man with metastatic pancreatic cancer presented to outside hospital after fall to face, broken left hip, febrile, concern for infection preceding trauma. Evaluate for cervical spine 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 5.8 s, 22.6 cm; CTDIvol = 37.1 mGy (Body) DLP = 838.3 mGy-cm. Total DLP (Body) = 838 mGy-cm. COMPARISON: CTA head and neck dated ___. FINDINGS: Overall alignment of the cervical spine is similar to the prior CT. Anterolisthesis of C3 on C4 is mild, unchanged. Retrolisthesis of C6 on C7 is mild, unchanged. Anterolisthesis of C7 on T1 is also mild, unchanged. Multilevel degenerative changes of the cervical spine are severe and most pronounced at C4 through C7 with prominent anterior and posterior osteophytes, loss of intervertebral disc height, and subchondral cyst formation. Mild anterior wedging of the C4 and C5 vertebral bodies is similar in appearance to the prior exam. No evidence of an acute cervical spine fracture. No prevertebral soft tissue swelling. The bones are diffusely demineralized. No lytic or sclerotic lesion concerning for malignancy or infection. At C4-C5, a broad-based disc bulge and posterior osteophytes result in narrowing of the anterior spinal canal and probably indents are flattens the spinal cord. At C5-C6, a broad-based disc bulge and posterior osteophytes indents the anterior spinal cord resulting in severe spinal canal stenosis. At C6-C7, posterior osteophytes and a broad-based disc bulge also indent the anterior spinal cord, resulting in severe spinal canal narrowing. Multilevel moderate to severe severe bilateral neural foraminal narrowing is most pronounced at C5-6 and C6-7. Please refer to the dedicated CT torso and CT facial bones exam from the same day for description of findings in areas. IMPRESSION: 1. Overall similar alignment to the prior CT with multiple levels of mild anterolisthesis and retrolisthesis as above. 2. No evidence of acute cervical spine fracture. 3. Severe multilevel degenerative changes as above with multiple levels of severe narrowing of the central canal and and bilateral severe neural foraminal narrowing, most pronounced at C5-6 and C6-7. These degenerative changes predisposes the patient to cord injury in the setting of minimal trauma. Consider MRI for further assessment of cord injury if there are neurological symptoms referable to a specific level. RECOMMENDATION(S): Consider MRI for further assessment of cord injury if there are neurological symptoms referable to a specific level. Radiology Report EXAMINATION: CT torso INDICATION: ___ man with metastatic pancreatic cancer presented to outside hospital after fall to face, broken left hip, febrile, concern for infection preceding trauma. Evaluate for fracture, pneumonia, pancreatic mass/prior stents/intraabdominal infection. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the torso following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP = 16.9 mGy-cm. 3) Spiral Acquisition 6.9 s, 75.0 cm; CTDIvol = 12.3 mGy (Body) DLP = 920.1 mGy-cm. Total DLP (Body) = 938 mGy-cm. COMPARISON: MRI liver dated ___. CT abdomen and pelvis dated ___. CT chest dated ___. FINDINGS: CHEST: A left subclavian approach central venous catheter tip ends in the distal SVC. The thoracic aorta is normal in caliber without evidence of stenosis or dissection. The heart is not enlarged. Coronary artery calcifications are moderate. Trace pericardial fluid is new (series 601b, image 26). The main, left, and right pulmonary arteries are normal in caliber without filling defect to indicate any incidental central acute pulmonary embolus. No pathologically enlarged axillary, supraclavicular, hilar, or mediastinal lymphadenopathy. Tiny hypodensity in the right thyroid lobe is unchanged from ___ (series 2, image 2). Epicardial lymph nodes measure up to 3 mm in short axis but appear morphologically normal (series 601b, image 30; series 2, image 45). A lobulated left lower lobe nodule measuring up to 1 cm is new, concerning for metastasis (series 2, image 38). Other bilateral pulmonary nodules and micronodules are unchanged (e.g., series 2, image 30, 32, 33). Bibasilar atelectasis is mild. The airways are patent to at least the subsegmental level. No pneumothorax. No pleural effusion. No osseous lesions in the chest concerning for metastasis or infection. Multilevel degenerative changes in lower thoracic spine are moderate. Mild anterior compression deformity of the T11 vertebral body is unchanged. No acute fractures in the thoracic cage. ABDOMEN: HEPATOBILIARY: Numerous hepatic hypodensities throughout the liver have increased in both number and size substantially since ___, most consistent with progression of metastases. Pneumobilia is compatible with a common bile duct stent patency. No intrahepatic biliary ductal dilation. The main portal vein is patent. A small amount of perihepatic fluid anterior to the liver is new (series 2, image 55; series 602b, image 32); no associated gas or peripheral rim enhancement. Small amount of subhepatic ascites is also noted (series 2, image 67). The gallbladder is not visualized. The position of the common bile duct is unchanged; however, there may be some debris within the stent (series 2, image 65). PANCREAS: This exam is not tailored for pancreatic staging. A hypoenhancing known pancreatic mass centered at the head of the pancreas has grown since ___, now measuring up to 4 x 3.8 cm (series 2, image 71). Associated dilation of the main pancreatic duct up to 7 mm distally is also more pronounced from the prior exam. The pancreatic body and tail are markedly atrophic. The mass is closely approximated with the main portal vein with probably at least 180 degrees contact. The mass also contacts the proximal SMV by about 180 degrees. The mass encases the replaced right hepatic artery which arises from the SMA. Mass abuts the medial aspect of the proximal SMA with less than 180 degrees contact (series 2, image 69). The left hepatic artery arises from the left gastric artery and is not contacted by the pancreatic mass. The mass does not contact the splenic vein. Multiple peripancreatic lymph nodes are enlarged, measuring up to 8 mm in short axis, increased in size from the prior exam (e.g., series 2, image 61). The peripancreatic vasculature appears patent without critical narrowing or thrombus. SPLEEN: The spleen is top-normal in size measuring up to 13 mm. No focal splenic lesion. 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. Tiny right renal cortical hypodensities are unchanged and too small to accurately characterize on CT. No concerning focal renal lesions, hydronephrosis, or perinephric abnormality. GASTROINTESTINAL: Gastric varices are noted in the proximal stomach (series 2, image 53, 55). The fat plane between the pancreatic mass and duodenum proximally is more indistinct compared to the prior exam. Otherwise, remaining small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. No bowel obstruction. No free air or intra-abdominal fluid collection. PELVIS: Streak artifact from the right hip prosthesis limits detailed evaluation of surrounding structures. The urinary bladder is partially distended with a Foley catheter in place. Moderate amount of air within the bladder lumen is compatible with Foley placement. The distal ureters are within normal limits. Small amount of free fluid in the pelvis is minimally complex. REPRODUCTIVE ORGANS: The prostate is not enlarged. LYMPH NODES: No pelvic or inguinal lymphadenopathy. Peripancreatic enlarged lymph nodes have grown since the prior exam are as detailed above. VASCULAR: No abdominal aortic aneurysm. Minimal calcified atherosclerotic disease is noted. An accessory left hepatic artery arises from the left gastric artery. BONES: A lucency through the left femoral neck is consistent with a mildly displaced and angulated acute subcapital fracture (series 601 B, image 32). No associated soft tissue hematoma. No osseous lesions concerning for metastasis. Multilevel degenerative changes of the lumbar spine are extensive, unchanged. L4-L5 fusion is unchanged. Mild anterolisthesis of L2 on L3 is also unchanged. Severe narrowing of the neural foramina in the lower lumbar spine also similar. A right hip prosthesis is partially imaged but appears intact without evidence of complication. SOFT TISSUES: A fat-containing umbilical hernia is tiny, unchanged. No organized fluid collections or soft tissue in the abdomen or pelvis. IMPRESSION: 1. Mildly displaced and angulated acute left subcapital femoral neck fracture. 2. Interval progression of known metastatic pancreatic cancer with growth in the pancreatic head mass and loss of fat plane between the mass and the adjacent proximal duodenum, persistent contact with multiple peripancreatic vessels as above, growth in peripancreatic lymphadenopathy, increased size and number of hepatic metastases, and a new left lower lobe pulmonary nodule, likely a metastasis. 3. No specific CT evidence for intra-abdominal infection or abscess. 4. Unchanged position of the common bile duct stent with pneumobilia confirming stent patency, although there is a small amount of debris within the common bile duct stent. 5. No pneumonia. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 8:45 ___, 60 minutes after discovery of the findings. Radiology Report INDICATION: ___ male status post fall with left femoral neck fracture, please obtain full length femur films for pre-operative planning TECHNIQUE: Left femur, two views COMPARISON: Reference left hip radiographs ___ at 09:27, CT torso ___ at 16:32 FINDINGS: Re- demonstrated is a nondisplaced left mid cervical femoral neck fracture. No dislocation is identified. Remainder of the left femur demonstrates no additional fractures, and no focal lytic or sclerotic osseous abnormality is identified. Moderate degenerative changes of the left femoral acetabular joint with joint space narrowing, subchondral sclerosis and osteophyte formation is noted. Well-circumscribed ovoid calcification lateral to the left greater trochanter likely reflects heterotopic ossification. Imaged aspect of the left knee demonstrates severe tricompartmental degenerative changes with marked joint space narrowing, subchondral sclerosis, and large osteophytes. Small joint effusion is noted. Spiral tacks are seen in the left pelvis compatible with prior herniorrhaphy. Minimal vascular calcifications are seen. IMPRESSION: Nondisplaced left mid cervical femoral neck fracture. No dislocation. Radiology Report INDICATION: Left hip ORIF. TECHNIQUE: 4 intraoperative fluoroscopic images were obtained without a radiologist present. Total fluoroscopic time of 104.8 seconds. COMPARISON: Radiographs from ___. FINDINGS: 4 intraoperative fluoroscopic images demonstrate fixation of a left femoral neck fracture. Hernia repair tacks are partially visualized. Please see operative note for further details. IMPRESSION: Left hip ORIF. Please see operative note for further details. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, s/p Fall, Confusion, Transfer Diagnosed with Unsp intracapsular fracture of left femur, init for clos fx, Fall on same level, unspecified, initial encounter temperature: 98.9 heartrate: 98.0 resprate: 10.0 o2sat: 94.0 sbp: 113.0 dbp: 80.0 level of pain: unable level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. Why you were here: - You had a fall at home and were found to have a fracture of the head of the L femur (a hip fracture). What we did while you were here: - You had surgery on your L femur by the orthopedic surgery team. They fixed the left femur on ___ - We took a look at the imaging that was done of the abdomen after the fall, and saw that your pancreatic cancer has progressed. We spoke with your oncologist, Dr. ___ told him these results. We had a meeting with you and your wife, and ultimately decided it would be best for you to return home with Hospice Services, to manage your symptoms as best we can and to make sure that you have everything at home that you will need to be safe and comfortable. - We gave you the electrolytes to replace the ones that were low. These included phosphate and magnesium. - You worked with the physical therapists and they felt that you would be safe to go home without needing to go to rehab. What to do when you go home? For the care of your broken hip: -Activity: weight-bearing as tolerated on your left leg -Walk several times per day. -Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. -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. OTHER INSTRUCTIONS: -Please follow up with Dr. ___ on ___ at 2pm. -You will need to have your electrolytes checked on ___, ___ ___. You may also need some extra fluid through the IV if you get dehydrated over the weekend or if you are unable to eat much. -Please call Dr. ___ or come to the ER if 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. - Continue taking all your medicines as prescribed below. Dr. ___ decide how long you should stay on the boosted dose of Prednisone. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Percocet Attending: ___. Chief Complaint: Bleeding/ulceration from RUE AVG Major Surgical or Invasive Procedure: ___ Revision and thrombectomy of RUE AVG History of Present Illness: HPI: Ms. ___ is a ___ female with ESRD due to hypertensive nephropathy on HD via RUE AV graft (TuThSa), who presents for evaluation due to report of bleeding from a new ulceration on her AVG. In brief, she has had a complex history in regards to dialysis access, with history of multiple failed LUE AV fistulas, numerous temporary and tunneled catheters in the past, multiple central venous stenoses, and currently with a RUE AV graft created in ___ which is being used till this time for HD. She has required multiple fistulagrams in the past ___ and ___ for angioplasties, thrombectomies for clot, and multiple stent placements. She is seen in AV Care, last seen on ___ by Dr ___, at which time she appeared to be doing well with no graft-related issues. Today, she is referred to the ED due to report of bleeding from an ulceration on her graft. On evaluation, patient reports that she noticed "slow" bleeding from an ulcerated area on the graft while at rest this morning. She ran the site under some cold water, and then placed a wet towel on top of it, after which it stopped spontaneously. She reports noticing this ulcer over the past ___ days, and has also had ___ days of subjective chills and shakes, no measured fevers. She systemically has no complaints and reports feeling well, with no aches/pains, no nausea/vomiting, tolerating POs. When she presented to dialysis today, they were able to access proximal to the ulcer, and completed a full dialysis treatment without any issues. She was given vancomycin due to the appearance of the ulcer. As noted below, the patient does take coumadin. Past Medical History: ESRD secondary to HTN, renal clots, Hep C pos, Hep B core Ab pos, HTN, hyperlipidemia, gout, uterine CA, B-cell lymphoma BSO in ___, multiple AVF on L arm (non-funtioning) Miscarriage Social History: ___ Family History: Non-Contributory Physical Exam: A&O, NAD, interactive and cooperative HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Clear to auscultation b/l ABD: Soft, nondistended, nontender RUE: graft palpable with good thril, palpable +distal radial pulse, ~1cm diameter dark-colored ulcer over graft with no visible bleeding at this time, no purulence or surrounding erythema, no warmth Laboratory: pending at time of evaluation Imaging: None obtained Pertinent Results: On Admission: ___ WBC-6.0 RBC-3.29* Hgb-9.7* Hct-29.8* MCV-91 MCH-29.5 MCHC-32.6# RDW-14.2 Plt ___ PTT-38.2* ___ Glucose-102* UreaN-25* Creat-4.0* Na-139 K-4.2 Cl-95* HCO3-33* AnGap-15 Calcium-8.9 Phos-4.2 Mg-1.8 . Labs at discharge: ___ ___ PTT-28.3 ___ Glucose-96 UreaN-63* Creat-8.1*# Na-138 K-4.5 Cl-99 HCO3-25 AnGap-19 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 100 mg PO BID 2. Losartan Potassium 50 mg PO BID 3. NIFEdipine CR 60 mg PO BID 4. Warfarin 5 mg PO DAILY 5. sevelamer CARBONATE 800 mg PO TID W/MEALS 6. Sodium Bicarbonate 650 mg PO TID Discharge Medications: 1. Losartan Potassium 50 mg PO BID 2. Metoprolol Tartrate 100 mg PO BID 3. NIFEdipine CR 60 mg PO BID 4. sevelamer CARBONATE 800 mg PO TID W/MEALS 5. Sodium Bicarbonate 650 mg PO TID 6. Warfarin 5 mg PO DAILY Have INR checked per home regimen 7. Acetaminophen 650 mg PO Q6H:PRN arm pain ___ use up to 8 of the 325 mg tablets daily Discharge Disposition: Home Discharge Diagnosis: ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ w/ESRD on HD TuThSa, h/o central stenoses multiple access operations, fistulograms/stents, p/w bleeding from ulcer over AVG s/p revision RUE AVG segment beneath ulceration // Needs tunneled HD cath; revision to RUE AVG - unable to use, will need catheter for discharge home COMPARISON: Tunneled dialysis line ___ TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr. ___ resident), and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. Dr. ___ radiologist, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 45 min during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl, midazolam, lidocaine CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 2.5 min, 7 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 right/left, upper chest/groin was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent internal jugular vein on the left 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 23cm tip-to-cuff length 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. During dilation, the bent wire became caught on the dilator and vascular access was lost. The left internal jugular vein was accessed through the same skin incision using ultrasound guidance and a micropuncture needle. Using a Nitinol wire and micropuncture sheath, ___ wire was advanced again into the IVC. The venotomy site was dilated. 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. ___ subcuticular Vicryl sutures and 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 patient tolerated the procedure well. FINDINGS: Patent internal jugular vein on the left. Final fluoroscopic image showing catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: FISTULA EVAL Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS, END STAGE RENAL DISEASE temperature: 98.0 heartrate: 76.0 resprate: 18.0 o2sat: 100.0 sbp: 160.0 dbp: 50.0 level of pain: 0 level of acuity: 3.0

You were admitted to ___ and underwent a revision of your AV graft on ___, and had a tunneled dialysis line placed on ___. You are now prepared to complete your recovery at home with the following instructions: - You may not shower with the dialysis line in place. The stitches in your wound will remain in place, to be removed at your follow-up appointment. Do not submerge the right arm, wash the incision gently and pat dry. - You may resume your usual diet, following a low potassium, low sodium, low phosphorous renal diet - You may resume all your usual home medications, including your Coumadin at the regular dose. You have also been prescribed a medication to help with pain control, which you may take once every 6 hours as needed. - You should receive dialysis per your usual schedule of ___ and ___, through the tunneled line until your surgeon tells you that the graft may be used. Please DO NOT allow dialysis to access your graft until your surgeon has approved it. - Try to keep arm elevated as much as possible. Sutures will be removed in follow up with Dr. ___. - Please call Dr. ___ office at ___ if you have any of the following: temperature of 101, shaking chills, Right upper arm appears larger, incision appears red/warm or has bleeding/drainage, numbness of arm or altered circulation

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hypotension, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ man with COPD, orthostatic hypotension, and recent admission for sepsis likely from osteomyelitis (vs HCAP), who was referred to the ED on ___ for removal of his PICC line. In the ambulance, pt was found to be altered, hypoxemic to the ___, and hypotensive. On arrival the ED, pt was arousable only by sternal rub, with blood pressures in the 70's/40's. He reportedly was grimacing with palpation over his abdomen. However after 2L NS, he became verbal and responsive, without any localizing symptoms. Pt has dementia at baseline, but is normally able to answer yes/no questions. He was discharged from ___ on ___ after a long hospitalization for sepsis, likely due to osteomyelitis of his R great toe. During that admission, vascular and podiatry followed closely, and the foot wound was debrided at the bedside. He was not deemed a surgical candidate for aggressive amputation given his multiple co-morbidities and overall frailty. His course was also complicated by HCAP, for which he completed a 7-day course of antibiotics. Of note, he has HCPs on file which were not reachable (has been a problem in the past as well), and so legal guardianship was obtained. He was discharged to ___ to complete a prolonged course of vancomycin, through ___. In the ED, initial vitals were: 97.7 65 74/43 30 100% RA Exam notable for: apparent abdominal tenderness, interactive and answering questions after 2L NS Labs notable for: Hgb 6.2, trop 0.06 -> 0.04 Imaging notable for: head CT without acute process, CT abd/pelvis without acute process (circumfrential bladder wall thickening of unclear significance) Patient was given: 2L NS, 1g vanco (12:49), 2g cefepime x2 (12:07 and 22:45) Vitals prior to transfer: 97.6 70 147/80 18 100% RA On the floor, pt is conversant and has no complaints, including no abdominal pain, no leg pain, and no shortness of breath. He is oriented to being in the hospital, and understands that he has a severe infection in his foot. Past Medical History: - COPD - HTN - Asthma - VT with choking incident - Mild-mod MR - Mod TR - Chronic orthostatic hypotension on florinef - ___: T12-L1, L4-L5, L5-S1 LAMINECTOMIES Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.2 149/70 83 38 97% RA General: NAD, chatty, knows he's in the hospital in ___ HEENT: dry MM, temporal wasting, cataract in L eye Neck: supple, no JVP CV: irreg, no murmurs Lungs: limited by effort, decreased breath sounds RLL, no wheezes Abdomen: + BS, non-tender, non-distended, no RUQ tenderness, no CVA tenderness Back: healed ulcer, no skin breakdown Skin: R foot ulcer: 5 x 6 x 2 cm hole with visible bone, healthy pink granulation tissue, minimal odor, no purulence or drainage. Foot is WWP. DISCHARGE PHYSICAL EXAM ======================= Vital Signs: 98.2, 113/55, 75, 16, 98%RA General: fetal position, AAOx2 (Knows hospital today, does not know city) HEENT: temporal wasting, L eye with severe dense cataract and purulence (does not appear to use L eye); R eye with mild cataract Neck: supple CV: RRR, S1/S2 Lungs: Decreased breath sounds over R lung base, no rales/crackles Abdomen: NTND, BS present Back: grade 2 sacral wound GU: Foley in place (tube likely from OSH, draining clear yellow fluid) EXTREMITY: R foot wrapped in dressing, increased warmth, no response to stimulus, possible numbness. L ankle dry ulcer no purulence. Pertinent Results: ADMISSION LABS =============== ___ 11:15AM BLOOD WBC-6.9 RBC-2.29* Hgb-6.2* Hct-20.7* MCV-90 MCH-27.1 MCHC-30.0* RDW-16.5* RDWSD-52.4* Plt ___ ___ 11:15AM BLOOD Neuts-70.0 Lymphs-17.1* Monos-8.3 Eos-3.9 Baso-0.3 Im ___ AbsNeut-4.82# AbsLymp-1.18* AbsMono-0.57 AbsEos-0.27 AbsBaso-0.02 ___ 11:15AM BLOOD ___ PTT-26.0 ___ ___ 07:50AM BLOOD ___ 07:50AM BLOOD Ret Aut-2.8* Abs Ret-0.07 ___ 11:15AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-142 K-4.8 Cl-104 HCO3-31 AnGap-12 ___ 11:15AM BLOOD estGFR-Using this ___ 11:15AM BLOOD ALT-14 AST-24 AlkPhos-52 TotBili-0.2 ___ 11:15AM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.4 Mg-1.8 ___ 11:24AM BLOOD ___ O2 Flow-2 pO2-26* pCO2-55* pH-7.42 calTCO2-37* Base XS-7 Intubat-NOT INTUBA Comment-NASAL ___ ___ 07:50AM BLOOD ___ 07:50AM BLOOD Ret Aut-2.8* Abs Ret-0.07 ___ 11:15AM BLOOD cTropnT-0.06* ___ 06:15PM BLOOD cTropnT-0.04* ___ 07:50AM BLOOD Hapto-243* ___ 07:50AM BLOOD CRP-43.0* DISCHARGE LABS =============== ___ 08:05AM BLOOD WBC-6.0 RBC-2.63* Hgb-7.4* Hct-24.6* MCV-94 MCH-28.1 MCHC-30.1* RDW-17.4* RDWSD-56.2* Plt ___ ___ 08:05AM BLOOD Plt ___ ___ 08:05AM BLOOD Glucose-72 UreaN-9 Creat-0.9 Na-144 K-4.1 Cl-104 HCO3-30 AnGap-14 ___ 08:05AM BLOOD CK(CPK)-45* ___ 08:05AM BLOOD CK-MB-2 cTropnT-0.05* ___ 08:05AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.7 MICRO =============== Foot Ulcer Swab - COAG + Staph IMAGING =============== CT ABD & PELVIS WITH CONTRAST Study Date of ___ IMPRESSION: 1. Circumferential bladder wall thickening, which should correlated with urinalysis for signs of urinary tract infection. 2. Resolution of the right pleural effusion, with persistent but improved ill-defined right basilar opacification, likely due to chronic aspiration. 3. Cholelithiasis without cholecystitis. 4. Aneurysmal dilatation of the ascending aorta measuring up to 4.8 cm. 5. Infrarenal abdominal aortic aneurysm measuring up to 3.7 cm with a chronic dissection flap extending into the proximal right common iliac artery. CT HEAD W/O CONTRAST Study Date of ___: IMPRESSION: 1. No evidence of acute intracranial process. 2. Chronic left frontal lobe encephalomalacia. 3. Basilar invagination of the odontoid process with significant narrowing of the foramen magnum, unchanged and likely chronic, however a cervical spine MRI is recommended, if not already obtained, as suggested on the prior CT. CHEST (PA & LAT) Study Date of ___ IMPRESSION: Interval removal of the left PICC. Improvement in the right basilar patchy opacity likely reflective of chronic aspiration with resolution of previously noted small right pleural effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Vancomycin 1000 mg IV Q 24H 3. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild 4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing 5. Aspirin 81 mg PO DAILY 6. Bisacodyl 10 mg PO QHS:PRN constipation 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing 8. Lactulose 30 mL PO Q8H:PRN constipation 9. Metoprolol Succinate XL 12.5 mg PO DAILY 10. Senna 8.6 mg PO BID:PRN constipation 11. Tamsulosin 0.4 mg PO QHS 12. TraZODone 25 mg PO Q12H:PRN agitation Discharge Medications: 1. Linezolid ___ mg PO Q12H RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 2. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild 3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing 4. Aspirin 81 mg PO DAILY 5. Bisacodyl 10 mg PO QHS:PRN constipation 6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing 7. Lactulose 30 mL PO Q8H:PRN constipation 8. Metoprolol Succinate XL 12.5 mg PO DAILY 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Senna 8.6 mg PO BID:PRN constipation 11. Tamsulosin 0.4 mg PO QHS 12. TraZODone 25 mg PO Q12H:PRN agitation 13.Outpatient Lab Work Weekly labs starting ___- CBC w/ diff, BUN, Cr, ESR, CRP. Please send to ___, MD, Phone: ___ ___: ___. ICD: M86.2 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Osteomyelitis Secondary: Anemia of chronic disease, atrial fibrillation, malnutrition Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with altered mental status TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: ___ at 13:08 FINDINGS: Exam is slightly limited by patient rotation. Previously demonstrated left PICC is no longer visualized. Cardiac and mediastinal contours are unchanged with tortuosity of thoracic aorta again noted. Pulmonary vasculature is not engorged. Patchy opacity in the right lung base appears slightly improved, likely reflective of residual aspiration. Small right pleural effusion also appears resolved compared to the prior study. No pneumothorax is appreciated. Degenerative changes of the right AC joint are again noted. IMPRESSION: Interval removal of the left PICC. Improvement in the right basilar patchy opacity likely reflective of chronic aspiration with resolution of previously noted small right pleural effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with altered mental status 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: Noncontrast head CT dated ___. FINDINGS: There is no evidence of acute infarction, hemorrhage, edema, or mass. There is chronic encephalomalacia of the left frontal lobe. The subcortical, deep, and periventricular white matter hypodensities are nonspecific, but likely represent the sequela of chronic microvascular ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. Basilar invagination of the odontoid process with significant narrowing of the foramen magnum is re- demonstrated, unchanged compared to ___, likely chronic. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. There are bilateral lens resections. Otherwise, the been visualized portion of the orbits are unremarkable. Mild soft tissue swelling overlies the posterior occiput, towards the vertex, as seen previously. IMPRESSION: 1. No evidence of acute intracranial process. 2. Chronic left frontal lobe encephalomalacia. 3. Basilar invagination of the odontoid process with significant narrowing of the foramen magnum, unchanged and likely chronic, however a cervical spine MRI is recommended, if not already obtained, as suggested on the prior CT. RECOMMENDATION(S): Basilar invagination of the odontoid process with significant narrowing of the foramen magnum, unchanged and likely chronic, however a cervical spine MRI is recommended, if not already obtained, as suggested on the prior CT. Radiology Report EXAMINATION: CT abdomen and pelvis with IV contrast. INDICATION: ___ with altered mental status. Intrabdominal infection? TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 624 mGy-cm. COMPARISON: CT chest dated ___. FINDINGS: LOWER CHEST: There is aneurysmal dilatation of the ascending aorta measuring up to 4.8 cm. Calcifications are seen involving the aortic valve and coronary arteries. There is moderate centrilobular emphysema. The previously visualized right pleural effusion has almost entirely resolved. There is right basilar bronchiectasis and ill-defined opacification, which has improved since ___, likely due to recurrent aspiration. There is no evidence of pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is a large exophytic simple cyst arising from the lower pole of the right kidney. There are multiple additional subcentimeter hypodensities within the kidneys bilaterally, which are too small to characterize, but likely also represent simple cysts. Otherwise, the kidneys are atrophic bilaterally with multiple foci of cortical scarring. No evidence of solid lesions or perinephric abnormality. There is mild dilation of the proximal right ureter, but no evidence of hydronephrosis. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis is noted, without evidence of wall thickening and fat stranding. The appendix is not visualized. There is a large stool ball within the rectum. PELVIS: There is mild circumferential bladder wall thickening, which should be correlated with urinalysis for the signs of urinary tract infection. 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: Moderate atherosclerotic disease is noted. There is an infrarenal abdominal aortic aneurysm measuring approximately 3.7 x 3.6 cm in axial ___ (series 300, image 50). There appears to be a chronic dissection flap, which extends into the proximal right common iliac artery. BONES: There are extensive degenerative changes within the lumbar spine. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Circumferential bladder wall thickening, which should correlated with urinalysis for signs of urinary tract infection. 2. Resolution of the right pleural effusion, with persistent but improved ill-defined right basilar opacification, likely due to chronic aspiration. 3. Cholelithiasis without cholecystitis. 4. Aneurysmal dilatation of the ascending aorta measuring up to 4.8 cm. 5. Infrarenal abdominal aortic aneurysm measuring up to 3.7 cm with a chronic dissection flap extending into the proximal right common iliac artery. Radiology Report INDICATION: ___ year old man with new L PICC // L DL Power PICC 46cm ___ ___ Contact name: ___: ___ COMPARISON: Radiographs from ___ IMPRESSION: There has been placement of a left-sided PICC line with the distal lead tip in the distal SVC. Heart size is enlarged but stable. Patient is somewhat rotated on the study. No focal consolidation or overt pulmonary edema or pleural effusions are seen. There are no pneumothoraces. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Hypotension Diagnosed with Hypotension, unspecified temperature: 97.7 heartrate: 65.0 resprate: 30.0 o2sat: 100.0 sbp: 74.0 dbp: 43.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, You were admitted because your blood pressure was low and you were confused. Your symptoms improved with intravenous fluids. You continue to have an infection in your foot. You were not deemed a surgical candidate given the high risk of the procedure. You were not able to get antibiotics through the "PICC" line because you kept pulling out your line. Instead we are giving you oral antibiotics with the goals of care discussed with your guardian to not pursue more aggressive care. We also initiated the process of transferring you to hospice care. Your infection in your foot is unlikely to improve. This will serve to focus treatment on measures that will make you more comfortable. Please follow up with the Infectious disease clinic for your antibiotics and the Podiatrists for your foot infection. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Augmentin / Nsaids / Tramadol / Niacin Attending: ___. Chief Complaint: L Shoulder Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of coronary artery disease presents to the emergency room with progressive L shoulder pain after recent ICU stay at ___ for pancreatitis and alcohol withdrawal. The patient initially presented to ___ on ___ with progressive abdominal pain. He states that he was previously sober for over ___ years, however, due to the abrupt discontinuation of his outpatient benzodiazepines, he started drinking again. He was admitted to the ICU with acute respiratory failure and aspiration and klebsiella PNA. He required intubation and was treated with ceftriaxone. This hospitalization was complicated further by delirium and alcohol withdrawal. Towards the end of the hospitalization, the patient started to note the progressive onset of acute on chronic left shoulder pain. he had undergone L shoulder arthroplasty in ___ and has had shoulder pain since. The patient states that the pain was exacerbated by lying in bed while he was critically ill. He has no radiation of the pain and does not note any dyspnea, palpitations or chest pain. He has no fevers/chill, no nausea/vomiting or diarrhea. In the ED initial vitals were: T 98.6 HR 99 BP 119/81 R 18 Spo2 100% RA EKG: Sinus Rhythm Rate 77. Sub mm STE II without reciprocal changes. J point elevation V2-V3. Labs/studies notable for: 139|98|6 ---------<109 4.0|28|0.9 Ca: 8.8 Mg: 2.0 P: 3.1 ALT: 12 AP: 72 Tbili: <0.2 Alb: 3.0 AST: 17 Lip: 45 Trop-T: 0.47 Lactate:1.5 9.3 8.0>----<550 29.5 ___: 13.3 PTT: 29.1 INR: 1.2 Imaging: ___ Imaging GLENO-HUMERAL SHOULDER IMPRESSION: Status post left total shoulder arthroplasty without hardware complications or alignment change. No acute fracture or dislocation. ___ Imaging CHEST (PA & LAT) IMPRESSION: Right lower lobe opacification concerning for pneumonia, with small right pleural effusion. Patient was given: ___ 13:29 PO Acetaminophen ___ 13:30 PO Aspirin 324 mg ___ 14:12 IV Heparin 4000 UNIT ___ 14:12 IV Morphine Sulfate 2 mg On the floor he endorses the history above REVIEW OF SYSTEMS: Per HPI Past Medical History: hypertension, anxiety. Past surgical history includes tonsillectomy, appendectomy, and a Bankart repair, left shoulder in ___. Social History: ___ Family History: bone cancer, diabetes, and heart disease. Physical Exam: ADMISSION PHYSICAL EXAM GEN: NAD HEENT: Clear OP ___: RRR no MRG RESP: No increased WOB, no wheezing, rhonchi or crackles ABD: NTND No HSM EXT: Warm, pitting edema to knee NEURO: No tremor PSYCH: Odd affect, tangential speech DISCHARGE PHYSICAL EXAM VS: T: 98.7 PO BP: 138/90 R Sitting HR: 90 RR: 17 O2 sat: 93% O2 delivery: Ra GEN: NAD, well-appearing HEENT: Clear OP, neck supple ___: RRR no MRG RESP: No increased WOB, no wheezing, rhonchi or crackles ABD: NTND No HSM EXT: Warm, pitting edema to knee NEURO: No tremor, ROM at left shoulder decreased, however distal strength intact PSYCH: Odd affect, tangential speech Pertinent Results: ADMISSION LABS ============== ___ 12:28PM ___ PTT-29.1 ___ ___ 12:28PM NEUTS-55.3 ___ MONOS-9.0 EOS-2.8 BASOS-1.0 IM ___ AbsNeut-4.41 AbsLymp-2.47 AbsMono-0.72 AbsEos-0.22 AbsBaso-0.08 ___ 12:28PM WBC-8.0 RBC-2.94* HGB-9.3* HCT-29.5* MCV-100* MCH-31.6 MCHC-31.5* RDW-14.5 RDWSD-52.5* ___ 12:28PM ALBUMIN-3.0* CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.0 ___ 12:28PM CK-MB-2 ___ 12:28PM cTropnT-0.47* ___ 12:28PM LIPASE-45 ___ 12:28PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-72 TOT BILI-<0.2 ___ 12:28PM GLUCOSE-109* UREA N-6 CREAT-0.9 SODIUM-139 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-28 ANION GAP-13 ___ 02:14PM LACTATE-1.5 ___ 09:50PM CK-MB-2 cTropnT-0.49* ___ 09:50PM CK(CPK)-27* DISCHARGE LABS ============== ___ 03:55PM BLOOD WBC-7.2 RBC-3.16* Hgb-10.0* Hct-31.8* MCV-101* MCH-31.6 MCHC-31.4* RDW-14.6 RDWSD-54.8* Plt ___ ___ 06:00AM BLOOD Glucose-97 UreaN-6 Creat-1.0 Na-141 K-3.8 Cl-101 HCO3-29 AnGap-11 ___ 06:00AM BLOOD ALT-9 AST-13 CK(CPK)-25* AlkPhos-59 TotBili-<0.2 ___ 06:00AM BLOOD CK-MB-2 cTropnT-0.42* ___ 06:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.0 REPORTS ======= ___ STRESS EKG: SINUS, Q-WAVES V1-V3 HEART RATE: 73BLOOD PRESSURE: 144/80 PROTOCOL / STAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP (MIN)(MPH)(%) RATEPRESSURE ___ MG/5 ML ___ TOTAL EXERCISE TIME: 0.33% MAX HRT RATE ACHIEVED: 60 ST DEPRESSION:NONE INTERPRETATION: ___ yo man with HL and HTN, prior ETT-ECHO in ___ reporting evidence of prior MI, however no ischemia was referred to evaluate his chronic left-shoulder discomfort in the setting of elevated troponin. The patient was administered 0.4 mg Regadenoson IV bolus over 20 seconds. Prior to the infusion the patient reported the chronic left-shoulder discomfort; ___. This discomfort did not change in intensity during the procedure. No other chest, back or neck discomforts were reported during the procedure. No significant ST segment changes were noted during the procedure. The rhythm was sinus with rare isolated VPBs. Resting systolic hypertension with an appropriate hemodynamic response to the Regadenoson infusion. Post-infusion, 60 mg IV caffeine was administered. IMPRESSION: Non-anginal type symptoms with no ischemic ST segment changes. Nuclear report sent separately. ___ CARDIAC PERFUSION PHARM IMPRESSION: 1. Moderate to severe reversible perfusion defects involving the anterior septal wall and apex, associated with decreased wall motion. 2. Enlarged left ventricular cavity size with EDV of 155 mL (normal < 110 mL). ___ L GLENO-HUMERAL SHOULDER/CLAVICLE Status post left total shoulder arthroplasty without hardware complications or alignment change. No acute fracture or dislocation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lidocaine 5% Patch 1 PTCH TD QAM 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Nicotine Patch 21 mg TD DAILY 4. Omeprazole 40 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Creon 12 Dose is Unknown PO TID W/MEALS Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Creon 12 2 CAP PO TID W/MEALS 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Nicotine Patch 21 mg TD DAILY 11. Omeprazole 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY Non-ST Elevated MI L shoulder pain Coronary Artery Disease 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 left shoulder pain// assess for fracture TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Heart size is mildly enlarged. The aorta is unfolded. The mediastinal and hilar contours are unremarkable. The pulmonary vasculature is not engorged. Focal opacity in the right lower lobe is concerning for pneumonia, with a trace right pleural effusion. Left lung is clear. No pneumothorax is identified. No acute osseous abnormalities detected. Patient is status post left shoulder arthroplasty. IMPRESSION: Right lower lobe opacification concerning for pneumonia, with small right pleural effusion. Radiology Report INDICATION: History: ___ with left shoulder pain// assess for fracture TECHNIQUE: Left clavicle, two views and left shoulder, three views COMPARISON: Left shoulder radiographs ___ FINDINGS: Patient is status post left shoulder arthroplasty without hardware complications or change in alignment. No acute fracture or dislocation is evident. Degenerative spurring of the left acromioclavicular joint is re-demonstrated. No concerning lytic or sclerotic osseous abnormalities are seen. There are no periarticular soft tissue calcifications. The imaged left shoulder is clear. IMPRESSION: Status post left total shoulder arthroplasty without hardware complications or alignment change. No acute fracture or dislocation. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, L Shoulder pain Diagnosed with Unspecified abdominal pain temperature: 98.6 heartrate: 99.0 resprate: 18.0 o2sat: 100.0 sbp: 119.0 dbp: 81.0 level of pain: 9 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you during your hospitalization. You came to ___ ___ because you are having left shoulder pain. We also did some blood tests that showed that your heart was under stress. You underwent a stress test that demonstrated you may have a narrowing in one of the blood vessels of your heart. You were started on aspirin and atorvastatin to prevent a blockage from forming in one of these blood vessels. We will arrange for you to follow up with a cardiologist as an outpatient to monitor this. We think that your left shoulder pain is likely due to your chronic left shoulder pain. Your discharge medications and follow-up appointments are detailed below. We wish you the best!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Technically successful ultrasound-guided drainage of right upper quadrant subcapsular hepatic collection with 2.1 liters of cloudy yellow-green fluid withdrawn. A small sample was sent for analysis. No immediate post-procedural complications. . ___: Successeful placement of a 10 ___ external biliary drainage catheter on the left. Successful exchange of a right biloma drain with a new 10 ___ drainage catheter. History of Present Illness: ___ was recently discharged to rehab following admission (___) for a bile duct transection sustained during laparoscopic cholecystectomy at an OSH. On ___, she underwent R PTC placement. Post-procedure, she developed a hemodynamically significant bleed that required exploratory laparotomy & washout on ___. She was discharged with the PTC/biliary drain and 2 PTCs. She returns to ED w/ band-like central abd pain since yesterday afternoon. She reports it worsened last night. She is unable to say whether it is better/worse/the same right now. She denies fevers, chills, and nausea; however, she reports night sweats overnight. She vomited (undigested food, no blood, no bile) 4 days ago and reports she has not eaten anything since then because she doesn't like the food at rehab. She says she drinks water, but is unable to quantify the amount. No diarrhea; she had 2 normal BMs yesterday. She initially was brought to ___, where her systolic BP was ___ the ___, HRs 110-120, WBC 26.2, and lactate 5.0. A R femoral CVL was placed. She was given vanc/Zosyn and 7L of NS and started on Levophed. CT scan reportedly showed a fluid collection around the liver that was felt to be c/w subacute hematoma. Past Medical History: PAST MEDICAL HISTORY: Biliary colic/cholecystitis Osteoarthritis Hypertension Type II diabetes Obstructive sleep apnea Severe panic disorder Bilateral carpel tunnel syndrome Fibromyalgia GERD Seasonal allergies PAST SURGICAL HISTORY Laparoscopic cholecystectomy Right knee arthroplasty Left hand sesamoid bone removal Left shoulder surgery Right hand cyst removal Tonsillectomy Adenoidectomy Social History: ___ Family History: Father: CAD, gallbladder disease Mother: ___ disease Physical Exam: On Admission: PE: Levo 0.25 91 111/54 25 97%RA Gen: NAD, nondiaphoretic, mental status at baseline ___: RRR Pulm: CTA b/l Abd: soft, obese, NT, ND, +BS, subcostal incision healing well without erythema or drainage, 2 JPs with minimal serous fluid (1 is faintly bile-tinged), PTC w/ free flowing bile Ext: +edema b/l ___ Prior Discharge: VS: 97.6, 83, 127/68, 18, 98% RA GEN: NAD, menatl status at baseline CV: RRR, no m/r/g PULM: CTAB ABD: Obese, right and left biliary drains to gravity drainage, sites with dry dressing and c/d/i. Minimal tenderness around drain site. Old incision healed well, ols JP sites with dry gauze dressing and c/d/i. EXTR: 2+ bilateral pitting edema Pertinent Results: ___ 03:52AM BLOOD WBC-14.7* RBC-3.29* Hgb-9.2* Hct-29.7* MCV-90 MCH-28.0 MCHC-31.0 RDW-15.0 Plt ___ ___ 05:41AM BLOOD Glucose-119* UreaN-8 Creat-0.7 Na-132* K-8.6* Cl-99 HCO3-29 AnGap-13 ___ 05:41AM BLOOD ALT-40 AST-82* AlkPhos-207* TotBili-0.4 ___ 05:41AM BLOOD Calcium-8.5 Phos-3.8# Mg-1.9 ___ 7:21 am BILE **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. FLUID CULTURE (Final ___: STAPH AUREUS COAG +. MODERATE 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. ENTEROCOCCUS SP.. MODERATE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- 2 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___: CT ABD CT abd/pelvis (OSH, reviewed w/ radiology fellow): extensive subcapsular fluid collection along lateral & superior aspect of the liver, ?biloma v. resolving hematoma (compared to ___ MRCP w/ small subcapsular fluid collection, MR characteristics more c/w bile) ___ ABD CT: IMPRESSION: Significant interval decrease ___ size of the subcapsular biloma status post percutaneous drainage catheter placement. There does remain a persistent collection though, which would benefit from continued percutaneous drainage. Stable organizing hematoma around multiple proximal loops of jejunum. Worsening right-sided pleural effusion and right lower lobe atelectasis. Medications on Admission: Dulcolax prn, Klonopin 0.5 qAM/1 qHS, lisinopril 40', metformin 500", omeprazole 20', Fleets prn, MVI', Tylenol prn, Maalox prn, milk of magnesia prn, oxycodone prn, simethicone prn Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H last dose on ___. ClonazePAM 0.5 mg PO QAM 3. ClonazePAM 0.5 mg PO QPM 4. Heparin 5000 UNIT SC TID 5. Miconazole Powder 2% 1 Appl TP TID:PRN rash 6. Omeprazole 20 mg PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 8. Citalopram 10 mg PO DAILY 9. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Hepatic subcapsular biloma 2. Biliary sepsis 3. Failure to thrive 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 HISTORY: Leukocytosis and new oxygen requirement. TECHNIQUE: Portable upright AP view of the chest. COMPARISON: CT abdomen pelvis ___ and chest radiograph ___. FINDINGS: Elevation of the right hemidiaphragm is due to the presence of a right subcapsular complex hepatic fluid collection as seen on the CT. Small right pleural effusion is also demonstrated with associated mild right basilar atelectasis. Minimal left basilar atelectasis is also present. The cardiac, mediastinal and hilar contours are unremarkable. There is no pulmonary vascular engorgement. There are multilevel degenerative changes in the thoracic spine. IMPRESSION: Small right pleural effusion with bibasilar atelectasis. Elevation of the right hemidiaphragm is due to the presence of a right subcapsular complex hepatic fluid collection as seen on CT. Radiology Report HISTORY: ___ woman status post laparoscopic cholecystectomy comes back with CBD transection, status post right PTC comes back with bleed, status post ex lap/washout, now with WBC 16, subcapsular fluid collection. Please drain. ?biloma. PHYSICIANS: Dr. ___, abdominal radiology attending, and Dr. ___, abdominal radiology fellow. PROCEDURE: The procedure including risks, benefits and alternatives were explained to the patient and after a detailed discussion, informed written consent was obtained from the patient. A preprocedure timeout was performed using three patient identifiers as per ___ protocol. The patient was prepped and draped in the usual sterile fashion. 3 cc of 1% lidocaine were used for local anesthesia in the subcutaneous tissues. An additional 5 cc of 1% lidocaine were administered under ultrasound guidance in the region of the peritoneum for local anesthetic effect. Under ultrasound guidance, an 8 ___ ___ pigtail catheter was inserted into the large right upper quadrant subcapsular hepatic collection and a total of 2.1 liters of cloudy yellow-green fluid were withdrawn, a small sample of which was sent for culture, cell count and chemistries. The pigtail was formed, fixed in place with a Statlock and attached to a drainage bag. There were no immediate post-procedural complications and the patient tolerated the procedure well. Post-procedure orders were entered into the ___ medical record. Moderate sedation was provided by administering fentanyl throughout the total intraservice time of 45 minutes, during which the patient's hemodynamic parameters were continuously monitored. A total of 25 mcg of fentanyl were administered to the patient. The attending radiologist, Dr. ___, was present throughout the entire duration of the procedure. IMPRESSION: Technically successful ultrasound-guided drainage of right upper quadrant subcapsular hepatic collection with 2.1 liters of cloudy yellow-green fluid withdrawn. A small sample was sent for analysis. No immediate post-procedural complications. Radiology Report HISTORY: New right PICC. COMPARISON: ___. FINDINGS: Single frontal radiograph of the chest demonstrates interval placement of a right PICC with the tip terminating in the right atrium. To be positioned at the approximate cavoatrial junction, this should be pulled back by approximately 3 cm. When compared to the prior radiograph, there has been interval layering of the right pleural effusion, likely due to patient positioning. The heart, mediastinal, and hilar contours are unchanged. IMPRESSION: Placement of right PICC line with the tip projecting into the right atrium. For approximate placement at the cavoatrial junction, this should be pulled back by no less than 3 cm. These findings were relayed to the venous access team, at 9:48 a.m. on the day of the examination. Radiology Report PORTABLE AP CHEST FILM ___ AT 1643 CLINICAL INDICATION: ___ with bile duct transection status post NG tube placement, check position. Comparison is made to the patient's prior study of ___. Portable AP upright chest film ___ at 1643 is submitted. IMPRESSION: 1. Interval placement of a nasogastric tube with its tip projecting over the expected location of the stomach. The right subclavian PICC line is unchanged in position with its tip in the mid SVC. Lung volumes are lower and there is a moderate-sized right pleural effusion which may have somewhat increased in size since ___. Left lung grossly clear given interval reduction in lung volumes. Overall, cardiac and mediastinal contours are likely stable. No pneumothorax. Radiology Report HISTORY: Biloma status post percutaneous drainage catheter placement, evaluate for interval change. TECHNIQUE: Volumetric CT imaging was performed through the abdomen after the administration of 130 mL Omnipaque nonionic intravenous contrast. Post processing performed in the coronal and sagittal planes. COMPARISON: CT from ___. FINDINGS: There is interval increase in size of the right-sided pleural effusion with worsening atelectasis of the right lower lobe. There is scarring at the left base. The liver is again noted to be markedly, diffusely hypodense. No focal liver lesions are identified. A percutaneous drainage catheter is noted in the right upper quadrant within the subcapsular biloma which is significantly decreased in size compared to the previous exam now measuring up to 2.7 cm in greatest thickness, previously measuring approximately 6.7 cm. Two other right upper quadrant drains are also noted. The percutaneous biliary drain has been removed. The gallbladder is surgically absent. Multiple clips are noted in the hepatic hilum. There is a left adrenal myelolipoma. The right adrenal gland is normal. The pancreas and both kidneys are normal in appearance. An NG tube is in the stomach. An organized hematoma adjacent to multiple proximal jejunal loops in the left upper quadrant appears unchanged. The visualized bowel loops and mesentery are otherwise normal. There is no significant mesenteric or retroperitoneal lymphadenopathy. The abdominal vasculature appears widely patent. The osseous structures are unremarkable. IMPRESSION: Significant interval decrease in size of the subcapsular biloma status post percutaneous drainage catheter placement. There does remain a persistent collection though, which would benefit from continued percutaneous drainage. Stable organizing hematoma around multiple proximal loops of jejunum. Worsening right-sided pleural effusion and right lower lobe atelectasis. Radiology Report HISTORY: CBD transection with a new biloma. COMPARISON: CT of the abdomen from ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending was present and supervising throughout the procedure. ANESTHESIA: General anesthesia was administered by the anesthesiology department. MEDICATIONS: The patient received pre-procedure antibiiotics. CONTRAST: 35 ml of Optiray contrast. FLOURORSCOPY TIME AND DOSE: 32 min, 959 mGy PROCEDURE: 1. Flouroscopic guided left percutaneous transhepatic bile duct access. 2. Left over-the-wire cholangiogram 3. Attempt to cross the CBD. 4. 10 ___ left external biliary drain placement. 5. 10 ___ right biloma drain exchange. PROCEDURE DETAILS: Following explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained. The patient was then brought to the angiographic suite and placed supine on the imaging table. The mid upper abdomen was prepped and draped in the usual sterile fashion. A pre-procedural time out was performed according to departmental protocol. Under flouroscopic guidance, a 21 gauge Cook needle was advanced into left biliary system and contrast was injected until the biliary tree was identified. A Headliner wire was advanced under fluoroscopic guidance into the common bile duct. A skin ___ was made over the needle and the needle was removed over the wire. An Accustick set was advanced over the wire and the inner stiffener was withdrawn. A contrast injection was performed to confirm biliary anatomy. The Headliner wire was exchanged for ___ wire which was placed into the common hepatic duct. The Accustick set was exchanged for a 6 ___ sheath. An over the wire cholangiogram was performed. The ___ wire was exchanged for a Roadrunner wire. Attempts to cross the CBD using the angle Glide catheter, a RDC guiding catheter and the sheath were unsuccessful. The catheters and sheath were removed. A 10 ___ Urasil biliary catheter was advanced and the pig-tail formed. Contrast injection confirmed good position. The catheter was flushed with saline, secured with stay sutures and a statlock device to the skin and sterile dressings were applied. The catheter was cattached to a bag. Next attention was turned to the existing biloma drain. A contrast injection showed appropriate position. The ___ wire was advanced through the catheter and looped around the liver. The existing catheter was removed and exchanged for a 10 ___ biliary drainage catheter. The loop was formed. Contrast injection confirmed good position. The catheter was flushed with saline, secured with stay sutures and a statlock device to the skin and sterile dressings were applied. The catheter was cattached to a bag. The patient tolerated the procedure well. FINDINGS: 1. Non dilated biliary system with non-opacification of the distal common bile duct and contrast leak from the right biliary tree (likely at the site of the prior tube entry into the liver). 2. Successful placement of a 10 ___ left PTBD catheter in the common hepatic duct. 3. Successful exchange of a right biloma drain for a 10 ___ biliary drainage catheter. IMPRESSION: Successeful placement of a 10 ___ external biliary drainage catheter on the left. Successful exchange of a right biloma drain with a new 10 ___ drainage catheter. Radiology Report CHEST RADIOGRAPH INDICATION: Dobbhoff placement. COMPARISON: Chest radiograph from ___. FINDINGS: As compared to the previous radiograph, the patient has received a right upper abdominal pigtail catheter. The Dobbhoff catheter shows normal course, the tip projects over the middle parts of the stomach. The right PICC line is in unchanged position. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Hypotension Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 4 level of acuity: 1.0

Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Right and left hepatic drains: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid ___ the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes ___ character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or ___ strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself ___ water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . What to watch out for when you have a Dobhoff Feeding Tube: 1. Blocked tube: If the tube won't flush, try using 15 mL carbonated cola or warm water. If it still will not flush, call your nurse or doctor. Always be sure to flush the tube with at least 60 mL water after giving medicine or feedings. 2.Vomiting: *Call doctor if vomiting persists. Vomiting causes the loss of body fluids, salts and nutrients. *Give the feeding ___ an upright position. *Try smaller, more frequent feedings. Be sure the total amount for the day is the same though. *Infection may cause vomiting. Clean and rinse equipment well between feedings. *Do not let formula ___ the feeding bag hang longer than 6 hours unrefrigerated. After the formula can is opened, it should be stored ___ refrigerator until used. 3. Diarrhea: *This is frequent loose, watery stools. *Can be caused by: giving too much feeding at once or running it too quickly, decreased fiber ___ diet, impacted stool or infection. Some medicines also cause diarrhea. *Avoid hanging formula for longer than 6 hours. *Give more water after each feeding to replace water lost ___ diarrhea. *Call doctor if diarrhea does not stop after ___ days. 4. Dehydration: *Due to diarrhea, vomiting, fever, sweating. (Loss of water and fluids) *Signs include: decreased or concentrated (dark) urine, crying with no tears, dry skin, fatigue, irritability, dizziness, dry mouth, weight loss, or headache. *Give more water after each feeding to replace the water lost. *Call your doctor. 5. Constipation: ___ be caused by too little fiber ___ diet, not enough water or side effects of some medicines. *Take extra fruit juice or water between feedings. *If constipation becomes chronic, call the doctor. 6. Gas, bloating or cramping: Be sure there is no air ___ the tubing before attaching the feeding tube. 7.Tube is out of place: If the tube is no longer ___ your stomach, tape it down and call your doctor or home health nurse. Do not use the tube. You will need to have a new tube placed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Optiray 350 / Gadolinium-Containing Agents / Keflex / CT CONTRAST / Cipro / Miralax / Sorbitol / Ultram / mirtazapine Attending: ___. Chief Complaint: Hip Fracture Major Surgical or Invasive Procedure: ___ - Intrameduallary nail placement (short trochanteric fixation nail), right hip History of Present Illness: ___ with hx of HTN, DM, HLD, dCHF, Afib not on warfarin, Dementia who presents from her nursing home s/p fall found to have R hip fracture. Per nursing home reports, patient fell ~1 week ago and xray was equivocal for fracture. She was then monitored for a week but fell again on day of admission and had signficiant R hip pain on external rotation per report therefore she was transferred to ___ for further eval. On arrival to the ED, vitals afebrile, HR 79, BP 121/51, RR 18, 94%RA. Exam in ED with reported tenderness with hip flexion and palpation of anterior hip but patient with fullr ROM and able to ambulate with limp. Labs notable for elevated BUN to 36 with otherwise unremarkable Chem 7, mild leukocytosis to 11.1, Hgb 8.5, INR 1. UA with >180 WBCs with no epis. CT head without acute intracranial process, CT C-Spine with no acute fractures but evidence of volume overload. CT of R lower extremity with minimally displaced comminuted fracture involving the right greater trochanter. EKG NSR. Ortho and trauma surgery consulted in the ED and recommended admission to medicine with ortho following. Upon arrival to the floor, patient resting comfortably in bed and denies any acute complaints. REVIEW OF SYSTEMS: Per HPI. Limited history due to mental status/dementia Past Medical History: (per OMR) 1. CARDIAC RISK FACTORS: +hypertension -dyslipidemia -diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - ___ - Atrial fibrillation, on Warfarin - MVR St Judes ___ with tricupsid valve repair - CKD - dementia - s/p Left CEA - h/o AAA - pulmonary HTN - B12 deficiency - GERD - Fibromylagia - Hearing loss - osteopenia - Sciatica - s/p APPY - b/l cataracts - varicose vein stripping ___ - s/p hysterectomy, has ovaries Social History: ___ Family History: - history of breast cancer and ovarian cancer (per OMR) Physical Exam: =========================== PHYSICAL EXAM ON ADMISSION =========================== VITALS: 98.6; 161/71; 98; 20; 95 GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PER, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: irregularly irregular, ___ SEM PULMONARY: bibasilar faint crackles ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. No external rotation of RLE. No pain with palpation of R hip. SKIN: Without rash. NEUROLOGIC: Pleasant, not answering questions appropriately. A&O to name only. Moving all extremities purposefully =========================== PHYSICAL EXAM ON DISCHARGE =========================== VITALS: 97.2 HR ___ BP 150/60 (108-150/50-60) 97 RA 24H I/O: 840/900+ GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus. CARDIAC: irregularly irregular, ___ SEM PULMONARY: bibasilar crackles ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. R hip bandage c/d/I, mild tenderness to palpation SKIN: Without rash. Scattered hyperkeratotic papules over torso. NEUROLOGIC: Pleasant, not answering questions appropriately. A&O to name only. Moving all extremities purposefully Pertinent Results: ===================== LABS ON ADMISSION ===================== ___ 04:03PM BLOOD WBC-11.1*# RBC-3.44* Hgb-8.5* Hct-29.2* MCV-85 MCH-24.7* MCHC-29.1* RDW-15.5 RDWSD-47.7* Plt ___ ___ 04:03PM BLOOD Neuts-78.2* Lymphs-10.2* Monos-7.8 Eos-2.5 Baso-0.3 Im ___ AbsNeut-8.68* AbsLymp-1.13* AbsMono-0.86* AbsEos-0.28 AbsBaso-0.03 ___ 04:03PM BLOOD ___ PTT-26.9 ___ ___ 04:03PM BLOOD Glucose-102* UreaN-36* Creat-1.1 Na-141 K-4.0 Cl-105 HCO3-26 AnGap-14 ___ 05:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2 ___ 11:30PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 11:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 11:30PM URINE RBC-1 WBC->182* Bacteri-FEW Yeast-NONE Epi-0 ===================== PERTINENT INTERVAL LABS ===================== ___ 05:35AM BLOOD CK-MB-5 cTropnT-<0.01 ===================== LABS ON DISCHARGE ===================== ___ 07:00AM BLOOD WBC-6.8 RBC-3.53* Hgb-8.7* Hct-30.1* MCV-85 MCH-24.6* MCHC-28.9* RDW-15.7* RDWSD-48.6* Plt ___ ___ 07:00AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-142 K-3.9 Cl-106 HCO3-24 AnGap-16 ___ 07:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 ===================== MICROBIOLOGY ===================== ___ 11:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ===================== IMAGING/STUDIES ===================== HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT Study Date of ___ 1. Oblique linear lucency involving the right greater trochanter suspicious for a minimally distracted fracture. No dislocation. Further assessment with CT is recommended. 2. Diffuse demineralization of the osseous structures. CT HEAD ___ CONTRAST Study Date of ___ No acute intracranial process. CT C-SPINE ___ CONTRAST Study Date of ___ 1. No acute fracture or prevertebral soft tissue swelling. 2. Multilevel moderate to severe degenerative changes. 3. Minimal chronic anterolisthesis of C7 on T1. 4. Mild fluid overload. CT LOW EXT ___ C RIGHT Study Date of ___ 1. Minimally displaced comminuted fracture involving the right greater trochanter. 2. Infrarenal abdominal aortic aneurysm measuring up to 3.3 cm. MR HIP ___ CONRAST RIGHT Study Date of ___ Comminuted avulsion fracture of the right greater trochanter again seen, in keeping with findings on the ___ CT scan. In addition, curvilinear marrow edema traversing the intertrochanteric portion of the right femur suggests the presence of an occult, more extensive intertrochanteric fracture component than suggested on the recent CT scan. Surrounding edema, fluid and hemorrhage noted. No other fractures detected in the pelvic girdle. 15.6 mm rounded high T2 focus left pelvis raises the possibility of a left adnexal cystic structure in this patient status post prior hysterectomy. Clinical correlation and if indicated, followup assessment assessment by ultrasound in ___ months to assess for stability, could be considered. CHEST (PORTABLE AP) Study Date of ___ Mild interstitial pulmonary edema, improved from ___. LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. Study Date of ___ Images from the operating suite show placement of a fixation device about previous fracture of the proximal femur. Further information can be gathered from the operative report HIP NAILING IN OR W/FILMS & FLUORO RIGHT IN O.R. Study Date of ___ Images from the operating suite show placement of a fixation device about previous fracture of the proximal femur. Further information can be gathered from the operative report. ===================== OPERATIVE REPORT ===================== PREOPERATIVE DIAGNOSIS: Right intertrochanteric hip fracture. POSTOPERATIVE DIAGNOSIS: Right intertrochanteric hip fracture. PROCEDURE: Intramedullary nailing of right hip with Synthes TFN System, 11 x ___ x ___ with 95 mm spiral blade. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 100 mg PO DAILY 5. Donepezil 5 mg PO Q24H 6. Fexofenadine 60 mg PO Q24H:PRN Allergies 7. Furosemide 40 mg PO DAILY 8. Memantine 10 mg PO BID 9. Metoprolol Tartrate 12.5 mg PO BID 10. Multivitamins 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Ranitidine 150 mg PO BID 13. Sertraline 100 mg PO QHS 14. Sucralfate 1 gm PO QID 15. Vitamin D 1000 UNIT PO DAILY 16. Ferrous Sulfate 325 mg PO DAILY 17. magnesium hydroxide 400 mg (170 mg) ORAL DAILY:PRN constipation 18. Acetaminophen 650 mg PO Q4H:PRN fever 19. Aspirin 81 mg PO DAILY 20. QUEtiapine Fumarate 25 mg PO QHS 21. TraZODone 50 mg PO QHS:PRN insomnia Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Amiodarone 200 mg PO DAILY 3. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Docusate Sodium 100 mg PO DAILY 7. Donepezil 5 mg PO Q24H 8. Ferrous Sulfate 325 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Memantine 10 mg PO BID 11. Metoprolol Tartrate 12.5 mg PO BID 12. Multivitamins 1 TAB PO DAILY 13. Ranitidine 150 mg PO BID 14. Sertraline 100 mg PO QHS 15. Sucralfate 1 gm PO QID 16. Vitamin D 1000 UNIT PO DAILY 17. Enoxaparin Sodium 30 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time 18. Fexofenadine 60 mg PO Q24H:PRN Allergies 19. magnesium hydroxide 400 mg (170 mg) ORAL DAILY:PRN constipation 20. QUEtiapine Fumarate 12.5 mg PO QHS:PRN agitation 21. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses ================== Right intertrochanteric hip fracture Leukocytosis Urinary Tract Infection Hypoxia Delirium Acute Kidney Injury Secondary Diagnoses ================== Atrial fibrillation Dementia Congestive heart failure Gastroesophageal reflux disease Depression Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with R hip fracture // better characterize fracture TECHNIQUE: 1.5 Tesla. Body array coil. Routine routine unilateral right hip protocol. COMPARISON: CT scan dated ___. FINDINGS: As demonstrated on the previous CT, there is a comminuted slightly distracted fracture of the greater tuberosity. In addition, there is marrow edema extending across the intertrochanteric portion of the right proximal femur (06:18 05:17). This suggests that there is an occult, more extensive intertrochanteric component to the fracture, that is nondisplaced. There is considerable fluid interposed between the right greater tuberosity fragment and the main portion of the femur (06:19, at 09:24) and a prominent amount of fluid/edema surrounding the fracture site and surrounding the intertrochanteric portion of the femur (07:14). The gluteus medius and minimus tendons remain intact, inserted, respectively, on the greater tuberosity fragment and the intact posterior aspect of the greater trochanter. (06:20, 06:19 6: 15). Marked atrophy of right and left gluteus minimus muscles is noted (05:15). The right femoroacetabular joint remains congruent, with relatively mild changes of osteoarthritis and without a significant effusion. Aside from mild degenerative changes, the left hip joint proximal an femur are within normal limits. Bones about the pelvic girdle are otherwise intact, without marrow edema to suggest fracture. Assessment of intrapelvic soft tissue structures is quite limited. Free intrapelvic fluid is noted posteriorly. There are multiple diverticuli. Apparent surgical absence of the uterus. A 15.6 mm high T2 focus in the left pelvis (06:19) could represent a left adnexal cystic structure. Limited assessment of the lower lumbar spine shows advanced degenerative changes, not fully evaluated on this examination. Chondrocalcinosis seen about the right hip and pubic symphysis on the recent CT are not well appreciated radiographically. The abdominal aortic aneurysm seen by CT is also not well visualized on this MRI due to a more limited field-of-view. IMPRESSION: Comminuted avulsion fracture of the right greater trochanter again seen, in keeping with findings on the ___ CT scan. In addition, curvilinear marrow edema traversing the intertrochanteric portion of the right femur suggests the presence of an occult, more extensive intertrochanteric fracture component than suggested on the recent CT scan. Surrounding edema, fluid and hemorrhage noted. No other fractures detected in the pelvic girdle. 15.6 mm rounded high T2 focus left pelvis raises the possibility of a left adnexal cystic structure in this patient status post prior hysterectomy. Clinical correlation and if indicated, followup assessment assessment by ultrasound in ___ months to assess for stability, could be considered. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with HTN, DM, dCHF, Afib with chest pain and shortness of breath with new O2 requirement // eval for edema, effusion, infiltrate, acute process TECHNIQUE: Portable chest radiograph COMPARISON: Chest radiograph ___ FINDINGS: There is mild interstitial pulmonary edema, which has slightly improved from ___. There is otherwise no focal consolidation. No pleural effusion or pneumothorax. Stable cardiomegaly. Median sternotomy wires are intact. IMPRESSION: Mild interstitial pulmonary edema, improved from ___. Radiology Report EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R. INDICATION: RT HIP FX.ORIF IMPRESSION: Images from the operating suite show placement of a fixation device about previous fracture of the proximal femur. Further information can be gathered from the operative report. Gender: F Race: WHITE - EASTERN EUROPEAN Arrive by AMBULANCE Chief complaint: s/p Fall, R Hip pain Diagnosed with Disp fx of greater trochanter of right femur, init, Fall on same level, unspecified, initial encounter, Unspecified atrial fibrillation, Long term (current) use of anticoagulants, Unspecified dementia without behavioral disturbance temperature: 98.4 heartrate: 79.0 resprate: 18.0 o2sat: 94.0 sbp: 121.0 dbp: 51.0 level of pain: unable level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you during your stay at ___. You were admitted to the hospital after a fall, and you were found to have a fracture of your right hip. The orthopedic surgery team took you to the OR on ___ and fixed this fracture. You were also found to have a urinary tract infection treated with antibiotics. You should weigh yourself every day, and call your doctor if your weight goes up by more than 3 pounds. After you leave the hospital you will need rehabilitation to regain your strength after the surgery. Your appointments and medications are listed in your discharge paperwork. We wish you the best! -Your ___ Care Team ORTHOPEDIC POST OPERATVE INSRUCTIONS ====================================== INSTRUCTIONS AFTER ORTHOPEDIC SURGERY: - You underwent surgical fixation of your right hip fracture during your hospitalization. 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: - You are encouraged to bear weight as tolerated on your right lower extremity. MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40 MG 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. - No dressing is needed if wound continues to be non-draining.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ ia ___ ___ woman with hypertension as well as past history of H. pylori gastritis presenting with abdominal pain. Per review of OMR, patient with history of chronic GI complaints; per ___ note, PCP ___ that Ms ___ had been experiencing intermittent nausea, belching, bloating, and occasional epigastric discomfort. At that time symptoms were thought secondary to gastritis and GERD. Work-up in the past, including an EGD in ___ showed evidence of gastritis and H. pylori. She was placed on omeprazole with some improvement in symptoms. Patient was in OSH when developed right sided abdominal pain on ___. Pain, described as sharp, is poorly localized but most severe in RUQ'epigastrium with occasional radiation to the back. No clear trigger to pain onset. No correlation with eating, urinating, defectating. Moving aggravates pain. Laying still seems to alleviate pain. No associated back pain, No associated GYN symptoms with last menses ___. Denies melena, BRPBR. Pain prompted presentation to ___ over the weekend with largely negative work-up. CT A/P: non cont> few small calc in liver. RUQ: NL study, no GB stones. Per patient returned home and developed worsening pain as well as vomiting and represented to ___. In the ___ ED, 97.5 63 121/54 16 100% RA. Labs unremarkable. UA negative. RUQ: Mildly distended gallbladder, sludge, equivocal positive sonographic ___ sign. No pericholecystic fluid or gallbladder wall thickening. "In the correct clinical setting this may represent acute cholecystitis". CT abdomen pelvis also performed without findings to explain the patient's abdominal pain. Decision made to admit to medicine for ? cholecystitis and likely HIDA On arrival to the floor, patient reports pain is "better" and currently a ___. No episodes of vomiting today but notes ___ NBNB episodes yesterday. Denies recent NSAID use; consumption of alcohol. Drinks one caffenated beverage/day. Past Medical History: # Hypertension # H.Pylori Social History: ___ Family History: Many family members; history of "many cancers" Physical Exam: ADMISSION EXAM VS: 97.1 113/66 48 16 99%RA GENERAL: pleasant NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no appreciable LAD LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: soft, NABS, soft/ND, tenderness to palp in R>L upper quadrant as well as epigastrium, no obvious masses or HSM, no rebound/guarding EXTREMITIES: WWP, no edema bilaterally in lower extremities, no erythema, induration, or evidence of injury or infection NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, gait stable DISCHARGE EXAM VS: Tc/m 97.7 113-114/64-66 48-63 16 99% RA GENERAL - Alert, interactive, well-appearing woman in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MM dry, OP clear HEART - RRR, nl S1-S2, no MRG LUNGS - Clear anteriorly, no w/r/r ABDOMEN - Soft, nondistended. TTP RUQ with ___ sign. NABS. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION/DISCHARGE LABS ___ 04:03PM WBC-6.6 RBC-4.99 HGB-13.5 HCT-41.5 MCV-83 MCH-26.9* MCHC-32.4 RDW-14.3 ___ 04:03PM NEUTS-54.8 ___ MONOS-4.9 EOS-1.5 BASOS-0.7 ___ 04:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 04:03PM URINE UCG-NEGATIVE ___ 04:03PM ALBUMIN-4.8 ___ 04:03PM LIPASE-32 ___ 04:03PM ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-70 TOT BILI-0.9 ___ 04:03PM GLUCOSE-97 UREA N-12 CREAT-0.7 SODIUM-145 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-29 ANION GAP-16 IMAGING HIDA SCAN ___: IMPRESSION: Normal hepatobiliary scan with no evidence for acute cholecystitis. CT ABD/PELVIS ___: CT ABDOMEN: The lung bases are clear. The visualized portions of the heart and pericardium are unremarkable. The liver enhances homogenously and there is no focal liver lesion. The hepatic and portal veins are patent. The gallbladder, pancreas, spleen, and adrenals are normal. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or mass. The stomach and small bowel are unremarkable. There is no portacaval, mesenteric, or retroperitoneal lymphadenopathy. There is no free air or free fluid. CT PELVIS: The appendix is not visualized, but there are no secondary signs of inflammation. The colon, rectum, uterus, adnexa, and urinary bladder are unremarkable. There is no pelvic lymphadenopathy. Trace free fluid is likely physiologic. OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for malignancy. IMPRESSION: No CT findings to explain the patient's abdominal pain. RUQ U/S ___: IMPRESSION: Mildly distended gallbladder which contains sludge. Positive sonographic ___ sign. No gallbladder wall thickening or pericholecystic fluid. Given above findings, acute cholecystitis is not excluded in the appropriate clinical setting. Consider further evaluation with HIDA if clinically appropriate. CXR ___: FINDINGS: Frontal and lateral views of the chest were obtained. Lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY hold for sbp<100 2. Omeprazole 20 mg PO BID 3. Prochlorperazine ___ mg PO Q8H:PRN nausea 4. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. Ferrous Sulfate 325 mg PO BID 2. Hydrochlorothiazide 25 mg PO DAILY hold for sbp<100 3. Omeprazole 20 mg PO BID 4. Prochlorperazine ___ mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Abdominal Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Right upper quadrant pain, question right lower lobe pneumonia. COMPARISON: None. FINDINGS: Frontal and lateral views of the chest were obtained. Lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Right upper quadrant pain. Evaluate for cholelithiasis. COMPARISON: Abdominal ultrasound on ___. FINDINGS: The liver is normal in echogenicity and there are no focal liver lesions. There is no intrahepatic or extrahepatic biliary duct dilatation. The common bile duct measures 4 mm. The gallbladder is mildly distended and there is sludge within the gallbladder. Positive sonographic ___ sign. No cholelithiasis. There is no pericholecystic fluid or gallbladder wall thickening. The spleen measures 8.5 cm and is normal. The pancreatic head and body are normal, the tail is not well visualized due to overlying bowel gas. The portal vein is patent with hepatopetal flow. Limited views of the right kidney demonstrate no hydronephrosis. IMPRESSION: Mildly distended gallbladder which contains sludge. Positive sonographic ___ sign. No gallbladder wall thickening or pericholecystic fluid. Given above findings, acute cholecystitis is not excluded in the appropriate clinical setting. Consider further evaluation with HIDA if clinically appropriate. Radiology Report INDICATION: Right upper quadrant abdominal pain. TECHNIQUE: MDCT images were obtained from the lung bases to the pelvic outlet after the administration of intravenous contrast. Coronal and sagittal reformations were acquired. COMPARISON: Abdominal ultrasound, ___. CT ABDOMEN: The lung bases are clear. The visualized portions of the heart and pericardium are unremarkable. The liver enhances homogenously and there is no focal liver lesion. The hepatic and portal veins are patent. The gallbladder, pancreas, spleen, and adrenals are normal. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or mass. The stomach and small bowel are unremarkable. There is no portacaval, mesenteric, or retroperitoneal lymphadenopathy. There is no free air or free fluid. CT PELVIS: The appendix is not visualized, but there are no secondary signs of inflammation. The colon, rectum, uterus, adnexa, and urinary bladder are unremarkable. There is no pelvic lymphadenopathy. Trace free fluid is likely physiologic. OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for malignancy. IMPRESSION: No CT findings to explain the patient's abdominal pain. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with ABDOMINAL PAIN RUQ, HYPERTENSION NOS temperature: 97.5 heartrate: 63.0 resprate: 16.0 o2sat: 100.0 sbp: 121.0 dbp: 54.0 level of pain: 10 level of acuity: 3.0

Ms. ___, It was a pleasure caring for you during your hospital stay. You were admitted for abdominal pain with concern for cholecystitis (infection or inflammation of the gallbladder). You had a scan of your gallbladder which showed that you do not have cholecystitis. Your abdominal pain improved overnight, and all of the lab and imaging studies were reassuring. You should follow up with your Gastroenterologist to discuss having an outpatient endoscopy to look for problems in the stomach and first part of the intestines which may be causing your pain.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ruptured appendicitis complicated by abscess Major Surgical or Invasive Procedure: Interventional drainage of abscess and placement of drain History of Present Illness: ___ presents with 2-week history of abdominal pain, originally across upper abdomen, now predominantly band-like pain in lower abdomen presented to ___ on ___. Sought medical attention twice at urgent care clinic and diagnosed with constipation. Presented to PCP earlier today and referred to ED for a CT scan given ongoing pain, which showed perforated appendicitis with abscess formation. Patient denies fevers, chills, nausea, vomiting, melena, hematochezia. Had constipation but now diarrhea after having taken stool softeners. Currently feels weak and dehydrated. Had colonoscopy years ago with unremarkable results per patient. Past Medical History: PMH: anxiety, depression, hyperlipidemia PSH: greater saphenous vein ablation (___) Social History: ___ Family History: non-contributory Physical Exam: Discharge Physical Exam: GEN: AA&O x 3, NAD, calm, cooperative. HEENT: mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally ABDOMEN: soft, mildly tender to palpation incisionally, non-distended. Incisions: clean, dry and intact, dressed and closed with steristrips. EXTREMITIES: Warm, well perfused, pulses palpable Pertinent Results: CT Abd & Pelvis w/ contrast ___: 1. Acute, perforated appendicitis with large rim enhancing, loculated fluid collection in the pelvis concerning for large periappendiceal abscess. Of note, the fluid collection appears to have 2 large pockets, one within the right hemipelvis adjacent to the cecum and one in the deep pelvis. 2. Dependent radiopacity in the RLQ fluid collection may represent an appendicolith or fecalith. CT Interventional Procedure ___: 1. CT-guided placement of a ___ pigtail catheter into the presacral abscess. A sample was sent for microbiology evaluation. 2. Ultrasound-guided placement of a 10 ___ pigtail catheter into the right lower quadrant abscess. A sample was sent for microbiology evaluation. 3. Hyperdensity within the right lower quadrant collection is likely an appendicolith. CT Pelvis w/o contrast ___: 1. Complete decompression of previously seen right lower quadrant and presacral fluid collections since prior study. Right lower quadrant and presacral drainage catheters are again in appropriate position. R ght lower quadrant mesenteric fat stranding likely inflammatory changes. 2. Small 2.7 x 2.4 cm fluid collection likely an abscess in the right mid abdomen which appears smaller from comparison study. 3. Radiopacity within the right lower quadrant likely representing fecalith or appendicolith. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety 3. Fluoxetine 20 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Simvastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO TID RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO Q8H RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 3. ClonazePAM 0.5 mg PO BID Anxiety 4. Docusate Sodium 100 mg PO BID take this while taking narcotics to prevent constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 5. Fluoxetine 20 mg PO DAILY 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN constipation take this while taking narcotics to prevent constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 8. Simvastatin 20 mg PO QPM 9. Aspirin 81 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ruptured appendicitis complicated by abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT INTERVENTIONAL PROCEDURE. INDICATION: ___ year old woman with ruptured appendicitis and subsequent abscesses // Please drain abscesses and leave drain in place. Send fluid for culture and Gram stain. COMPARISON: CT ___ PROCEDURE: 1. CT-guided drainage of presacral collection. 2. Ultrasound-guided drainage of a right lower quadrant collection. OPERATORS: Dr. ___, MD (___), and Dr. ___, attending radiologist. Dr. ___ ___ supervised the trainee during the entire 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. CT-GUIDED DRAINAGE OF PRESACRAL COLLECTION: The patient was placed in a prone position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. Based on the CT findings, an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. A 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of a ___ Exodus pigtail catheter into the collection. The metal stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 200 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag to gravity. Sterile dressing was applied. ULTRASOUND-GUIDED DRAINAGE OF RIGHT LOWER QUADRANT COLLECTION: Attention was then turned to the right lower quadrant collection. The patient was placed in a supine position on the CT scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings, an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, a ___ Exodus drainage catheter was advanced via trocar technique into the collection. A sample of fluid was aspirated, confirming catheter position within the collection. The pigtail was deployed. The position of the pigtail was confirmed within the collection via ultrasound. Approximately 180 cc of purulent fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: DLP: Total DLP (Body) = 992 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of 40 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Limited preprocedure CT scan again demonstrates multiple intra-abdominal fluid collections, better assessed on CT ___. An 8.3 x 7.1 cm presacral fluid collection (3:27) was targeted for CT-guided catheter drainage. A 10.5 x 6.2 cm right lower quadrant fluid collection (03:11) was targeted for ultrasound guided catheter drainage. A hyperdensity within the right lower quadrant fluid collection (3:19) is likely an appendicolith. Multiple additional smaller fluid collections are better evaluated on the prior contrast-enhanced CT. 2. Postprocedure CT scan demonstrates a 10 ___ catheter within the presacral collection, which is largely collapsed. A 10 ___ catheter is seen in the right lower quadrant fluid collection, which is also partially collapsed. Additional smaller fluid collections are better assessed on the prior contrast-enhanced CT. IMPRESSION: 1. CT-guided placement of a ___ pigtail catheter into the presacral abscess. A sample was sent for microbiology evaluation. 2. Ultrasound-guided placement of a 10 ___ pigtail catheter into the right lower quadrant abscess. A sample was sent for microbiology evaluation. 3. Hyperdensity within the right lower quadrant collection is likely an appendicolith. RECOMMENDATION(S): Followup microbiology. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephoneon ___ at 2:30 ___, upon procedure completion. Radiology Report INDICATION: ___ year old woman s/p ruptured appens s/p ___ drainage // eval drain for obstruction/eval drain patency 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: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 3.0 s, 33.4 cm; CTDIvol = 13.7 mGy (Body) DLP = 456.4 mGy-cm. Total DLP (Body) = 456 mGy-cm. COMPARISON: ___ CT abdomen pelvis FINDINGS: PELVIS HEPATOBILIARY: Images of the inferior portions of the liver showed no focal lesion. The gallbladder is within normal limits. 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: Drainage catheter is seen terminating within the right lower quadrant. Previously seen large right fluid collection has been completely decompressed. There is a small fluid collection measuring 2.7 x 2.4 cm (02:23) in the right mid abdomen which appears smaller from comparison study, likely an abscess. There is significant mesenteric fat stranding in the right lower quadrant secondary inflammatory changes. There is a 9 x 8 mm high-density focus within the bowel in the right lower quadrant likely consistent with a fecalith or appendicolith (02:32) PELVIS: Another drainage catheter is seen terminating in the presacral space. Previously described large presacral fluid collection has been completely decompressed since prior study. REPRODUCTIVE ORGANS: Fibroid uterus is again seen. LYMPH NODES: Prominent mesenteric lymph node measuring 1 cm (02:17) likely reactive . VASCULAR: There is no abdominal aortic aneurysm. Mild calcified plaques within the infrarenal aorta and bilateral common iliac arteries. No evidence of stenosis. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The pelvic wall is within normal limits. IMPRESSION: 1. Complete decompression of previously seen right lower quadrant and presacral fluid collections since prior study. Right lower quadrant and presacral drainage catheters are again in appropriate position. R ght lower quadrant mesenteric fat stranding likely inflammatory changes. 2. Small 2.7 x 2.4 cm fluid collection likely an abscess in the right mid abdomen which appears smaller from comparison study. 3. Radiopacity within the right lower quadrant likely representing fecalith or appendicolith. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: RLQ abdominal pain Diagnosed with Right lower quadrant pain temperature: 99.5 heartrate: 109.0 resprate: 16.0 o2sat: 97.0 sbp: 110.0 dbp: 62.0 level of pain: 2 level of acuity: 3.0

Dear Ms. ___, You were seen at ___ for evaluation of your ruptured appendicitis and abscess. You had this abscess drained by interventional radiology and they left a drain in place. Drains were placed in both the right lower part of your abdomen and the presacral area (pelvis). You were started on IV antibiotics as well and improved after that. You will go home with an oral antibiotic. Please take these as instructed and take them to completion. 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. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation.

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, leg swelling Major Surgical or Invasive Procedure: CORONARY ANGIOGRAPHY (___) History of Present Illness: Mr. ___ is an ___ man with HFrEF (EF 40%), LBBB, HTN, HLD who presents with dyspnea, progressive leg swelling, and weight gain consistent with acute on chronic heart failure exacerbation. The patient had an ECHO in ___ that demonstrated a newly reduced ejection fraction of 40% and was started on diuretic therapy at that time. He's been compliant with his medical therapy but over the past two weeks has noticed progressive leg swelling with adjustments made to his diuretics. Most recently, his cardiologist put him on torsemide 40mg this past ___. Despite these interventions, he continued to have progressive leg swelling with the development of orthopnea and worsening shortness of breath. Additionally, his weight has increased approximately 25 lb over the past four weeks. He's not experienced any chest pain or shortness of breath at rest over this time. Of note, the patient carries a diagnosis of biopsy-proven inclusion body myositis for which he is followed by rheumatology at ___. Over the past several months, he's had significant leg pain and has been taking 800mg of ibuprofen TID. Giving his progressive symptoms of decompensated heart failure, he presented to the ED for further evaluation. In the ED initial vitals were: T 98.1, HR 87, BP 128/57, 94% on RA. EKG: LBBB (known) not meeting Sgarbosa's criteria. Labs/studies notable for: trop 0.7 -> 0.63, CK-MB 30, CK 393. ProBNP ___. Patient was given: 40mg IV Lasix, ibuprofen 600mg, ASA 243mg, and heparin. Vitals on transfer: HR 83, BP 102/54 RR 18, 92% RA. On the floor the patient confirms the above history. He denies any current shortness of breath or chest pain. He is particularly bothered by his bilateral leg pain that has been worsening over the past several weeks and attributed to his known inclusion body myositis. Past Medical History: - HFrEF (40%) - LBBB - HTN - Inclusion Body Myositis (followed at ___; not on any immunosuppressant) - gout (last flare > ___ years ago) Social History: ___ Family History: Family History: brother - kidney stones, valve replacement; father - died from heart disease at ___ yo; sister - died from heart disease at age ___ brother - heart disease. No family history of gallstones. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: ___ 2230 Temp: 98.1 PO BP: 129/74 R Lying HR: 90 RR: 20 O2 sat: 95% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 15 cm. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: + crackles to mid-lung fields bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Significant 3+ edema to thighs bilaterally SKIN: warm, bilateral stasis dermatitis noted without evidence of superimposed SSTI. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM VS: 24 HR Data (last updated ___ @ 820) Temp: 98.2 (Tm 99.4), BP: 155/62 (72-155/40-75), HR: 61 (58-67 marching in place), RR: 18 (___), O2 sat: 93% (90-100), O2 delivery: ra Fluid Balance (last updated ___ @ 817) Last 8 hours Total cumulative -50ml IN: Total 400ml, PO Amt 400ml OUT: Total 450ml, Urine Amt 450ml Last 24 hours Total cumulative -685ml IN: Total 1140ml, PO Amt 1140ml OUT: Total 1825ml, Urine Amt 1825ml GENERAL: Pleasant elderly man, lying down in bed, appears comfortable and in no acute distress NECK: Supple with JVP 6 cm CARDIAC: RRR, nl s1/s2, no m/r/g LUNGS: Intermittent anterior rhonchi, no wheezes or rales ABDOMEN: Soft, non tender, non distended, normal bowel sounds EXTREMITIES: Trace ___ edema to the ankles, no clubbing or cyanosis, warm and well perfused SKIN: Warm, bilateral stasis dermatitis Pertinent Results: ADMISSION LABS ___ 05:40PM BLOOD WBC-11.2* RBC-3.61* Hgb-10.9* Hct-33.8* MCV-94 MCH-30.2 MCHC-32.2 RDW-14.7 RDWSD-50.1* Plt ___ ___ 05:40PM BLOOD Neuts-62.0 ___ Monos-7.2 Eos-7.1* Baso-0.4 Im ___ AbsNeut-6.92* AbsLymp-2.55 AbsMono-0.80 AbsEos-0.79* AbsBaso-0.04 ___ 05:45PM BLOOD ___ PTT-26.0 ___ ___ 05:40PM BLOOD Glucose-89 UreaN-57* Creat-1.3* Na-142 K-3.6 Cl-102 HCO3-26 AnGap-14 ___ 05:40PM BLOOD CK(CPK)-394* ___ 05:40PM BLOOD CK-MB-34* MB Indx-8.6* ___ PERTINENT/DISCHARGE LABS ___ 06:26AM BLOOD WBC-9.6 RBC-3.22* Hgb-9.9* Hct-30.3* MCV-94 MCH-30.7 MCHC-32.7 RDW-15.0 RDWSD-51.6* Plt ___ ___ 06:12AM BLOOD WBC-11.4* RBC-3.66* Hgb-11.0* Hct-34.4* MCV-94 MCH-30.1 MCHC-32.0 RDW-15.2 RDWSD-51.7* Plt ___ ___ 06:12AM BLOOD Glucose-90 UreaN-30* Creat-1.1 Na-143 K-4.5 Cl-102 HCO3-27 AnGap-14 ___ 05:40PM BLOOD cTropnT-0.71* ___ 05:52PM BLOOD CK-MB-34* cTropnT-1.17* ___ 07:30AM BLOOD CK-MB-15* cTropnT-1.15* ___ 06:12AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7 ___ 07:30AM BLOOD calTIBC-173* Ferritn-437* TRF-133* ___ 08:15AM BLOOD %HbA1c-5.3 eAG-105 ___ 03:24AM BLOOD Triglyc-78 HDL-28* CHOL/HD-4.4 LDLcalc-78 IMAGING/STUDIES CXR ___- No significant interval change. Chronic blunting of the right lateral costophrenic angle lead, likely due to component of pleural thickening and effusion. No definite superimposed acute process. LENIs ___- No evidence of deep venous thrombosis in the imaged portion of the right or left lower extremity veins. Bilateral posterior tibial and peroneal veins not well assessed due to edema, similar in appearance to prior. TTE ___- CONCLUSION: The left atrium is elongated. The right atrium is mildly enlarged. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional left ventricular systolic function. There is visual left ventricular dyssnchrony. The visually estimated left ventricular ejection fraction is 55-60%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. There is abnormal septal motion c/w conduction abnormality/paced rhythm. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch diameter is normal with a mildly dilated descending aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular global systolic function with evidence of intraventricular LV dyssynchrony. Mild mitral regurgitation. ___ , the left ventricular systolic function is slightly improved. Cardiac cath ___- Impressions: Low filling pressures. Diffuse CAD involving proximal LAD, proximal Ramus and LCx (CTO). CT chest ___- 1. No acute cardiopulmonary process. 2. Moderate atherosclerotic calcifications of the thoracic aorta and marked coronary artery disease. 3. Trace bilateral pleural effusions. Lower lobe bronchiectasis. 4. 1 cm hypodense nodule in the right thyroid lobe. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Torsemide 40 mg PO DAILY 4. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 6. Pantoprazole 20 mg PO Q24H 7. Spironolactone 25 mg PO BID 8. Zolpidem Tartrate 10 mg PO QHS 9. Aspirin 81 mg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Allopurinol ___ mg PO DAILY 4. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 5. Aspirin 81 mg PO DAILY 6. Citalopram 20 mg PO DAILY 7. Pantoprazole 20 mg PO Q24H 8. Spironolactone 25 mg PO BID 9. Torsemide 40 mg PO DAILY 10. Zolpidem Tartrate 10 mg PO QHS 11. HELD- Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate This medication was held. Do not restart Ibuprofen until your primary care physician says it is alright to restart Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: PRIMARY DIAGNOSIS ================ Acute on chronic heart failure exacerbation Heart failure with recovered ejection fraction NSTEMI/multivessel CAD SECONDARY DIAGNOSES =================== Anemia HTN Inclusion body myositis Depression Insomnia Gout 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: ___ with new onset heart failure and crackles on exam// ?pulmonary edema, effusion, cardiomegaly COMPARISON: ___ FINDINGS: AP and lateral views of the chest provided. Since prior, there has been no significant interval change. There is chronic blunting of the right lateral costophrenic angle likely in part due to pleural thickening though underlying effusion would be possible. There is no large left pleural effusion. Posterior costophrenic angles are excluded from the field of view. Lung volumes are relatively lower compared to the prior exam resulting in crowding of bronchovascular structures. There is mild bibasilar atelectasis. No pneumothorax. Cardiomediastinal silhouette is unchan within normal limits when allowing for AP technique and low lung volumes. IMPRESSION: No significant interval change. Chronic blunting of the right lateral costophrenic angle lead, likely due to component of pleural thickening and effusion. No definite superimposed acute process. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with history of inclusion body myositis and heart failure with worsening ___ edema and very little ambulation// Please eval for ___ DVT b/l TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: Lower extremity ultrasound from ___ FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. The bilateral posterior tibial and peroneal veins were not well assessed, as on prior secondary to technical considerations from body habitus. 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 imaged portion of the right or left lower extremity veins. Bilateral posterior tibial and peroneal veins not well assessed due to edema, similar in appearance to prior. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with HFpEF, HTN, HLD found to have three vessel CAD now getting worked up for CABG// evaluate aortic calcification TECHNIQUE: Axial CT images of the thorax from the thoracic inlet through the diaphragm were performed without IV contrast. Coronal and sagittal reformats were recreated at the workstation. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.7 s, 33.5 cm; CTDIvol = 16.3 mGy (Body) DLP = 521.1 mGy-cm. Total DLP (Body) = 531 mGy-cm. COMPARISON: CT chest ___. FINDINGS: BASE OF NECK: 1 cm hypodense nodule in the right thyroid lobe. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar adenopathy. HEART AND VASCULATURE: The heart is normal size. No pericardial effusion. Moderate atherosclerotic calcifications of the thoracic aorta and great vessels. Marked coronary artery disease. Calcifications of the mitral and aortic valve. PLEURAL SPACES: Trace bilateral pleural effusion with compressive atelectasis. No pneumothorax. LUNGS/AIRWAYS: Mild bilateral dependent atelectasis right greater than left as well as right greater than left basilar bronchiectasis. ABDOMEN: Unremarkable. BONES: Degenerative changes of the spine with anterior osteophytes. No suspicious osseous lesions. IMPRESSION: 1. No acute cardiopulmonary process. 2. Moderate atherosclerotic calcifications of the thoracic aorta and marked coronary artery disease. 3. Trace bilateral pleural effusions. Lower lobe bronchiectasis. 4. 1 cm hypodense nodule in the right thyroid lobe. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Dyspnea, Leg swelling Diagnosed with Heart failure, unspecified temperature: 98.1 heartrate: 87.0 resprate: 24.0 o2sat: nan sbp: 128.0 dbp: 57.0 level of pain: 0 level of acuity: 2.0

Dear Mr ___, WHY YOU WERE ADMITTED - You were having shortness of breath and leg swelling WHAT WE DID FOR YOU HERE _ You were found to be volume overloaded, and fluid was removed from your body with a medication called a diuretic - Your heart numbers were elevated in the blood suggesting disease. Coronary angiography showed blockages in many arteries of the heart - You were started on new medications for your heart including metoprolol XL 25mg daily. WHAT YOU SHOULD DO WHEN YOU LEAVE - Please take your medication as directed - Please follow with your primary care doctor and cardiologist - ___ weight yourself daily and if your weight is up by 3 pounds in one day, please call your primary physician! It was a pleasure caring for you! Sincerely, Your ___ Care 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: right frontal/parietal stroke Major Surgical or Invasive Procedure: None History of Present Illness: This is an ___ left handed man with a history of hypertension, BPH, dementia of unkwown variety, history of longstanding tobacco abuse and recent hospitalization for a drug resistant UTI who presents to the ED as a transfer from an OSH where a subacute stroke was discovered on CT scan. I received a brief report of his baseline status when speaking with his daughter on the phone. She did clarify that he is DNR. She reoprts that he has had dementia for some years now. While he is quite physically able at baseline, he does get assistance for help with his ADLs due to his ongoing issues with confusion, disorientation and inattention. He had been doing well until very recently when he was hospitalized for an infection. She mentioned that there was a "drug resistant organism", and a UTI caused "acute kidney failure". He was sent home after placing a power PICC line and sent home with instructions to get imipenem/cilastatin until the ___ ___. His PICC line was being flushed with heparin at home and maintained by a home IV nurse. This morning, when getting showered, the nurse noted that he was having difficulty getting words out. The family was notified. Instead of going to the ED directly, they decided to keep their appointment with the PCP later this morning. The PCP referred them to the ED where a CT scan was done and was read as subacute right frontal stroke. I do not have the actual report. The CT has been uploaded to our system. He was transferred for further neurologic evaluation. His daughter reports that at baseline, he is not dysarthric and there is no left sided weakness. Review of systems: Is difficult in this patient at this time, given his mental status. Daughter did report no new symptoms in the past couple of days other than what is described above. Past Medical History: - Hypertension - H/o tobacco abuse - BPH and urinary retention - recurrent UTI - Dementia (long standing, is not oriented to time or to place at baseline) - Hypercholesterolemia - Right frontal and parietal embolic stroke Social History: ___ Family History: Unable to obtain. Physical Exam: ADMISSION EXAM: Vitals: 97.2, 71, 188/93, 16, 95% General: Thin, appears younger than stated age, awake, cooperative, NAD, no specific complaints. + right picc line HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, edentulous Neck: Supple, no masses or lymphadenopathy Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no murmurs Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: warm and well perfused Skin: no rashes or lesions noted. Neurologic: - Mental Status: Alert, awake. He can tell me his name, but does not know where he is or why he is here. He relates no specific complaints. He does not know the date. He could not recall his address or phone number. He was significantly dysarthric but somewhat comprehensible. He was able to identify and name "reading glasses", key and glove, but could not identify feather, cactus or hammock. He could not identify the color of my scrubs as blue. He was able to read, but would often skip words. So instead of "they heard him speak on the radio last night", he read "heard speak radio last night". When having him describe the scene on the stroke cards, he had very limited verbal incomprehensible output. Could not test memory, attention. - Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. III, IV and VI: EOM are intact with saccadic intrusions, no nystagmus 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: Paratonia without atrophy. Relative paucity of movement in the LUE, with ? neglect when asking him to perform specific instructions. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 4 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 - Sensory: Was not attentive to formal sensory testing. - DTRs: 1+ in upper extremities. - Coordination: Gait testing deferred. Was not able to cooperate for FTN testing. DISCHARGE EXAM: AF VSS Mental Status: fluctuates between being arousable to voice/light touch and being somewhat interactive/following simple commmands (wriggling toes, showing thumb) to being very somnolent and difficult to arouse even with sternal rub. When patient is difficult to arouse, occasionally becomes combative with noxious stimuli and then goes right back to sleep. Says few words when awake but not very conversant. Motor: Right side is strong and has good spontaneous movements. Left side has less spontaneous movements but withdraws briskly from noxious stimuli (nailbed pressure). Pertinent Results: ADMISSION LABS: ___ 05:45PM BLOOD WBC-11.1* RBC-4.26* Hgb-12.3* Hct-36.9* MCV-87 MCH-29.0 MCHC-33.4 RDW-14.8 Plt ___ ___ 05:45PM BLOOD Neuts-55.9 ___ Monos-5.4 Eos-5.3* Baso-0.4 ___ 05:45PM BLOOD ___ PTT-32.2 ___ ___ 05:45PM BLOOD Glucose-109* UreaN-18 Creat-1.5* Na-140 K-4.2 Cl-105 HCO3-28 AnGap-11 ___ 05:45PM BLOOD ALT-31 AST-31 AlkPhos-111 TotBili-0.4 ___ 05:45PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.1* Mg-2.0 CARDIAC ENZYMES: ___ 05:45PM BLOOD cTropnT-0.03* ___ 05:26AM BLOOD CK-MB-2 cTropnT-0.04* ___ 06:50PM BLOOD CK-MB-2 cTropnT-0.03* RELEVANT LABS: ___ 11:13AM BLOOD %HbA1c-PND ___ 05:26AM BLOOD Triglyc-85 HDL-45 CHOL/HD-3.4 LDLcalc-89 ___ 06:50PM BLOOD TSH-PND ___ 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG DISCHARGE LABS: ___ 05:18AM BLOOD WBC-9.2 RBC-4.01* Hgb-11.5* Hct-34.1* MCV-85 MCH-28.6 MCHC-33.6 RDW-15.1 Plt ___ ___ 05:18AM BLOOD Glucose-98 UreaN-13 Creat-1.5* Na-139 K-3.6 Cl-107 HCO3-24 AnGap-12 ___ 05:15AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0 MICROBIOLOGY: ___ 09:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG ___ 9:00 pm URINE CULTURE (Final ___: <10,000 organisms/ml. ** ___ 3:00 am URINE URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- =>64 R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- 1 S GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R ============================= IMAGING: ___ MRI/MRA OF HEAD/NECK: IMPRESSION: 1. Multiple cortical foci of acute infarction in the right frontal and anterior parietal lobes, in the right middle cerebral artery territory. No significant mass effect at this time. No evidence of hemorrhagic transformation. 2. Two punctate chronic microhemorrhages in the paramedian right frontal lobe, which could be related to amyloid angiopathy, hypertension, or less likely a cavernous malformation. 3. Unremarkable neck MRA. 4. The superior and inferior division branches of the right middle cerebral artery are smaller in caliber compared to the left. ___ TTE: The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. EEG ___: IMPRESSION: This is an abnormal video EEG recording with slowed theta background frequencies seen during most awake portion of this recording. In addition, there were bursts of generalized and more focal slowing over the right frontocentral regions. Multifocal sharp transients were seen as described above as well as broad-based right hemisphere sharp and slow discharges. One clinical event described above concerning for seizure. (At 00:06 a.m., the patient can be seen lying in bed asleep with right side of his face down when he wakes, suddenly turns head towards left with tonic flexion of upper extremities which lasts a few seconds and is followed by chewing movements as he scans the space around him appearing confused.) Medications on Admission: - Simvastatin 20mg daily - Imipenem/cilastatin 250mg q8 until ___ - Rivastigmine 1.5mg BID - Flomax 0.4mg QHS - Lisinopril 5mg daily - Tylenol ___ q4hrs - Metoprolol 25mg BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain/fever 2. Metoprolol Tartrate 25 mg PO BID hold if SBP <100 or HR <60 3. Simvastatin 20 mg PO DAILY 4. Tamsulosin 0.4 mg PO HS 5. LeVETiracetam 500 mg PO BID 6. rivastigmine *NF* 1.5 mg Oral BID 7. Aspirin (Buffered) 325 mg PO DAILY 8. Meropenem 500 mg IV Q8H day 1 = ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: right frontal and parietal ischemic stroke, dementia, hypertension, urinary tract infection, hypoactive delirium Secondary Diagnosis: benign hypertrophic prostate Discharge Condition: Mental Status: Confused - most of the time. Not oriented to month/year, oriented to the fact he's in the hospital but not to reason. Level of Consciousness: fluctuates between being alert and interactive and being lethargic but arousable to noxious stimuli Activity Status: Ambulatory - requires assistance or aid (walker or cane). Needs supervision. Neurologic Status: fluctuating level of alertness, does not move left side as much as right side, but withdraws all extremities to noxious stimuli. Appears to have left sided neglect, though difficult to determine. Followup Instructions: ___ Radiology Report INDICATION: ___ man with acute neurological change. Evaluate for evidence of intracranial process. COMPARISON: Non-contrast head CT performed on ___ at ___ ___. Prior Brain MRI dated ___ from ___. TECHNIQUE: Axial contiguous MDCT images were obtained through the brain without the administration of IV contrast. FINDINGS: There is no evidence of hemorrhage, or mass effect. The ventricles and sulci are slightly prominent, consistent with age-related degeneration. Unchanged cortical foci of low attenuation, consistent with acute infarction in the right frontal and anterior parietal lobes, right middle cerebral artery territory, demonstrated on the prior brain MRI. Periventricular white matter changes suggest chronic small vessel ischemic disease. An area of hypodensity in the area of the coronal radiata of the right frontal lobe (2:19) suggests a small area of encephalomalacia due to prior infarction. The basal cisterns appear patent. There is no fracture. There is an air-fluid level in the left maxillary sinus but the remaining paranasal sinuses, mastoid air cells and middle ear cavities are clear. There are no soft tissue abnormalities. IMPRESSION: 1. Unchanged cortical foci of low attenuation, consistent with acute infarction in the right frontal and anterior parietal lobes, right middle cerebral artery territory. No evidence of hemorrhagic transformation. 2. Periventricular white matter changes suggest chronic small vessel ischemic disease. Radiology Report CHEST ON ___ HISTORY: Verify PICC line placement. FINDINGS: There is a right-sided PICC line with tip in the mid SVC. The lungs are clear without infiltrate or effusion. The right hemidiaphragm is mildly elevated. The aorta is mildly tortuous. Cardiac silhouette is normal. Radiology Report HEAD MRI WITHOUT CONTRAST, HEAD MRA WITHOUT CONTRAST, NECK MRA WITH AND WITHOUT CONTRAST INDICATION: New onset of right frontal stroke. COMPARISON: Non-contrast head CT performed on ___ at ___ ___. TECHNIQUE: Sagittal T1-weighted, and axial T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the head were obtained. Three-dimensional time-of-flight MRA of the head was obtained, with multiplanar maximal intensity projection reformatted images. Coronal VIBE imaging of the neck was performed before, during, and after intravenous gadolinium administration, with multiplanar maximal intensity projection reformatted images of the neck arteries. FINDINGS: HEAD MRI: There are multiple cortical foci of slow diffusion in the right posterior frontal and anterior parietal lobes, in the middle cerebral artery territory. Several smaller foci of slow diffusion are also noted in the anterior right frontal lobe. These demonstrate faint high signal on FLAIR images, indicating that the evolving acute infarction is more than six hours old. There are no associated blood products. However, there are two punctate foci of low signal intensity on gradient echo images in the paramedian right frontal lobe, indicating chronic microhemorrhages, which could be related to amyloid angiopathy, hypertension, or less likely a cavernous malformation. FLAIR images also demonstrate multiple foci of high signal in the deep and periventricular white matter, and to a lesser extent in the subcortical white matter of the cerebral hemispheres, likely sequela of chronic small vessel ischemic disease in a patient of this age. There is a small chronic infarction in the left inferior cerebellar hemisphere. There is moderate cerebral atrophy with associated prominence of the ventricles and sulci. There is fluid and mild mucosal thickening in the left maxillary sinus. There is moderate mucosal thickening in the ethmoid air cells bilaterally. NECK MRA: There is a three-vessel aortic arch. The cervical common carotid, internal carotid, and vertebral arteries appear patent without evidence of hemodynamically significant stenoses. HEAD MRA: Flow is visualized in the intracranial internal carotid and vertebral arteries, and their major branches. M1 segment of the middle cerebral arteries demonstrate symmetric flow. However, superior and inferior division branches of the right middle cerebral artery are smaller in caliber compared to the left. There is no evidence for an intracranial aneurysm. IMPRESSION: 1. Multiple cortical foci of acute infarction in the right frontal and anterior parietal lobes, in the right middle cerebral artery territory. No significant mass effect at this time. No evidence of hemorrhagic transformation. 2. Two punctate chronic microhemorrhages in the paramedian right frontal lobe, which could be related to amyloid angiopathy, hypertension, or less likely a cavernous malformation. 3. Unremarkable neck MRA. 4. The superior and inferior division branches of the right middle cerebral artery are smaller in caliber compared to the left. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SLURRED SPEECH Diagnosed with CEREBRAL ART OCCLUS W/INFARCT temperature: 97.2 heartrate: 71.0 resprate: 16.0 o2sat: 95.0 sbp: 188.0 dbp: 93.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure to take care of you at ___ ___. You were transferred to here because you had difficulty speaking and moving your left side, and you were found to have right frontal and parietal stroke. In the hospital, you had episodes of very deep sleeping, so EEG was done to monitor your brain waves. Because it showed sharp waves, you were started on a medication called Keppra to help with that. You DID NOT have a clear seizure. You were also found to have a urinary tract infection, so you were started on antibiotics.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The patient is a ___ year old ___ woman who comes in with LOC and a MVC who is 5 weeks pregnant with a history of anxiety, depression, ADHD, OCD, migraine headaches, h/o gastric bypass ___ and subsequent 130 lb wt loss. We were consulted to evaluate ___ weeks of episodes of bizarre visual symptoms, lightheadedness, syncope. For the past ___ weeks the patient has been having recurrent episodes of visual phenomenon, lightheadedness, and generalized weakness. These three symptoms sometimes occur separately and at other times occur together. They have been growing more frequent and are now occuring at least ___ times per day. The visual phenomenon she describes as "checkers" of skinny, tan colored, horizontal lines across her vision that mostly obscures her vision. There is also a variation on this which she calls "sand" which also covers her vision and obscures it. There is no migration or progression from one quadrant to another, instead the phenomenon covers her entire visual field. These episodes tend to occur mostly when she is standing up for a prolonged period, or when she goes from sitting to standing quickly. Thus she has started to try to stand up slower. Generally when this happens she has to grab onto things around her and lowers herself to the ground which helps. The symptoms generally resolved after ___ minutes. She has also been having episodes of lightheadedness intermittently which can be associated with the visual symptoms but not always. Finally, she has epsideso of "legs going noodles" which she describes as a generalized weakness. When she tries to stand up from her bed to go to the bathroom especialyl she notes that she feels generally weak and her legs give out on her. On several occasions she has had to lower herself to the ground and call for help. She also notes that she finds herself needing to sit down or lean against objects more often than prior. The patient has had 3 episodes of syncope in the past 2 weeks (including the episode leading to her current MVC). Her first episode occured when she was walking down the hallway in her house. She then felt lightheaded and felt her legs buckle, and she remembers lowering herself towards the floor, but she then lost conciousness and awoke to find her daughter next to her. The second episode occured when she was in the shower and she sat down in the shower, she does not remember this episode well. The third episode was today leading to her MVC. She was driving back from ___ when she experienced the visual "checkers" phenomenon, and then blacked out. She slammed her car into a pole and does not remember waking up until after the accident. This is one of the first times she has had an episode like this while she was sitting down. On neurologic review of systems, the patient denies current headache, lightheadedness, or confusion. Endorses some recent word finding difficulty in the past several weeks. Denies loss of vision, blurred vision, diplopia, vertigo Denies muscle weakness. Denies loss of sensation, although she notes she occasionally gets tingling in 2 toes on her R foot Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, rigors, she does get "hot sweats" day and night. 130 lb weight loss recently after gastric bypass. Denies chest pain, palpitations, dyspnea, or cough. Endorses nausea, vomiting with the pregnancy, endorses constipation Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Endorses occasional anxiety attacks but no palpitations associated with the events above. Past Medical History: - 5 weeks pregnant - s/p gastric banding procedure ___, lost 130 lbs since then - anxiety - depression - ADHD - OCD - h/o headaches, likely migrinous: she describes a throbbing pressure on the top of her head, no nausea or vomiting but + photo and phonophobia. These occur 2x per month. No recent increase in frequency. Social History: ___ Family History: No history of seizure. M aunt with stroke. DM in the family. Fathers side has fibromyalgia, RSD. Physical Exam: General: NAD, lying in bed comfortably. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no meningismus Pulmonary: non labored Abdomen: Soft, obese Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. She is moderately inattentive. She gets the MOYB all mixed up and cannot proceed, she is able to do DOWB. History is disjointed. Structure of speech demonstrates fluency with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No dysarthria. Verbal registration and recall ___. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - I. not tested II. Equal and reactive pupils (3mm to 2mm). On fundoscopic exam, optic disc margins were sharp. Visual acuity was ___ R eye and ___ L eye, and visual fields were full to finger wiggling. III, IV, VI. smooth and full extraocular movements without diplopia or nystagmus. V. facial sensation was intact, muscles of mastication with full strength VII. face was symmetric with full strength of facial muscles VIII. hearing was intact to finger rub bilaterally. IX, X. symmetric palate elevation and symmetric tongue protrusion with full movement. XI. SCM and trapezius were of normal strength and volume. - Motor - Muscule bulk and tone were normal. No pronation, no drift. No tremor or asterixis. Delt Bic Tri ECR FExt FFlx IP Quad Ham TA Gas L 5 5 ___ 5 5 5 5 5 5 R 5 5 ___ 5 5 5 5 5 5 - Sensation - Intact to light touch, pinprick, and proprioception at the great toes. - DTRs - Bic Tri ___ Quad Gastroc L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. - Cerebellar - No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait - Normal initiation. Narrow base. Normal stride length and arm swing. Pertinent Results: ___ 10:45AM ___ PTT-33.6 ___ ___ 10:45AM PLT COUNT-199 ___ 10:45AM WBC-9.5 RBC-4.65 HGB-12.5 HCT-39.8 MCV-86 MCH-27.0 MCHC-31.5 RDW-13.3 ___ 10:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG ___ 10:57AM HGB-13.4 calcHCT-40 O2 SAT-59 CARBOXYHB-3 MET HGB-0 ___ 04:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 04:21PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 05:56AM WBC-6.8 RBC-4.16* HGB-11.4* HCT-36.0 MCV-86 MCH-27.4 MCHC-31.7 RDW-13.5 ___ 05:56AM VIT B12-315 ___ 05:56AM TSH-1.5 ___ 05:56AM CALCIUM-8.8 PHOSPHATE-4.7* MAGNESIUM-2.0 ___ 05:56AM ALT(SGPT)-13 AST(SGOT)-13 CK(CPK)-41 ALK PHOS-49 TOT BILI-0.3 ___ 05:56AM GLUCOSE-82 UREA N-9 CREAT-0.6 SODIUM-137 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-27 ANION GAP-9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 5 mg PO TID 2. BuPROPion 300 mg PO DAILY Discharge Medications: 1. Diazepam 5 mg PO TID 2. BuPROPion 300 mg PO DAILY 3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain refractory to tylenol RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: SYNCOPE MOTOR VEHICLE ACCIDENT BACK PAIN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRV HEAD W/O CONTRAST INDICATION: ___ year old pregnant woman status post syncope. Evaluate for dural venous sinus thrombosis. TECHNIQUE: 2D time-of-flight MRV of the brain with angiographic maximal intensity projection reformatted images. COMPARISON: None FINDINGS: Flow is visualized in the major dural venous sinuses, including the superior sagittal sinus, straight sinus, bilateral transverse sinuses, bilateral sigmoid sinuses, and visualized upper internal jugular veins, without evidence for occlusion. There are 2 small, centrally located, nonocclusive apparent filling defects in the left transverse sinus on image 100:9, which are most likely related to invagination of arachnoid granulations, or less likely fenestrations. Their central location and nonocclusive nature are not consistent with thrombus. This may be confirmed by conventional routine brain MRI. IMPRESSION: No evidence for dural venous sinus thrombosis. Arachnoid granulations invaginating into the left transverse sinus versus fenestrations, which may be better defined with conventional routine brain MRI, if clinically warranted. Radiology Report EXAMINATION: EARLY OB US <14WEEKS INDICATION: ___ year old woman with 5 weeks pregnant // assess location of fetus LMP: unknown TECHNIQUE: Transabdominal and transvaginal examinations were performed. Transvaginal exam was performed for better visualization of the embryo. COMPARISON: None available FINDINGS: An intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of 5.3 mm representing a gestational age of 6 weeks 3 days for an estimated due date of ___. The uterus is normal. The left ovary is normal. The right ovary demonstrates a 0.6 x 0.7 x 0.6 cm echogenic focus in addition to a collapsed or hemorrhagic corpus luteum cyst. IMPRESSION: 1. Single live intrauterine pregnancy with gestational age of 6 weeks 3 days correlating with estimated due date of ___ 2. 7 mm echogenic focus within the right ovary likely representing an ovarian dermoid. Recommend followup ultrasound after pregnancy. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 13:20 AM Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: MRV with some irregularity in the transverse sinuses. // Eval for stroke, venous sinus thrombosis. TECHNIQUE: Routine ___ nonenhanced MRI examination of the brain, including sagittal T1 FLAIR, axial T2, axial FLAIR, axial T2 GRE, and axial diffusion images. COMPARISON: MRV from ___ and CT head from ___ FINDINGS: There is no acute infarct or intra cerebral hemorrhage. Principal intracranial vascular flow voids are preserved. Flow voids of the dural venous sinuses are also preserved. There is no increased signal on T1 and FLAIR and no negative susceptibility in the medial left transverse sinus to correspond to the possible filling defect seen on the MRV. The tiny filling defect in the lateral left transverse sinus is below the resolution of this exam. There is no T2 hyperintense focus to suggest an arachnoid granulation. A punctate focus of FLAIR hyperintensity in the left frontal lobe is nonspecific. No extra-axial blood or fluid collection is present. The ventricles and sulci are normal in size and configuration. No diffusion abnormality is detected. No intracranial mass is identified. The brainstem, posterior fossa, and cervicomedullary junction are preserved.No abnormality of the skull base or calvarium is identified. IMPRESSION: 1. No increased signal on T1 or FLAIR and no evidence of negative susceptibility in the medial left transverse sinus to suggest thrombosis. The finding seen on the MRV is likely due to slow flow. 2. The tiny filling defect in the lateral left transverse sinus is below the resolution of this exam. No T2 hyperintense signal to suggest an arachnoid granulation. If there is still concern for a small dural venous thrombosis, consider CTV Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: MVC Diagnosed with OTH CURR COND-ANTEPARTUM, MYALGIA AND MYOSITIS NOS, MV COLLISION NOS-DRIVER temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Dear ___, ___ were admitted to ___ neurology after ___ presented with episodes of loss of consciousness concerning for a seizure resulting in a motor vehicle accident. ___ had CT scans of your spine that were normal. ___ had a MRI of your brain that was normal. ___ had a prolonged EEG that was normal. To check for any cardiac causes for your symptoms ___ had a ECG and echocardiogram that were both normal. They recommended an outpatient holter monitor. After ___ are discharged from here ___ should go to the cardiology clinic on Deaconess ___ room 316 to get the holter monitor placed. ___ were seen by the obgyn doctors who recommended a fetal ultrasound that showed an intrauterine pregnancy. ___ should follow up with them in their Family Planning clinic as an outpatient as scheduled below.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro Attending: ___ Chief Complaint: Shortness of breath and chest pain Major Surgical or Invasive Procedure: Cardiac catheterization ___ History of Present Illness: ___ with H/O CAD s/p CABG x 3v in ___, S/P permanent pacemaker for paroxysmal atrial fibrillation with sick sinus syndrome, with recent admission for chest pain with recent dipyridamole-MIBI showing no reversible defects (but chest discomfort with vasodilator administration), who presents with several day history of jaw and left arm pain (which is her anginal equivalent), chest pain, and dyspnea. She reports that the pain in her jaw has been constant and is worsened over the past several days. The pain is worse with exertion, with associated shortness of breath and diaphoresis. Patient endorses chronic dyspnea, slightly worse from baseline recently. She reported no cough, no nausea or vomiting, and no other changes in symptoms in the interval since discharge. Patient was admitted ___ for similar symptoms and underwent dipyridamole-MIBI with no evidence of ischemia on nuclear imaging and LVEF 65%, but dipyridamole induced chest pressure radiating to throat and jaw. Her pacemaker was adjusted at that point for increased rate responsiveness with exertion, but there has not been any substantial improvement in her respiratory symptoms. Overall, respiratory symptoms seem to have come on gradually without any inciting event over the course of multiple weeks. In the ED initial vitals were: T 98.1 BP 142/81 HR 62 RR 16 SaO2 99% on RA. EKG showed atrial pacing at 63 bpm, normal axes and intervals, and no ST elevations. CXR showed no acute cardiopulmonary process with stable elevation of the right hemidiaphragm. Labs/studies notable for Troponin-T <0.01, Na 127; Chem 7, CBC, coags otherwise normal. Patient was given ASA 325 mg, acetaminophen 1000 mg, and lorazepam 0.5 mg. Vitals on transfer: T 97.8 BP 135/50 HR 61 RR 18 SaO2 98% on RA On arrival to the cardiology ward, the patient reported some ongoing shortness of breath and jaw pain with minimal chest pressure. Past Medical History: -Coronary Artery Disease -Stents (3) to RCA ___ -Stent to RCA ___ -POBA PDA and stent to LCX ___ -Stent to RCA ___ -CABG in ___ (LIMA-LAD, SVG-RCA, SVG-OM; Dr. ___ -Paroxysmal atrial fibrillation -S/P pacemaker for sick sinus syndrome ___ after syncope with 10 second pauses after conversion to NSR from atrial fibrillation -Raynaud's -subdural hematoma ___ -Depression -Gastroesophageal Reflux Disease -Hemorrhoids -Hyperlipidemia -Irritable Bowel Syndrome (Constipation) -Left Leg Weakness following Spine Surgery -Low Back Pain -Sciatica -Osteoarthritis Past Surgical History: -S/P Hemorrhoidectomy ___ -S/P Laminectomy L4-L5 ___ -S/P Total Abdominal Hysterectomy ___ -S/P Cholecystectomy ___ -S/P Bladder Sling ___ Social History: ___ Family History: Mother - died of myocardial infarction, age ___ Father - died of stroke, age uncertain Brother - died of complications from Diabetes mellitus, history of CABG x3, age ___ Physical Exam: On admission GENERAL: elderly white woman in NAD. Oriented x3. Mood, affect appropriate. VS: T 97.8 BP 135/50 HR 61 RR 18 SaO2 98% on RA HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP flat at 90 degrees CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops. LUNGS: Resp were unlabored, no accessory muscle use, speaking without difficulty. CTAB--no crackles, wheezes or rhonchi. ABDOMEN: Soft, not distended. No HSM or tenderness. NEURO: CN ___ intact, strength ___ and sensation intact throughout At discharge GENERAL: elderly woman in NAD. Oriented x3. Mood, affect appropriate. VS: T 98.3 BP 111-147/47-107 HR 60-71 RR 18 SaO2 95% on RA 24 hours ins/outs: 1140/none reported Overnight ins/outs: 0/none reported Wt 68.2 kg HEENT: NCAT. Sclera anicteric. MMM NECK: Supple with JVP to lower third of neck. CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops. LUNGS: Resp were unlabored, no accessory muscle use, speaking without difficulty. CTAB--no crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended. Ext: warm and well perfused; +1 distal and radial pulses bilaterally, no edema. Right femoral arteriotomy site clean, dry and intact; no femoral bruit. Pertinent Results: ___ 12:00PM BLOOD WBC-5.9 RBC-4.76 Hgb-13.6 Hct-41.3 MCV-87 MCH-28.6 MCHC-32.9 RDW-13.5 RDWSD-43.2 Plt ___ ___ 12:00PM BLOOD Glucose-95 UreaN-17 Creat-0.7 Na-127* K-4.4 Cl-92* HCO3-24 AnGap-15 ___ 12:00PM BLOOD cTropnT-<0.01 ___ 06:05PM BLOOD cTropnT-<0.01 ___ 07:55AM BLOOD cTropnT-<0.01 ___ 06:00AM BLOOD CK(CPK)-39 ___ 06:00AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-99 ___ 08:20AM BLOOD proBNP-168 ___ 08:20AM BLOOD WBC-5.0 RBC-4.49 Hgb-13.0 Hct-39.0 MCV-87 MCH-29.0 MCHC-33.3 RDW-13.5 RDWSD-43.1 Plt ___ ___ 08:20AM BLOOD ___ PTT-39.9* ___ ___ 08:20AM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-134 K-4.5 Cl-99 HCO3-25 AnGap-15 ___ 08:20AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3 ECG ___ 11:04:03 AM Atrial paced rhythm with intrinsic ventricular conduction. RSR' pattern in lead V1 (normal variant). Compared to the previous tracing of ___ the findings are similar. CXR ___ A left-sided pacemaker and dual leads as well as sternotomy wires are unchanged from prior examinations. The heart is normal in size. Aorta is unfolded, similar to prior. On lateral view, calcified or stented coronary artery is noted, also unchanged. Elevation and possible eventration of the right hemidiaphragm is similar to the prior film. No focal consolidation, pleural effusion, pulmonary edema or pneumothorax is identified. In the right cardiophrenic region, there is subsegmental atelectasis and/or scarring similar to ___ and ___. Linear atelectasis and/or scarring at the left base is also unchanged. Minimal blunting of one of the costo vertebral angles posteriorly is also unchanged. IMPRESSION: No acute pulmonary process identified. Stable elevation of the right hemidiaphragm. Stable atelectasis/scarring at both bases. Cardiac catheterization ___ Hemodynamics: State: Baseline LV 196/10 HR 64 AO 194/71/116 HR 64 Coronary Anatomy Dominance: Right * Left Main Coronary Artery: The LMCA is normal. * Left Anterior Descending: The LAD is moderately diseased mid, supplied by ___. The ___ Diagonal is supplied by ___. * Circumflex: The Circumflex is minimally diseased. The ___ Marginal is minimally diseased, supplied by SVG jump graft * Right Coronary Artery: The RCA is moderately diffusely diseased. Modest ostial dz. The Right PDA is minimally diseased. CTA CHEST ___ The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. There is a background of moderate calcific and noncalcific atherosclerosis. There is a dual lead pacemaker in situ, with leads located in the right ventricle in the right atrium. 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 supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is no pleural effusion. Mild bibasal linear atelectasis. There is a small calcified right apical granuloma. There is minimal bronchial wall thickening within the right lower lobe. Limited images of the upper abdomen demonstrate multiple hypodense lesions within the liver, representing cysts or biliary hamartomas. No lytic or blastic osseous lesion suspicious for malignancy is identified. There has been prior sternotomy. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Mild bibasal linear atelectasis. 3. Multiple hepatic cysts versus biliary hamartomas. Echocardiogram ___ The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Compared with the prior study (images reviewed) of ___, the findings are similar. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO BID 4. Escitalopram Oxalate 5 mg PO TID 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. Hydrocortisone Acetate Suppository ___AILY:PRN rectal pain 7. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN pain 8. LORazepam 0.5 mg PO TID 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Phenazopyridine 100 mg PO DAILY:PRN urinary pain 11. Vitamin D ___ UNIT PO DAILY 12. Zolpidem Tartrate 5 mg PO QHS 13. Cyclobenzaprine 5 mg PO TID:PRN back pain 14. Dexilant (dexlansoprazole) 60 mg oral DAILY 15. Lidocaine Jelly 2% 1 Appl TP Q6H:PRN hemorrhoids 16. Mylanta 2 teaspoons oral TID 17. salt irrigation solution ___ % nasal unknown 18. Senna with Docusate Sodium (sennosides-docusate sodium) 8.6-50 mg oral DAILY 19. TheraTears (carboxymethylcellulose sodium) 1 drop OPHTHALMIC Frequency is Unknown Discharge Medications: 1. Acetaminophen 1000 mg PO BID:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO BID 4. Escitalopram Oxalate 5 mg PO TID 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. Hydrocortisone Acetate Suppository ___AILY:PRN rectal pain 7. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN pain 8. Lidocaine Jelly 2% 1 Appl TP Q6H:PRN hemorrhoids 9. LORazepam 0.5 mg PO TID 10. Mylanta 2 teaspoons oral TID 11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 12. Phenazopyridine 100 mg PO DAILY:PRN urinary pain 13. Vitamin D ___ UNIT PO DAILY 14. Zolpidem Tartrate 5 mg PO QHS 15. Cyclobenzaprine 5 mg PO TID:PRN back pain 16. Dexilant (dexlansoprazole) 60 mg oral DAILY 17. salt irrigation solution ___ % nasal unknown 18. Senna with Docusate Sodium (sennosides-docusate sodium) 8.6-50 mg oral DAILY 19. TheraTears (carboxymethylcellulose sodium) 1 drop OPHTHALMIC Frequency is Unknown 20. Diltiazem 30 mg PO Q8H RX *diltiazem HCl 30 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: - Shortness of breath - Chest wall pain unlikely to be ischemic in origin - Costochondritis - Coronary artery disease - Prior coronary artery bypass surgery - Sick sinus syndrome - Paroxysmal atrial fibrillation - Prior implantation of a dual-chamber permanent pacemaker - Hyponatremia - Chronic back pain - Gastroesophageal reflux disease - Chronic abdominal pain - Depression and anxiety - Insomnia - Raynaud's 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 radiograph INDICATION: History: ___ with chest pressure // Eval for acute process TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs from ___ through ___ FINDINGS: A left-sided pacemaker and dual leads as well as sternotomy wires are unchanged from prior examinations. The heart is normal in size. Aorta is unfolded, similar to prior. On lateral view, calcified or stented coronary artery is noted, also unchanged. Elevation and possible eventration of the right hemidiaphragm is similar to the prior film. No focal consolidation, pleural effusion, pulmonary edema or pneumothorax is identified. In the right cardiophrenic region, there is subsegmental atelectasis and/or scarring similar to ___ and ___. Linear atelectasis and/or scarring at the left base is also unchanged. Minimal blunting of one of the costo vertebral angles posteriorly is also unchanged. IMPRESSION: No acute pulmonary process identified. Stable elevation of the right hemidiaphragm. Stable atelectasis/scarring at both bases. Radiology Report INDICATION: ___ with PMHx of CAD s/p CABG x 3 in ___, PPM for paroxysmal afib/sick sinus syndrome, with recent admission for chest pain w/ recent negative p-MIBI, who presents with several day history of jaw pain (which is her anginal equivalent), diaphoresis, and dyspnea. // any e/o PE or dissection 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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 8.0 s, 1.0 cm; CTDIvol = 18.5 mGy (Body) DLP = 18.5 mGy-cm. 3) Stationary Acquisition 2.0 s, 1.0 cm; CTDIvol = 4.6 mGy (Body) DLP = 4.6 mGy-cm. 4) Spiral Acquisition 8.4 s, 32.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 282.6 mGy-cm. Total DLP (Body) = 317 mGy-cm. COMPARISON: None FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. There is a background of moderate calcific and noncalcific atherosclerosis. There is a dual lead pacemaker in situ, with leads located in the right ventricle in the right atrium. 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 supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is no pleural effusion. Mild bibasal linear atelectasis. There is a small calcified right apical granuloma. There is minimal bronchial wall thickening within the right lower lobe. Limited images of the upper abdomen demonstrate multiple hypodense lesions within the liver, representing cysts or biliary hamartomas. No lytic or blastic osseous lesion suspicious for malignancy is identified. There has been prior sternotomy. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Mild bibasal linear atelectasis. 3. Multiple hepatic cysts versus biliary hamartomas. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain, L Arm pain Diagnosed with Other chest pain temperature: 98.1 heartrate: 62.0 resprate: 16.0 o2sat: 99.0 sbp: 142.0 dbp: 81.0 level of pain: 7 level of acuity: 2.0

Dear Ms. ___, Thank you for choosing to receive your care at ___. You were admitted for shortness of breath and chest pressure. Given your history of coronary artery disease and your recent hospital admission for similar symptoms, we assessed the degree of heart vessel blockage by coronary angiogram. The cornoary angiogram did not reveal any blockages in the blood flow. You also underwent a CT scan of your chest, which did not demonstrate any clots or damage to the large vessels in your chest. We did an ultrasound of your heart and the heart valves and pump function was normal. The ultrasound did show that the left side of your heart was enlarged but this was unchanged from your previous ultrasound in ___. We think your pain is likely related to pain in the muscles and bones in your chest wall affecting your jaw, versus small vessel disease in your heart which would not cause significant effects to your heart function. Moving forward, you should make sure to take the medications as listed below, and attend the follow up appointments listed below. If you develop worsening shortness of breath, chest pain, or other concerning symptom, please talk to your doctor right away. Again, it was our pleasure participating in your care here at ___. We wish you the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Codeine Attending: ___. Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: Liver biopsy ___. History of Present Illness: ___ male with BRCA1 mutation, breast cancer s/p mastectomy and axillary lymph node dissection, chemotherapy and radiation, prostate cancer, melanoma, and left ___ DVT s/p coumadin treatment presenting with abdominal pain. The patient's history is challenging secondary to slight confusion from dilaudid in the ER and his admittedly being overwhelmed with being told he likely has metastasis in the ER. He states that he has chronic abdominal pain but the morning of admission, it awoke ___ from sleep. It was on the right side of his abdomen, ___ in intensity, sharp, and not relieved by Maalox. He also "slipped" but did not his his head. He was admitted at another hospital 3 days ago for a routine endoscopy which was unrevealing; he was also started on Bactrim there for a UTI which he does not like because sulfa upsets his stomach. On arrival to the floor, he is anxious, frustrated, and overwhelmed but has less abdominal pain with the dilaudid. . Review of Systems: Unable to obtain complete ROS secondary to patient not cooperating. Past Medical History: Right breast cancer s/p mastectomy Secondary malignancy of breast to right axilla Prostate cancer treated ___ ago Melanoma s/p excision ___ years ago Left lower lobe pulmonary nodules arthritis Left lower extremity DVT ___ duplex Chronic left renal obstruction due to staghorn calculus noted on CT ___ . Right modified radical ___ Right rotator cuff repair cholecystectomy colon resection prostatectomy multiple excisions of skin lesions . CURRENT ONCOLOGY HISTORY (from note on ___: He was diagnosed with breast cancer in ___. He is a BRCA1 mutation carrier. The tumor in the right breast was 1.8 cm, ER positive, PR positive, grade 3 infiltrating ductal cancer, HER-2 negative. There were two involved lymph nodes also positive LVI. He had a right mastectomy. He started tamoxifen in ___. . When we started, his CEA was 14 that came down to about 11 in ___, has been stable. His ___ had been 40 and has been normal since then. His biggest issue is that when he went to get radiation therapy, there was so much erythema and inflammation of his chest wall and his right arm. He had already had right shoulder and arm discomfort ever since right shoulder surgery. The pain was so intolerable. . he still suffers from chronic pain. He takes 600 mg gabapentin (Neurontin) at night and one pill of 300 mg in the morning. The only other medicine is tamoxifen. . He had a DVT in his leg previously and had been on Coumadin, but he is off of that now. . He has a history of prostate cancer as well as a tumor at the base of his brain ___ years ago. . He had a CTA of his chest in ___ because of some shortness of breath and other symptoms. He had had some pulmonary nodules seen on his initial staging. It was unclear whether they were benign or cancerous. In any case, they were stable on the ___ CAT scan compared to ___. . Each time he comes over six months, we will draw extensive labs including tumor markers. Social History: ___ Family History: Significant for having two daughters with breast cancer at ages ___s a sister. He underwent genetic testing and is a mutation carrier. Physical Exam: ADMISSION EXAM: Vitals: T 97.8 bp 122/40 HR 73 RR 18 SaO2 96RA Wt 143.6 lbs GENERAL - Somewhat somnlent but easily aurosable HEENT - EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG, surgical scar from right mastectomy, tender on palpation of chest with discolored skin LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - diffusely tender with no distention, no rigidity or peritoneal signs, cannot fully appreciate liver margin secondary to pain EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, reports decreased sensation in both feet due to neuropathy; limited range of motion of right shoulder, tender on palpation of right arm/axilla/chest NEURO - awake, A&Ox3, CNs II-XII grossly intact PSYCH - tangential thought process, normal thought content, irritable Pertinent Results: ADMISSION LABS: ___ 03:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 03:30PM URINE BLOOD-TR NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 03:30PM URINE RBC-12* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 ___ 11:41AM LACTATE-1.1 ___ 11:36AM GLUCOSE-90 UREA N-25* CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 ___ 11:36AM ALT(SGPT)-20 AST(SGOT)-26 ALK PHOS-77 TOT BILI-0.4 ___ 11:36AM LIPASE-24 ___ 11:36AM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-2.0 ___ 11:36AM WBC-5.5 RBC-4.06* HGB-12.9* HCT-39.7* MCV-98 MCH-31.8 MCHC-32.5 RDW-13.0 ___ 11:36AM NEUTS-73.2* LYMPHS-17.0* MONOS-7.1 EOS-1.9 BASOS-0.7 ___ 11:36AM PLT COUNT-240 ___ 11:36AM ___ PTT-27.8 ___ . ___ CXR: No acute cardiopulmonary abnormality. . ___ CT ABD/PELVIS: IMPRESSION: 1. At least two new ill-defined hypodense hepatic lesions, measuring up to 2.0 cm, with new distal CBD wall enhancement and thickening resulting in intra- and extra-hepatic biliary obstruction. Findings are concerning for metastases from breast cancer involving the liver and distal common bile duct, although primary cholangiocarcinoma with hepatic metastases may also be considered. ERCP/MRCP is recommended for further evaluation. 2. Innumerable subcentimeter hepatic hypodensities, previously characterized as biliary hamartomas, grossly stable in size and number. 3. Chronic left renal obstruction due to staghorn calculus. 4. Numerous bilateral renal cysts, one of which has enlarged and another of which is complex. Renal ultrasound may be obtained for further evaluation if indicated. 5. No evidence of bowel obstruction or diverticulitis. . ___ RUQ U/S: FINDINGS: Within segment VIII near the junction with segment ___, there is a 2.0 cm round hypoechoic lesion with central slight relative increased echogenicity compared to the periphery. This lesion is concerning for metastasis. Similarly within segment VI, there is a slightly smaller lesion measuring 1.2 cm, also hypoechoic and concerning for metastasis. These lesions are feasible for US guided biopsy. . DISCHARGE LABS: ___ 07:42AM BLOOD WBC-5.9 RBC-3.82* Hgb-12.4* Hct-36.8* MCV-96 MCH-32.5* MCHC-33.8 RDW-13.3 Plt ___ ___ 07:55AM BLOOD Neuts-72.8* Lymphs-15.5* Monos-7.2 Eos-3.9 Baso-0.6 ___ 06:40AM BLOOD ___ PTT-28.3 ___ ___ 07:42AM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-139 K-4.2 Cl-106 HCO3-25 AnGap-12 ___ 07:55AM BLOOD Albumin-3.4* Calcium-8.6 Phos-3.1 Mg-1.7 ___ 06:20AM BLOOD ALT-14 AST-21 LD(LDH)-131 AlkPhos-68 TotBili-0.3 ___ 07:55AM BLOOD TSH-1.5 ___ 07:55AM BLOOD T4-6.8 calcTBG-1.07 TUptake-0.93 T4Index-6.3 ___ 06:40AM BLOOD Cortsol-5.7 ___ 07:55AM BLOOD CEA-19* ___ Medications on Admission: GABAPENTIN 300 mg PO qAM and 600mg PO qHS [M-VIT] TAMOXIFEN 10 mg PO BID (NOT TAKING) TEMAZEPAM 15 mg PO qHS PRN Bactrim ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] 500-1000mg PO PRN pain MELATONIN - 1 mg PO at night OMEPRAZOLE [PRILOSEC] Colace 100mg PO BID Maalox ___ PO QID PRN heartburn Clarilax PRN Discharge Medications: 1. gabapentin 600 mg PO TID. Disp:*180 Capsule(s)* Refills:*2* 2. tamoxifen 10 mg PO BID. Disp:*60 Tablet(s)* Refills:*1* 3. temazepam 15 mg PO HS. 4. acetaminophen 325-650mg PO q6HR PRN pain. 5. omeprazole 20 mg PO DAILY. 6. oxycodone 20 mg Extended Release 12 hr PO Q12H. Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* 7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H PRN pain. Disp:*100 Tablet(s)* Refills:*0* 8. docusate sodium 100 mg PO BID. 9. senna 8.6 mg PO BID. 10. polyethylene glycol 3350 17 gram Powder in Packet PO DAILY. Disp:*20 Powder in Packet(s)* Refills:*1* 11. prochlorperazine maleate ___ PO q6HR PRN nausea. Disp:*20 Tablet(s)* Refills:*1* 12. alum-mag hydroxide-simeth 200-200-20mg/5mL Sig: ___ PO QID PRN heartburn. 13. ciprofloxacin 500 mg PO Q12H x2 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Abdominal pain. 2. New liver metastases. 3. Breast cancer. 4. Chronic right arm and chest pain/neuropathy. 5. Urinary tract infection (UTI). 6. Kidney stone. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Esophageal dilatation one week ago. COMPARISON: ___. PA AND LATERAL VIEWS OF THE CHEST: The heart size is normal. The aorta is mildly tortuous and demonstrates mild calcification at the aortic arch. The pulmonary vascularity is normal. A 7-mm calcified nodule within the left lower lobe is again demonstrated compatible with a granuloma. Hyperinflation of lungs is unchanged suggestive of underlying COPD. There are no acute osseous abnormalities. Surgical anchors from prior rotator cuff repair are seen within the right humeral head, partially imaged. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report INDICATION: ___ man with right lower quadrant abdominal pain and tenderness. History of appendectomy and cholecystectomy. Evaluate for obstruction or diverticulitis. COMPARISONS: Multiple prior CT abdomen and pelvis, most recently CT torso of ___. TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis. 130 cc of IV Omnipaque contrast were administered. Axial images were interpreted in conjunction with coronal and sagittal reformats. DLP: 279 mGy-cm. FINDINGS: The visualized heart is normal. Bibasilar opacities are compatible with atelectasis or scarring. Right calcified pleural plaques are again seen. Previously described pulmonary nodules are not imaged on this exam. At least two new ill-defined hypodense lesions are seen in the liver, the largest of which measures 2.0 x 1.2 cm in hepatic segment VIII (601B:18). A smaller new 1.3 x 0.9 cm hepatic segment VI hypodensity (2:19) is also seen. Innumerable subcentimeter hypodense hepatic lesions, previously characterized as biliary hamartomas, are again seen. There is increased intra- and extra-hepatic bile duct dilatation with wall thickening and enhancement of the distal common bile duct (___), with the distal CBD now measuring 1 cm in diameter. The gallbladder is absent. The pancreas and pancreatic duct are unremarkable. No pancreatic mass is seen. The spleen and bilateral adrenal glands are unremarkable. A large staghorn calculus is again seen in the left kidney and the left kidney demonstrates subtly decreased enhancement relative to the right kidney. No excreted contrast is seen in the left ureter. Numerous bilateral renal hypodensities are again seen. A 1.6 x 1.5 cm left lower pole hypodensity has enlarged since the prior exam, previously 9-mm. A complex left renal cyst with a peripheral calcification (2:23) is again seen. The stomach is unremarkable. The visualized small and large bowel have a normal course and caliber. Diverticulosis is present without evidence of diverticulitis. The appendix is absent, compatible with history of appendectomy. No retroperitoneal or mesenteric lymphadenopathy. The portal vasculature is normal. Dense abdominal aortic calcifications are again seen. A large atherosclerotic calcification is present at proximal left renal artery. Left perirenal varices are again seen. No abdominal wall hernia, pneumoperitoneum, or abdominal free fluid. PELVIS: The bladder is normal. Evaluation of pelvic structures is obscured by beam hardening from numerous metallic pelvic clips, compatible with prostatectomy, and inguinal clips. No inguinal or pelvic side wall lymphadenopathy. No free pelvic fluid or inguinal hernia. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. At least two new ill-defined hypodense hepatic lesions, measuring up to 2.0 cm, with new distal CBD wall enhancement and thickening resulting in intra- and extra-hepatic biliary obstruction. Findings are concerning for metastases from breast cancer involving the liver and distal common bile duct, although primary cholangiocarcinoma with hepatic metastases may also be considered. ERCP/MRCP is recommended for further evaluation. 2. Innumerable subcentimeter hepatic hypodensities, previously characterized as biliary hamartomas, grossly stable in size and number. 3. Chronic left renal obstruction due to staghorn calculus. 4. Numerous bilateral renal cysts, one of which has enlarged and another of which is complex. Renal ultrasound may be obtained for further evaluation if indicated. 5. No evidence of bowel obstruction or diverticulitis. Radiology Report CLINICAL HISTORY: Patient with new liver lesions suspicious for metastases. Feasibility to assess for ultrasound-guided biopsy. STUDY: Limited ultrasound, liver. ___. FINDINGS: Within segment VIII near the junction with segment ___, there is a 2.0 cm round hypoechoic lesion with central slight relative increased echogenicity compared to the periphery. This lesion is concerning for metastasis. Similarly within segment VI, there is a slightly smaller lesion measuring 1.2 cm, also hypoechoic and concerning for metastasis. These lesions are feasible for US guided biopsy. Radiology Report ULTRASOUND-GUIDED LIVER BIOPSY DATED ___ INDICATION: ___ man with liver mass. History of breast, prostate and melanoma. Biopsy liver lesion. COMPARISON: Comparison is made to previous ultrasound dated ___ and CT dated ___. PHYSICIANS: Dr. ___ and Dr. ___, performed the procedure. Dr. ___ attending radiologist, was present throughout the procedure. SEDATION: Moderate sedation was provided by administering divided doses of Versed 1 mg and fentanyl 50 mcg throughout the total intraservice time of 20 minutes, during which the patient's hemodynamic parameters were continuously monitored. PROCEDURE: Following a detailed discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained. The patient was transferred to the ultrasound suite and placed in a supine position. Initial preprocedure timeout was performed to localize the segment VIII liver lesion. A suitable skin point for biopsy was obtained. A preprocedure timeout was performed using three unique patient identifiers as per ___ protocol. The skin overlying the right upper quadrant was prepped and draped in usual sterile fashion. Approximately 6 mL of 1% lidocaine was infiltrated into the skin, subcutaneous tissue and to the liver capsule for local anesthesia. An 18-gauge core biopsy needle was advanced into the liver lesion and a single 18-gauge core biopsy sample was obtained. Onsite cytology confirmed sample adequacy. The patient tolerated the procedure well. There were no immediate complications. The patient was transferred back to the floor in stable condition. Sample was sent to pathology for further analysis. IMPRESSION: Technically successful ultrasound-guided 18-gauge core biopsy of segment VIII liver lesion. Onsite cytology confirmed sample adequacy. No immediate complication. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN RUQ temperature: 97.4 heartrate: 86.0 resprate: 22.0 o2sat: 97.0 sbp: 105.0 dbp: 68.0 level of pain: 10 level of acuity: 3.0

You were admitted to the hospital for worsening abdominal pain that is likely due to cancer in the liver. To confirm this, you had a liver biopsy, the results are still pending. In case this is breast cancer and considering your high risk of a breast cancer recurrence, tamoxifen was restarted. Your pain has been controlled with a combination of OxyContin and hydromorphone (Dilaudid). The OxyContin is long-acting and should be taking twice a day regardless of the level of your pain. It will not help taking it for acute/sudden pain. The hydromorphone (Dilaudid) can be taken in addition to the OxyContin for acute/sudden pain. For the chronic pain at the right arm and chest, your gabapentin (Neurontin) dose was increased. You also have a urinary tract infection and will need to complete a course of antibiotics at home. CT of your abdomen shows that you have chronic kidney stones that may be contributing to the urinary tract infection. . MEDICATION CHANGES: 1. OxyContin 20mg 2x a day. 2. Hydromorphone as needed for breakthrough pain. 3. Gabapentin (Neurontin) 600mg 3x a day. 4. Tamoxifen 2x a day. 5. Ciprofloxacin 2x a day.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: ___ TEE ___ Cardiac Catheterization ___ CABG x1 (SVG-PDA), MVR (31mm ___ tissue valve) History of Present Illness: ___ male with history of untreated HTN and 80 pack-year smoking history, presenting with progressive dyspnea. Patient presented to ___ for 3 months of progressive dyspnea. The patient that his first symptoms was worsening sleep at night, as he has severe PND limiting him to 1 hour of sleep at night. Because of this he quit smoking around 4 weeks ago, but he has become progressively dyspneic since this time. He has significant dyspnea on exertion and is limited to only ___ steps before becoming short of breath. He also notes fatigue during this time because he cannot sleep. Denies full review of systems including fevers, chills, cough, abdominal pain, nausea, vomiting, chest. At ___, he underwent an ECHO that showed severe MR, a flail mitral leaflet, and possible mass on the valve cusp. He was transferred to ___ for further evaluation, including cardiac surgery. In the ___ ED, he underwent bedside ECHO with cardiology which confirmed the above findings. He was then admitted to the ___ service for further management. In the ED... - Initial vitals: 96.7 ___ 18 96% RA - EKG: NSR, poor R wave progression - Labs/studies notable for: BNP 5168 On the floor, the patient endorsed the above history. Last seen a primary care doctor ___ years ago, at which time he was told he has hypertension but declined any medical therapies. He has not had a colonoscopy or any other routine screening. Past Medical History: Hypertension Social History: ___ Family History: Noncontributory to presenting complaint Physical Exam: Admission: ___ Temp: 97.6 PO BP: 169/121 HR: 103 RR: 20 O2 sat: 95% O2 delivery: ra GEN: Well appearing, NAD HEENT: Conjunctiva clear, PERRL, MMM NECK: No JVD noted LUNGS: Decreased lungs sounds apically HEART: RRR, nl S1, S2. III/VI holosystolic murmur heard at apex, radiating into back ABD: NT/ND, normal bowel sounds. EXTREMITIES: No edema. WWP. SKIN: No rashes. NEURO: AOx3. Discharge: Vital Signs I/O 24 HR Data (last updated ___ @ 1123) Temp: 97.4 (Tm 98.5), BP: 125/84 (123-156/78-108), HR: 62 (62-72), RR: 18 (___), O2 sat: 99% (94-99), O2 delivery: Ra, Wt: 198.63 lb/90.1 kg Fluid Balance (last updated ___ @ 1123) Last 8 hours Total cumulative -1460ml IN: Total 290ml, PO Amt 240ml, IV Amt Infused 50ml OUT: Total 1750ml, Urine Amt 1750ml Last 24 hours Total cumulative -2645ml IN: Total 530ml, PO Amt 480ml, IV Amt Infused 50ml OUT: Total 3175ml, Urine Amt 3175ml Physical Examination: General: NAD [x] Neurological: A/O x3 [x] non-focal [x] HEENT: PEERL [x] Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [] Respiratory: Decreased bilat [x] No resp distress [x] 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 1 Left Lower extremity Warm [x] Edema 1 Pulses: DP Right:1 Left:1 ___ Right:1 Left:1 Radial Right: Left: Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema [x] Bone stable & small amount serous drainage[x] Sternum stable [x] Lower extremity: Right [] Left [x] CDI [x] Other: Pertinent Results: Admission Labs: ___ 02:40PM BLOOD WBC-8.9 RBC-5.26 Hgb-14.9 Hct-46.7 MCV-89 MCH-28.3 MCHC-31.9* RDW-13.2 RDWSD-43.3 Plt ___ ___ 02:40PM BLOOD ___ PTT-32.1 ___ ___ 02:40PM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-137 K-4.6 Cl-100 HCO3-20* AnGap-17 ___ 02:40PM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.3 Mg-1.8 ___ 07:25AM BLOOD %HbA1c-5.4 eAG-108 Discharge Labs: ___ 04:24AM BLOOD WBC-10.7* RBC-3.53* Hgb-9.9* Hct-31.3* MCV-89 MCH-28.0 MCHC-31.6* RDW-13.7 RDWSD-43.8 Plt ___ ___ 04:24AM BLOOD ___ ___ 04:33AM BLOOD ___ ___ 04:18AM BLOOD ___ PTT-29.9 ___ ___ 04:24AM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-134* K-4.5 Cl-98 HCO3-24 AnGap-12 ========================================================= Studies: PA/LAT CXR ___ pulmonary edema has resolved. Small bilateral pleural effusions. Intraop TEE ___ PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm. Preop Comments: Sever MR. ___ thickened leaflets. Ruptured chordae tendineae in A1 and A3 region eith a large echodense mass attached to the chord in the A1 region which may represent part of the papillary muscle or a vegetation. Left Atrium ___ Veins: Dilated ___. No spontaneous echo contrast is seen in the ___. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): DIlated RA. Normal interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Mild symmetric hypertrophy. Normal cavity size. No apical aneurysm Normal regional & global systolic function Normal ejection fraction. No resting LV outflow tract gradient. Grade III diastolic dysfunction. Right Ventricle (RV): Normal wall thickness. Normal cavity size. Low normal free wall motion. Aorta: Normal sinus diameter. Normal ascending diameter. Normal arch diameter. Normal descending aorta diameter. No dissection. Siimple atheroma of ascending aorta. No arch atheroma. Simple descending atheroma. Aortic Valve: Mildly thickened (3) leaflets. Mild leaflet calcification. Mild (>1.5cm2) stenosis. No regurgitation. Mitral Valve: Mildly thickened leaflets. Mild leaflet calcification. Large (>1.0cm) mobile MASS on ___ of valve most c/w a vegetation, tumor, or thrombus. No valvular ___. No stenosis. Mild annular calcification. SEVERE [4+] regurgitation. Eccentric, inferolaterally directed jet. Tricuspid Valve: Normal leaflets. Mild-moderate [___] regurgitation. Eccentric, interatrial septal directed jet. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 18:00:00. AV paced rhythm. Support: Vasopressor(s): norepinephrine. Interatrial Septum: No atrial septal defect by 2D/color flow Doppler. Left Ventricle: Similar to preoperative findings. Global ejection fraction is normal. Right Ventricle:No change in systolic function. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. Mitral Valve: Bioprosthesis. Well-seated prosthesis. Normal leaflet motion. Post-bypass, mean mitral valve gradient = 5mmHg. Trace regurgitation. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. Pericardium: No effusion. Cardiac Cath ___ • Normal left and right heart filling pressures. • Single vessel coronary artery disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever max 4000mg/day 2. Amiodarone 400 mg PO BID postop AFib 400mg BID x 3 days, then 200mg BID x 7 days, then 200mg daily RX *amiodarone 400 mg 1 tablet(s) by mouth as directed Disp #*30 Tablet Refills:*2 3. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 4. Atorvastatin 10 mg PO DAILY RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*1 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. Furosemide 40 mg PO BID 40mg po BID x 3 days, then decrease to 40mg daily x 7 days RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day Disp #*13 Tablet Refills:*0 7. Metoprolol Tartrate 6.25 mg PO TID RX *metoprolol tartrate 25 mg 0.25 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*1 8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 9. Potassium Chloride 20 mEq PO BID 20meq po BID x 3 days, then 20meq po daily x 7 days RX *potassium chloride [K-Tab] 20 mEq 1 tablet(s) by mouth as directed Disp #*13 Tablet Refills:*0 10. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 11. Warfarin 1 mg PO ASDIR tiss MVR & postop Afib Duration: 3 Months 0.5-2 tablets daily as directed for goal INR ___ RX *warfarin 1 mg ___ tablet(s) by mouth as directed Disp #*60 Tablet Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Acute mitral regurgitation atrial fibrillation Secondary: Hypertension Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema. Small amount serous drainage from middle incision. Stable bone. Edema- 1+ BLE Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old man with history of HTN presents with severe MR and concern for flail leaflet// pre-op CXR Surg: ___ (MVR) COMPARISON: Chest radiograph from ___. FINDINGS: PA and lateral views of the chest provided. Since the prior radiograph from ___, mild pulmonary edema has improved. There is no pleural effusion or pneumothorax. Borderline cardiomegaly is stable. Multiple healed right posterior rib fractures. Mild vertebral body height loss in the midthoracic spine, of uncertain chronicity. IMPRESSION: Mild pulmonary edema, improved. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ yo M s/p MVR// cardiac surgery protocol Contact name: icu provider, Phone: 1 TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: There are postsurgical changes from mitral valve replacement. The endotracheal tube terminates 5.4 cm above the carina. The right internal jugular Swan-Ganz catheter terminates in the main pulmonary outflow tract. The enteric tube terminates in the fundus of the stomach. A left chest tube and pericardial and mediastinal drains are in place. The cardiac silhouette remains enlarged. There is mild widening of the upper mediastinum, in keeping with recent postsurgical changes. Patchy opacities in the left lung most likely represent asymmetric pulmonary edema. No pleural effusion or pneumothorax is identified. No acute osseous abnormalities are identified. Radiology Report INDICATION: ___ year old man s/p MVR, CABG// eval for pneumothorax s/p CT removal COMPARISON: Radiographs from ___ IMPRESSION: Endotracheal tube, Swan-Ganz catheter, feeding tube, and chest tube have been removed. There is a residual right IJ Cordis. There is cardiomegaly which is stable. There has been mild improvement of the pulmonary edema which is now mild. No large pleural effusions or pneumothoraces are seen. Old left upper posterior rib fractures are seen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man with s/p CABG/MVR// eval pulmonary edema/pleural effusion eval pulmonary edema/pleural effusion IMPRESSION: Compared to postoperative chest radiographs ___. Mild pulmonary edema has developed since ___. Postoperative appearance of the cardiomediastinal silhouette is expected, and unchanged. Pleural effusions are small if any. No pneumothorax. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man s/p MVR, CABG// please check after 2pm todaypredischarge eval COMPARISON: Chest radiograph ___ FINDINGS: PA and lateral views of the chest provided. There has been interval resolution of mild pulmonary edema. There are small bilateral pleural effusions. There is no pneumothorax. Cardiomediastinal silhouette is within normal postoperative limits. There are multiple healed posterior left rib fractures. Median sternotomy wires are well aligned. IMPRESSION: Mild pulmonary edema has resolved. Small bilateral pleural effusions. Gender: M Race: NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Dyspnea, unspecified temperature: 96.7 heartrate: 102.0 resprate: 18.0 o2sat: 96.0 sbp: 152.0 dbp: 105.0 level of pain: 0 level of acuity: 2.0

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

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / pravastatin / simvastatin / Tricor / rosuvastatin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: TEE and Ablation on ___ History of Present Illness: Mr. ___ is a ___ yo M with hx of aortic stenosis s/p AVR (tissue), CAD s/p CABGx2 ___, DM, ESRD on HD (MWF), HLD, HTN, AV block who presents with progressively worsening dyspnea for ___ days despite regularly scheduled dialysis sessions. Dyspnea worse with minimal exertion, initially saw PCP on ___, who recommended ED evaluation but he instead went to scheduled dialysis and had 2.2L fluid removed which improved his dyspnea. However, since then, dyspnea worsened. He slept in chair the night before admission and notes increased leg swelling particularly starting last night. He notes improving chest pain surrounding his sternal incision (required less pain medicine). On exertion, patient sometimes has chest tightness and lightheadedness with SOB, but none at rest. Denies palpitations and syncope. Most recent TTE on ___ showed mild LVH and normal LV systolic function (EF > 55%) with well-seated biopresthetic AVR, no aortic regurgitation and mild pulmonary artery systolic hypertension (PASP 31) In the ED initial vitals were: T 97, HR 54-62, BP 133-164/53-57, RR ___, 96% 3L NC. Exam notable for JVP 10 cm H2O, ___ systolic murmur at RUSB, decreased BS in the lung bases, 1+ ___ pitting edema. EKG showed NSR at 71, atrial flutter with 3:1, no STE & TWI in V6. Labs remarkable for BUN 30, Cr 5.6, Hb 9.9, BNP 9610, Troponin 0.17 (decreased from 0.40 on ___, INR 1.7, lactate 1.7. UA positive for 33 WBC, 15 RBC, proteinuria. Urine and blood cultures pending. CTA showed no evidence of PE but had interval minimal dehiscence of median sternotomy with erosion of the margins and stranding of the subcutaneous concerning for inflammation/infection and near complete collapse of RLL (progressed since ___ with bilateral pleural effusions (right greater than left), stable lung nodules in RUL. Renal was consulted and patient underwent hemodialysis. On the floor, patient reports improved SOB after dialysis. He denies fevers, chills, dysuria, abdominal pain, diarrhea. Denies changes in diet other than decreased appetite due to abdominal distension. Patient states lowest weight has been after dialysis on ___ (94.5 kg). Past Medical History: Aortic Stenosis Arrhythmia Colitis Coronary Artery Disease Depression Diabetes Mellitus, Insulin Dependent Difficult Intubation End-Stage Renal Disease, HD ___ via right chest access Facial Droop, ___, self-resolved First Degree AV block Gastroesophageal Reflux Disease Gout Hearing Loss Hyperlipidemia Hypertension Hypothyroid Lipomas bilateral axilla Low Testosterone Neuropathy Reflux Laryngitis Pancreatic Insufficiency Pancreatitis s/p resection Scoliosis ? Seizure while on Depakote for diabetic nerve pain ___ yrs ago Sleep Apnea Surgical History: Cholycystectomy and Partial Pancreatectomy Left Radiocephalic AVF and Left brachiocephalic AVF Right otologic procedure x ___ Microlaryngeal procedure Tooth extraction Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.1F 149/79, HR 65, RR 22, 94% 3L GENERAL: Well developed, well nourished in NAD HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. MMM, oropharynx clear NECK: Supple. JVP of 12 cm sitting up. CARDIAC: regular rate, ___ systolic ejection murmur at RUSB CHEST: midline sternotomy scar with dried granulomatous tissue, mildly tender with palpation LUNGS: Decreased BS at bases, no crackles or wheezing ABDOMEN: soft, non-distended, nontender, normoactive BS EXTREMITIES: warm, 1+ pitting edema to knees bilaterally PULSES: DP pulses 2+ bilaterally NEURO: CN II-XII intact except decreased bilateral hearing, sensation intact bilaterally, strength symmetric DISCHARGE PHYSICAL EXAMINATION: VS: 98.3F, 125/58, HR 55, RR 18, 94% RA GENERAL: Well developed, well nourished in NAD HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. MMM, oropharynx clear NECK: Supple. No JVP elevation CARDIAC: bradycardic, ___ systolic ejection murmur at RUSB CHEST: left chest pain reproducible with palpation LUNGS: Decreased BS at RLL, no crackles or wheezing ABDOMEN: soft, non-distended, nontender, normoactive BS EXTREMITIES: warm, non-edematous, non-tender bilaterally. PULSES: ___ pulses 2+ bilaterally Pertinent Results: ADMISSION LABS ___ 09:39AM BLOOD WBC-7.8 RBC-3.32* Hgb-9.9* Hct-33.3* MCV-100* MCH-29.8 MCHC-29.7* RDW-17.4* RDWSD-63.7* Plt ___ ___ 09:39AM BLOOD Neuts-76.1* Lymphs-12.4* Monos-7.4 Eos-2.0 Baso-0.8 NRBC-0.3* Im ___ AbsNeut-5.96 AbsLymp-0.97* AbsMono-0.58 AbsEos-0.16 AbsBaso-0.06 ___:39AM BLOOD ___ PTT-33.4 ___ ___ 09:39AM BLOOD Plt ___ ___ 09:39AM BLOOD Glucose-299* UreaN-30* Creat-5.6*# Na-137 K-4.5 Cl-94* HCO3-28 AnGap-15 ___ 09:39AM BLOOD proBNP-9610* ___ 09:39AM BLOOD cTropnT-0.17* ___ 09:40PM BLOOD CK-MB-4 cTropnT-0.17* ___ 09:39AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.1 ___ 10:45AM BLOOD VitB12-426 Hapto-204* ___ 09:39AM BLOOD TSH-1.8 ___ 08:00AM BLOOD CRP-27.7* ___ 07:42AM BLOOD CRP-19.9* DISCHARGE LABS ___ 06:19AM BLOOD WBC-7.6 RBC-3.41* Hgb-9.9* Hct-33.3* MCV-98 MCH-29.0 MCHC-29.7* RDW-16.3* RDWSD-59.3* Plt ___ ___ 06:19AM BLOOD Plt ___ ___ 07:51AM BLOOD ___ PTT-84.1* ___ ___ 06:19AM BLOOD Glucose-146* UreaN-46* Creat-6.3*# Na-140 K-5.0 Cl-95* HCO3-26 AnGap-19* ___ 06:19AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.4 IMAGING CTA ___ 1. No evidence of acute pulmonary embolism. 2. Interval minimal dehiscence of the median sternotomy by 4 mm with erosion of the margins and stranding of the overlying subcutaneous tissue, concerning for inflammation/infection. No drainable fluid collection. Wires are intact. 3. Near complete collapse of the right lower lobe, progressed since ___. Mild enlargement of the bilateral nonhemorrhagic pleural effusions, moderate on the right and small on the left. 4. Stable solid lung nodules as described above. 8 mm ground-glass nodule is likely inflammatory given short term interval change. Please refer to the prior exams for follow-up. CXR ___ Compared to chest radiographs ___. Moderate right pleural effusion and severe right lower lobe atelectasis are unchanged. Moderate enlargement of the cardiac silhouette has increased and mild interstitial edema has developed best appreciated in the left lower lung. No pneumothorax. Right jugular line ends in the right atrium as before. CXR ___ Moderate right and small left pleural effusions with overlying atelectasis. CXR ___ The tip of a right hemodialysis catheter extends to the right atrium. The patient is post median sternotomy and aortic valve replacement. Atelectasis is noted at the right lung base as well as a small pleural effusion. No pneumothorax. Pulmonary vascular congestion is present without frank pulmonary edema. The size of the cardiac silhouette is enlarged but unchanged. CXR ___ Mild venous congestion with unchanged small right and minimal left pleural effusions. CXR ___ Mild pulmonary venous congestion. Possible small right effusion. MICROBIOLOGY Urine Culture ___: no growth Blood Culture ___: no growth Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 30 mL PO Q6H:PRN constipation 2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 3. Allopurinol 50 mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. DULoxetine 60 mg PO DAILY 6. Fluticasone Propionate 110mcg 2 PUFF IH BID SOB 7. HydrALAZINE 25 mg PO BID 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. LORazepam 1 mg PO TID 11. Nephrocaps 1 CAP PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Rosuvastatin Calcium 5 mg PO QPM 14. Warfarin 2.5 mg PO DAILY16 15. TraMADol ___ mg PO Q4H:PRN Pain - Severe 16. Asmanex HFA (mometasone) 200 mcg/actuation inhalation Q4H:PRN 17. Baclofen ___ mg PO QHS:PRN Muscle Spasms 18. Calcium Acetate 1334 mg PO TID W/MEALS 19. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash 20. Hydrocortisone Oint 2.5% 1 Appl TP PRN rash 21. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe 22. QUEtiapine Fumarate 25 mg PO QHS 23. Torsemide 100 mg PO DAILY 24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash 25. amLODIPine 10 mg PO DAILY 26. Glargine 55 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Ezetimibe 10 mg PO DAILY RX *ezetimibe 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Glargine 35 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe 6. QUEtiapine Fumarate 25 mg PO QHS 7. HydrALAZINE 100 mg PO TID RX *hydralazine 100 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 8. LORazepam 0.5 mg PO QHS:PRN anxiety/airhunger without hypoxia RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*15 Tablet Refills:*0 9. Warfarin 5 mg PO DAILY16 RX *warfarin [Coumadin] 1 mg 5 tablet(s) by mouth daily Disp #*150 Tablet Refills:*0 10. Allopurinol 50 mg PO EVERY OTHER DAY 11. amLODIPine 10 mg PO DAILY 12. Asmanex HFA (mometasone) 200 mcg/actuation inhalation Q4H:PRN 13. Aspirin EC 81 mg PO DAILY 14. Baclofen ___ mg PO QHS:PRN Muscle Spasms 15. Calcium Acetate 1334 mg PO TID W/MEALS 16. DULoxetine 60 mg PO DAILY 17. Fluticasone Propionate 110mcg 2 PUFF IH BID SOB 18. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash 19. Hydrocortisone Oint 2.5% 1 Appl TP PRN rash 20. Lactulose 30 mL PO Q6H:PRN constipation 21. Levothyroxine Sodium 50 mcg PO DAILY 22. LORazepam 1 mg PO TID 23. Nephrocaps 1 CAP PO DAILY 24. Pantoprazole 40 mg PO Q24H 25. TraMADol ___ mg PO Q4H:PRN Pain - Severe 26. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash 27.Outpatient Lab Work ___ INR, Na, K, Cl, HCO3, BUN, creatinine. 786.09, ___ Fax: Dr. ___ ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======== Heart failure with preserved ejection fraction Pleural effusion Right lung collapse Atrial flutter Coronary artery disease Thrombocytopenia End stage renal disease Hypertension SECONDARY ========== Diabetes Mellitus Anemia Hyperlipidemia Gastroesophageal reflux disease Hypothyroidism Depression Anxiety Gout Back spasm Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with sob, recent cardiac surgery// ? infectious process, effusions TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiographs from ___ and CT from ___. FINDINGS: Right subclavian dialysis catheter root tip over the right atrium. Median sternotomy wires are aligned intact. Aortic valve replacement is again noted. Since ___, right pleural effusion has increased in size, now moderate. Small left pleural effusion is also likely increased. There is no pneumothorax. Resultant atelectasis of the lower lobes have worsened, right greater than left. The aerated upper lungs remain mostly clear. The cardiomediastinal silhouette is grossly stable, though persistently moderately enlarged. IMPRESSION: Increasing pleural effusions, now moderate on the right and small on the left with worsening atelectasis. Radiology Report EXAMINATION: CTA chest INDICATION: History: ___ with dyspnea// 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) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP = 6.1 mGy-cm. 2) Spiral Acquisition 3.9 s, 30.6 cm; CTDIvol = 14.7 mGy (Body) DLP = 448.5 mGy-cm. 3) Spiral Acquisition 0.8 s, 6.1 cm; CTDIvol = 12.1 mGy (Body) DLP = 73.9 mGy-cm. 4) Spiral Acquisition 0.8 s, 6.1 cm; CTDIvol = 12.1 mGy (Body) DLP = 74.0 mGy-cm. Total DLP (Body) = 602 mGy-cm. COMPARISON: Chest CT from ___ and CTA from ___. FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. Postsurgical changes along the ascending aorta is noted with unchanged appearance calcifications as seen on ___ (3:61, 71, 99). Patient is status post endovascular aortic valvular replacement, though the evaluation of the valve placement is limited on the this non gated study. Right internal jugular central venous catheter tip terminates in the right atrium, unchanged. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar or segmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber. Patient is status post median sternotomy with cerclage wires, which are intact. However, compared to prior exam, there is evidence of dehiscence of the sternotomy by 4 mm with irregularity of the cortical margins, concerning for erosion. There is stable amount of hyperdense stranding in the mediastinum, presumably postsurgical changes. However, increased soft tissue stranding along the median sternotomy, extending slightly into the anterior abdomen is concerning for inflammatory changes. There is no supraclavicular, axillary or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is no pleural effusion. There is near complete collapse of the right lower lobe, progressed since ___. 8 mm ground-glass opacity in the aerated portion of the right lower lobe is likely inflammatory (3:101). Moderate nonhemorrhagic pleural effusions have also increased, moderate on the right and small on the left. Atelectasis in the left lower lobe is stable. Scattered calcified granulomas are again noted. 7 mm nodule in the right upper lobe with peripheral calcification is unchanged from ___ (03:35). The airways are patent to the subsegmental level. Limited images of the upper abdomen are unremarkable. Pre-existing nondisplaced right first, second and fifth rib fractures are again noted. There is evidence of interval healing of the right fifth rib fracture. No new fractures are seen. IMPRESSION: 1. No evidence of acute pulmonary embolism. 2. Interval minimal dehiscence of the median sternotomy by 4 mm with erosion of the margins and stranding of the overlying subcutaneous tissue, concerning for inflammation/infection. No drainable fluid collection. Wires are intact. 3. Near complete collapse of the right lower lobe, progressed since ___. Mild enlargement of the bilateral nonhemorrhagic pleural effusions, moderate on the right and small on the left. 4. Stable solid lung nodules as described above. 8 mm ground-glass nodule is likely inflammatory given short term interval change. Please refer to the prior exams for follow-up. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ESRD, hypoxia found to have RLL collapse on CTA and pleural effusions before dialysis// Interval change after dialysis Interval change after dialysis IMPRESSION: Compared to chest radiographs ___. Moderate right pleural effusion and severe right lower lobe atelectasis are unchanged. Moderate enlargement of the cardiac silhouette has increased and mild interstitial edema has developed best appreciated in the left lower lung. No pneumothorax. Right jugular line ends in the right atrium as before. Radiology Report INDICATION: ___ year old man with pleural effusions, atelectasis and RLL collapse on prior CTA.// Please evaluate for interval change after dialysis TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: The tip of the right hemodialysis catheter projects over the right atrium, unchanged. The sternotomy wires are intact. There are moderate right and small left pleural effusions with overlying atelectasis. No pneumothorax. The size and appearance of the cardiomediastinal silhouette is unchanged.. IMPRESSION: Moderate right and small left pleural effusions with overlying atelectasis. Radiology Report INDICATION: ___ year old man with atrial flutter and known right sided pneumothorax with new onset dyspnea// please evaluate for fluid overload TECHNIQUE: AP portable chest radiograph COMPARISON: ___ IMPRESSION: The tip of a right hemodialysis catheter extends to the right atrium. The patient is post median sternotomy and aortic valve replacement. Atelectasis is noted at the right lung base as well as a small pleural effusion. No pneumothorax. Pulmonary vascular congestion is present without frank pulmonary edema. The size of the cardiac silhouette is enlarged but unchanged. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old man with pleural effusions, hypoxia// interval change? TECHNIQUE: AP portable. COMPARISON: ___ FINDINGS: Right double-lumen hemodialysis catheter terminates in the right atrium. Mild cardiomegaly is stable. Patient is status post sternotomy and aortic valve replacement. Mild venous congestion is unchanged and small right and minimal left pleural effusion are stable. IMPRESSION: Mild venous congestion with unchanged small right and minimal left pleural effusions. Radiology Report INDICATION: ___ year old man with cough, dyspnea, ESRD on HD// Please evaluate for volume overload, consolidation, infiltrates TECHNIQUE: Chest PA and lateral COMPARISON: Chest x-ray ___ FINDINGS: The right-sided hemodialysis catheter terminates in the right atrium. Sternal wires appear intact. The patient is status post valve replacement. There is mild pulmonary venous congestion. There are low lung volumes. There may be a small right effusion. There is mild cardiomegaly, similar to previous. The trachea is midline. IMPRESSION: Mild pulmonary venous congestion. Possible small right effusion. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Dyspnea, unspecified temperature: 97.0 heartrate: 71.0 resprate: 20.0 o2sat: 91.0 sbp: 164.0 dbp: 49.0 level of pain: 5 level of acuity: 2.0

Dear Mr. ___, WHAT BROUGHT YOU INTO THE HOSPITAL? - You were admitted for shortness of breath WHAT WAS DONE FOR YOU IN THE HOSPITAL? - You had a CT scan that showed a partial collapse of your right lung and fluid in your lungs. - You had an echocardiogram of your heart showing that your heart was volume overloaded. - You had dialysis to remove excess fluid from your body and your NEW DRY WEIGHT IS = 88.8kg. - You underwent an ablation procedure to treat your abnormal heart rhythm called "atrial flutter," which corrected to sinus rhythm. WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL? - It is important that you continue to take your medications as prescribed. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. - You need to follow up with your PCP, cardiologist and interventional pulmonology according to the appointments below. We wish you the best in your recovery! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / levofloxacin Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ F h/o COPD p/w SOB. Pt had onset of worsening SOB 3 wks ago. Reports "bad cold" at that time, which she could not get ride of. She got Z-pack and prednisone. Both "definitely" helped. However, SOB recurred and got worse. Has SOB with walking. SOB was at its worst yesterday, prompting her to present to ED. Has sensation of chest heaviness but denies frank chest pain. She reports cough x 2 weeks, but just today she started coughing up green mucous, no hemoptysis. Getting mucous out has led to subjective improvement in symptoms. She reports sweating at night but denies fever/chills. Also reports sore throat x 1 day and runny nose x 2 day. Today, the right eye "closed over" with crust. It is sore, "annoying," no burning. In the ED, initial vitals were: 96.9 76 158/86 20 98%. Pt had CTA neg for PE and two neg troponins. On the floor, VS 98.4 127/84 80 20 94% RA. Pt is comfortable appearing with non-labored breathing on room air. Review of systems: Gen: Weight 110->95 since this ___ HEENT: No vision/hearing change. Otherwise as per HPI. Pulm: As per HPI CV: Chest heaviness GI: No abd pain/n/v/c/d/hematochezia GU: No hematuria, no dysuria, no foul smelling urine MSK: No myalgia/arthralgia Skin: No rash Heme: No LAD, no abnormal bruising/bleeding Past Medical History: COPD Heart murmur Depression Social History: ___ Family History: Father with lung cancer at age ___, no history of blood clots, no DM, no heart disease, no early MI Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.4 127/84 80 20 94% RA General: Lean female laying in bed, NAD HEENT: Injected sclera of right eye with purulent drainage in medial canthus. White patches on superior palate and mucosa of left inner cheek. Neck: No cervical/supraclavicular/submandibular LAD. CV: RRR, no appreciable murmur, no gallops/rubs Lungs: No wheezes/crackles/rhonchi b/l but tight breath sounds. Non labored breathing on room air. Abdomen: +BS, soft, nontender, nondistended Ext: Warm, well perfused Neuro: Grossly nonfocal Skin: No obvious rashes. DISCHARGE PHYSICAL EXAM: VS: 97.8 116/61 79 18 Tmax 98.6 SBP 116-133 HR ___ 94-96% on RA I/O (24H): 1060 PO / BRP I/O (since MN): 200 PO / BRP General: Lean female laying in bed, NAD HEENT: Sclera not injected. No purulent drainage. CV: RRR, no appreciable murmur, no gallops/rubs Lungs: Decreased aeration in all lung fields, mild left basilar wheeze. Non labored breathing on room air. Abdomen: +BS, soft, nontender, nondistended Back: Poorly circumscribed erythematous patch in midline of superior buttocks. Skin intact. Ext: Warm, well perfused Neuro: Grossly nonfocal Skin: No obvious rashes Pertinent Results: ADMISSION LABS ___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 04:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:50PM ___ PTT-34.2 ___ ___ 04:50PM PLT COUNT-228 ___ 04:50PM NEUTS-91.0* LYMPHS-6.4* MONOS-2.3 EOS-0.1 BASOS-0.2 ___ 04:50PM WBC-13.3*# RBC-4.12* HGB-12.3 HCT-38.8 MCV-94 MCH-29.9 MCHC-31.8 RDW-13.5 ___ 04:50PM D-DIMER-756* ___ 04:50PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-2.2 ___ 04:50PM proBNP-143 ___ 04:50PM cTropnT-<0.01 ___ 04:50PM GLUCOSE-138* UREA N-8 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14 ___ 05:00PM LACTATE-1.4 ___ 11:10PM cTropnT-<0.01 INTERIM STUDIES ___ Sputum cytology NEGATIVE FOR MALIGNANT CELLS; (evaluation is limited, see note.) Squamous cells, neutrophils and few macrophages. Note: Only few macrophages are identified, limiting evaluation. DISCHARGE LABS ___ 05:45AM BLOOD WBC-11.2* RBC-4.31 Hgb-12.8 Hct-40.2 MCV-93 MCH-29.8 MCHC-31.9 RDW-13.4 Plt ___ ___ 05:45AM BLOOD Plt ___ ___ 05:45AM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-142 K-4.1 Cl-107 HCO3-25 AnGap-14 ___ 05:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2 IMAGING/OTHER STUDIES ECG ___ Sinus rhythm. Poor R wave progression in the right precordial leads. Non-specific diffuse ST-T wave abnormalities. Compared to the previous tracing of ___ ST-T wave abnormalities are new. Ventricular rate is faster and the premature atrial beat is absent. CXR (PA/lateral) ___ There is no pleural effusion, pneumothorax or focal airspace consolidation worrisome for pneumonia. Irregular linear opacities are consistent with emphysema changes. The heart is normal size and the mediastinal contours are unremarkable. CTA chest ___ Contrast is seen opacifying the segmental and subsegmental vessels of the pulmonary arterial tree, without filling defects indicate a pulmonary embolus. The main pulmonary artery and aorta are normal caliber. There is no evidence for aortic injury. The heart is normal size and there is no pericardial effusion. The trachea is normal. The airways are patent the subsegmental level. There is diffuse bronchial wall thickening. Small amount of retained secretions are seen at the level of the carina (3:95). No pleural effusion or pneumothorax. There is no focal airspace consolidation worrisome for pneumonia. Scattered ground-glass opacities within the right middle lobe may reflect early atypical infection (3:36). Linear opacities in this same area are likely scarring. There are severe changes of centrilobular emphysema. There is no axillary, supraclavicular or central lymphadenopathy. The esophagus is unremarkable. Views of the arterially enhanced liver, adrenal glands, kidneys and spleen are unremarkable. IMPRESSION: 1. No pulmonary embolus. 2. Diffuse bronchial wall thickening compatible with bronchitis. 3. ___ opacities within the right middle lobe may reflect early small airways infection. 4. Severe changes of centrilobular emphysema. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Topiramate (Topamax) 350 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. PredniSONE 20 mg PO DAILY Tapered dose - DOWN 4. Azithromycin 250 mg PO Q24H 5. Estradiol 1 mg PO DAILY 6. Albuterol 0.083% Neb Soln 1 NEB IH PRN dyspnea 7. proGESTerone micronized 100 mg oral q HS 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation PRN dyspnea 9. Venlafaxine XR 75 mg PO DAILY 10. Simvastatin 40 mg PO QHS 11. Tiotropium Bromide 1 CAP IH DAILY 12. BuPROPion (Sustained Release) 200 mg PO QAM 13. QUEtiapine Fumarate 200 mg PO BID Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH PRN dyspnea 2. Azithromycin 250 mg PO Q24H Stop taking this medication after two more doses on ___ and ___. RX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 3. BuPROPion (Sustained Release) 200 mg PO QAM 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. QUEtiapine Fumarate 200 mg PO BID 6. Simvastatin 40 mg PO QHS 7. Topiramate (Topamax) 350 mg PO DAILY 8. Venlafaxine XR 75 mg PO DAILY 9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID Duration: 7 Days Stop taking this medication on ___ (or as early as ___ if symptoms have resolved). RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) inch each eye four times a day Disp #*2 Bottle Refills:*0 10. Nicotine Patch 7 mg TD DAILY RX *nicotine 7 mg/24 hour 1 patch daily Disp #*14 Unit Refills:*0 11. Nystatin Oral Suspension 5 mL PO TID Take this medication until 48 hours after symptoms resolve. RX *nystatin 100,000 unit/mL 5 mL by mouth three times a day Disp #*1 Bottle Refills:*0 12. Estradiol 1 mg PO DAILY 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q ___ hrs PRN dyspnea 14. proGESTerone micronized 100 mg oral q HS 15. Tiotropium Bromide 1 CAP IH DAILY 16. PredniSONE 40 mg PO DAILY Duration: 5 Days Tapered dose - DOWN RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*20 Tablet Refills:*0 17. PredniSONE 20 mg PO DAILY Duration: 3 Days Tapered dose - DOWN RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*6 Tablet Refills:*0 18. PredniSONE 10 mg PO DAILY Duration: 2 Days Tapered dose - DOWN RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: COPD exacerbation, bronchitis, small airway infection Secondary diagnosis: Conjunctivitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Chest pain with dyspnea. Evaluate for an acute process. COMPARISON: Chest radiograph ___. FRONTAL AND LATERAL VIEWS OF THE CHEST: There is no pleural effusion, pneumothorax or focal airspace consolidation worrisome for pneumonia. Irregular linear opacities are consistent with emphysema changes. The heart is normal size and the mediastinal contours are unremarkable. Radiology Report HISTORY: Chest pain and elevated D-dimer. Evaluate for pulmonary embolus. TECHNIQUE: MDCT axial images were acquired through the chest during the pulmonary arterial phase of enhancement with 100 mL of Omnipaque. Coronal and sagittal reformations were provided and reviewed. Maximum intensity projection images were created and reviewed as well. DLP: 154.35 mGy/cm. COMPARISON: None. FINDINGS: Contrast is seen opacifying the segmental and subsegmental vessels of the pulmonary arterial tree, without filling defects indicate a pulmonary embolus. The main pulmonary artery and aorta are normal caliber. There is no evidence for aortic injury. The heart is normal size and there is no pericardial effusion. The trachea is normal. The airways are patent the subsegmental level. There is diffuse bronchial wall thickening. Small amount of retained secretions are seen at the level of the carina (3:95). No pleural effusion or pneumothorax. There is no focal airspace consolidation worrisome for pneumonia. Scattered ground-glass opacities within the right middle lobe may reflect early atypical infection (3:36). Linear opacities in this same area are likely scarring. There are severe changes of centrilobular emphysema. There is no axillary, supraclavicular or central lymphadenopathy. The esophagus is unremarkable. Views of the arterially enhanced liver, adrenal glands, kidneys and spleen are unremarkable. IMPRESSION: 1. No pulmonary embolus. 2. Diffuse bronchial wall thickening compatible with bronchitis. 3. ___ opacities within the right middle lobe may reflect early small airways infection. 4. Severe changes of centrilobular emphysema. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: DYSPNEA Diagnosed with SHORTNESS OF BREATH, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION temperature: 96.9 heartrate: 76.0 resprate: 20.0 o2sat: 98.0 sbp: 158.0 dbp: 86.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking part in your care at ___ ___. As you know, you came to the hospital due to worsening shortness of breath. In the ED, you had a CT scan that was negative for a blood clot in the lungs, and labs were reassuring against a problem with the heart muscle (which were checked due to your chest heaviness). The CT scan did show bronchitis, a possible infection of the small lung airways, and severe emphysema. You were admitted for further treatment of an exacerbation of your emphysema/COPD with prednisone and nebulizer treatments, and you received antibiotics for bronchitis. You were also found to have conjunctivitis, and you were given eye drops. Your breathing improved. Please see the attached medication list for changes to your home medication regimen. You will have short courses of azithromycin and prednisone to finish at home. Other medications include eye drops and nystatin mouth solution. Also, you have a prescription for a nicotine patch. We strongly encourage you to continue avoiding cigarettes, as you have done while hospitalized. Smoking cessation is an important step toward improving your health. Please follow up with Pulmonary Medicine according to the appointment list below. You should have a repeat chest CT scan in ___ weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: EGD ___ attach Pertinent Results: ADMISSION LABS ============== ___ 01:27AM BLOOD WBC-7.2 RBC-3.72* Hgb-10.9* Hct-34.9* MCV-94 MCH-29.3 MCHC-31.2* RDW-14.2 RDWSD-48.0* Plt ___ ___ 01:27AM BLOOD Neuts-86.6* Lymphs-9.6* Monos-3.4* Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.20* AbsLymp-0.69* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01 ___ 01:50PM BLOOD ___ PTT-28.9 ___ ___ 01:27AM BLOOD Glucose-525* UreaN-89* Creat-15.0* Na-137 K-6.4* Cl-89* HCO3-21* AnGap-27* ___ 01:50PM BLOOD Calcium-9.7 Phos-5.5* Mg-2.1 ___ 03:09AM BLOOD ___ pO2-109* pCO2-48* pH-7.36 calTCO2-28 Base XS-0 Comment-GREEN TOP IMAGING ======= CXR ___ Mild pulmonary vascular congestion. No edema. MICRO ===== ___ 1:30 pm BLOOD CULTURE Source: Line-R fem line 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. STUDIES ======= EGD ___ - Grade C esophagitis in the mid and distal esophagus - A small, non-bleeding ___ tear was noted in the distal esophagus - A brief view of the stomach body was notable for normal mucosa without any blood - Due to the large esophageal clot, a full endoscopic view of the stomach fundus, antrum or duodenum was not obtained. DISCHARGE LABS ============== ___ 07:42AM BLOOD WBC-5.7 RBC-2.67* Hgb-8.0* Hct-25.0* MCV-94 MCH-30.0 MCHC-32.0 RDW-14.4 RDWSD-47.3* Plt ___ ___ 07:42AM BLOOD Glucose-134* UreaN-27* Creat-6.5*# Na-139 K-4.4 Cl-97 HCO3-27 AnGap-15 ___ 07:42AM BLOOD Calcium-8.5 Phos-4.9* Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Glargine 50 Units Breakfast Insulin SC Sliding Scale using REG Insulin 5. Pantoprazole 40 mg PO Q24H 6. Losartan Potassium 25 mg PO DAILY 7. TraMADol 50 mg PO BID:PRN Pain - Moderate 8. Gabapentin 100 mg PO TID 9. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia 10. Apixaban 2.5 mg PO BID 11. sevelamer CARBONATE 800 mg PO TID W/MEALS 12. CARVedilol 12.5 mg PO BID Discharge Medications: 1. Glargine 55 Units Dinner Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. CARVedilol 12.5 mg PO BID 6. Gabapentin 100 mg PO TID 7. Losartan Potassium 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. TraMADol 50 mg PO BID:PRN Pain - Moderate 11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= Acute Gastrointestinal Bleed SECONDARY DIAGNOSES =================== Gastroparesis Atrial Fibrillation with RVR ESRD on HD Hypoxemic respiratory failure, Resolved 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 esrd on dialysis, missed dialysis, k >6 // eval for pulmonary congestion TECHNIQUE: Chest PA and lateral COMPARISON: None FINDINGS: A vascular stent projects over the left axilla. Patient is status post sternotomy with intact wires. Lung volumes are low, exaggerating pulmonary vascular congestion. No no definite pulmonary edema. Cardiomediastinal contours are normal. No pleural effusion or pneumothorax. IMPRESSION: Mild pulmonary vascular congestion. No edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypotension. // Please evaluate for pneumonia. TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: There are postsurgical changes from CABG. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities are identified. There is a vascular stent in the left subclavian/axillary region. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abnormal labs, Transfer Diagnosed with Hyperkalemia temperature: 97.2 heartrate: 88.0 resprate: 18.0 o2sat: 100.0 sbp: 128.0 dbp: 90.0 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 nauseous and vomiting. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received dialysis - You were in the Intensive Care Unit for special monitoring and care of your breathing - You developed bloody vomit and a scope was placed down through your mouth which showed bleeding coming from your feeding tube - You were given medications to help your nausea and to prevent further bleeding WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Tetanus / Demerol Attending: ___. Chief Complaint: Hematemesis, shock Major Surgical or Invasive Procedure: ___ EGD with variceal ligation ___ intubation for EGD s/p extubation ___ History of Present Illness: ___ is a ___ y/o woman with PMH of EtOH cirrhosis c/b EV, PHG, GAVE who p/w hematemesis. Yesterday afternoon, felt dizzy in the afternoon and nauseous after dinner. Had episode of dark red emesis. Presented to ___ hypotensive with SBP 68, and had 2 large volume episodes of coffee ground emesis. Hgb 7.1. Lactate 3.0. Received 2U pRBCs. Hgb up to 8.8. Received 1L NS. Started CTX and octreotide gtt. Had a 20g L AC, 18g R FA PIV placed. Last Hepatology visit ___ ___. Has been declining relapse prevention. In ___ and ___ had admissions for anemia, hematemesis, and melena with Hgb < 5. Most recent EGD ___ with GAVE, PHG, and 3 cords of medium size varices w/o active bleeding. Hgb had been stable at 9.0. She also recently had a car accident one month ago where she was rear-ended. Hurt her shoulder, had hematuria, and had a concussion. In the ED, Initial Vitals: T 97.7 HR 70 BP 107/70 RR 16 SaO2 94% RA Exam: Labs: - Hgb 7.4 - CMP ___ - ALT 17 AST 41 AP 121 Tbili 1.7 Alb 3.4 lipase 70 Imaging: Consults: - Hepatology Interventions: - octreotide gtt VS Prior to Transfer: HR 80 BP ___ RR 18 SaO2 95% RA ROS: Positives as per HPI; otherwise negative. Past Medical History: EtOH cirrhosis c/b EV, PHG, GAVE, ascites EtOH hepatitis anxiety phobias - of choking, needs sedation with Propofol for EGD depression hypothyroidism back pain T12 compression fracture scoliosis Social History: ___ Family History: Mother - migraines, COPD (died at ___) Father - esophageal cancer (died at ___) Son - ___ muscular dystrophy (died at ___) Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: AF HR 76 BP 85/38 (53) Sa97% 1LNC GEN: alert, NAD HEENT: sclera white CV: RRR, normal S1/S2, no m/r/g RESP: CTAB GI: abd soft, NTND, normoactive BS EXT: warm, well-perfused, trace ___ edema NEURO: EOMI DISCHARGE PHYSICAL EXAM: ======================== ___ 2337 Temp: 99.0 PO BP: 125/80 HR: 89 RR: 18 O2 sat: 88% O2 delivery: Ra GENERAL: NAD. Comfortable Eyes: Anicteric ENT: MMM. ___: RRR, no m/r/g LUNGS: CTAB, no w/r/c ABDOMEN: soft, nontender, nondistended, normoactive bowel sounds, no rebound or guarding SKIN: Warm. Dry. EXT: well perfused, trace bilateral edema NEURO: No asterixis. Pertinent Results: ADMISSION LABS =============== ___ 03:15AM BLOOD WBC-6.4 RBC-3.56* Hgb-7.4* Hct-26.3* MCV-74* MCH-20.8* MCHC-28.1* RDW-22.5* RDWSD-59.2* Plt Ct-88* ___ 05:43AM BLOOD WBC-6.0 RBC-3.27* Hgb-6.8* Hct-23.7* MCV-73* MCH-20.8* MCHC-28.7* RDW-22.1* RDWSD-58.0* Plt Ct-85* ___ 10:51AM BLOOD WBC-8.7 RBC-3.57* Hgb-7.6* Hct-25.9* MCV-73* MCH-21.3* MCHC-29.3* RDW-22.1* RDWSD-57.2* Plt ___ ___ 03:15AM BLOOD Neuts-62.8 ___ Monos-8.4 Eos-2.8 Baso-0.8 Im ___ AbsNeut-4.02 AbsLymp-1.58 AbsMono-0.54 AbsEos-0.18 AbsBaso-0.05 ___ 03:15AM BLOOD Plt Smr-LOW* Plt Ct-88* ___ 05:43AM BLOOD ___ PTT-31.5 ___ ___ 03:15AM BLOOD Glucose-150* UreaN-22* Creat-0.6 Na-130* K-4.6 Cl-95* HCO3-19* AnGap-16 ___ 03:15AM BLOOD ALT-17 AST-41* AlkPhos-121* TotBili-1.7* ___ 03:15AM BLOOD Lipase-70* ___ 03:15AM BLOOD Albumin-3.4* Calcium-7.9* Phos-2.8 Mg-1.4* ___ 05:43AM BLOOD ___ ___ 05:39AM BLOOD Lactate-2.7* ___ 11:22AM BLOOD Lactate-2.0 DISCHARGE LABS: =============== ___ 05:20AM BLOOD WBC-4.8 RBC-3.26* Hgb-7.7* Hct-25.6* MCV-79* MCH-23.6* MCHC-30.1* RDW-22.5* RDWSD-64.7* Plt Ct-73* ___ 05:20AM BLOOD ___ PTT-30.6 ___ ___ 05:20AM BLOOD Glucose-188* UreaN-11 Creat-0.6 Na-138 K-3.6 Cl-99 HCO3-28 AnGap-11 ___ 05:20AM BLOOD ALT-15 AST-25 AlkPhos-102 TotBili-1.4 ___ 05:20AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-1.6 MICROBIOLOGY: ============= __________________________________________________________ ___ 11:10 am BLOOD CULTURE Source: Venipuncture 1 OF 2. Blood Culture, Routine (Pending): No growth to date. IMAGING/STUDIES: ================ ___ CXR PORTABLE FINDINGS: Endotracheal tube tip is approximately 1 cm above the carina. The heart remains enlarged. There is mild pulmonary vascular congestion. No pneumothorax. Bibasilar opacities which could represent atelectasis. PROCEDURES: =========== ___ EGD -4 cords of grade II varices were seen in the distal esophagus. One cord of varices below gastroesophageal junction most likely represent GOV was oozing. Three bands were applied for hemostasis successfully. -Congestion, petechiae, and mosaic mucosal pattern in the stomach fundus and stomach body compatible with portal hypertensive gastropathy. -Blood in the stomach. -Normal mucosa in the whole examined duodenum. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID 2. DULoxetine ___ 90 mg PO DAILY 3. TraZODone 150 mg PO QHS:PRN sleep 4. Omeprazole 40 mg PO DAILY 5. Levothyroxine Sodium 175 mcg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Nadolol 40 mg PO DAILY 8. HydrOXYzine 25 mg PO Q8H:PRN itching 9. Spironolactone 100 mg PO DAILY 10. Thiamine Dose is Unknown PO DAILY 11. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Sucralfate 1 gm PO QID Duration: 2 Weeks RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp #*56 Tablet Refills:*0 2. Thiamine 200 mg PO DAILY 3. DULoxetine ___ 90 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. HydrOXYzine 25 mg PO Q8H:PRN itching 7. Levothyroxine Sodium 175 mcg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Nadolol 40 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Spironolactone 100 mg PO DAILY 12. TraZODone 150 mg PO QHS:PRN sleep Discharge Disposition: Home Discharge Diagnosis: #Acute decompensated alcohol cirrhosis #Upper gastrointestinal bleeding #Acute blood loss anemia #Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with upper GI bleed now intubated// Evaluate ET tube placement Evaluate ET tube placement COMPARISON: Chest x-ray ___ 122 hours FINDINGS: Endotracheal tube tip is approximately 1 cm above the carina. The heart remains enlarged. There is mild pulmonary vascular congestion. No pneumothorax. Bibasilar opacities which could represent atelectasis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 11:50 am, 1 minutes after discovery of the findings. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Hematemesis, Transfer Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 97.7 heartrate: 70.0 resprate: 16.0 o2sat: 94.0 sbp: 107.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

Dear ___, You were admitted to the hospital because you were vomiting blood. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You received blood transfusions for your bleeding - You also underwent an endoscopy to identify the source of your bleeding. You were noted to have dilated blood vessels in your esophagus (called "varices") which were bleeding. - These blood vessels can cause very serious bleeding that can be life-threatening - You underwent a procedure to stop this bleeding by putting a band around these bleeding blood vessels - After the procedure, we monitored your blood counts and you did not have any repeat bleeding - Overall you were improved and ready to leave the hospital.. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - You must never drink alcohol again or your liver will fail and you will die from this - Please enroll in AA and work with your primary care doctor to determine the best strategy to help you stay sober - Take all of your medications as prescribed (listed below) - Keep your follow up appointments with your doctors - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - If you 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 you the best! - Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Labetalol Attending: ___. Chief Complaint: DKA, hypertensive urgency Major Surgical or Invasive Procedure: 1) Hemodialysis ___ and ___ History of Present Illness: ___ yo male w/ history diabetes type 1, ESRD on HD, multiple hospitalizations for DKA/hyperglycemia, and recent ER visit ___ for hypoglycemic seizure presents for critically high blood sugar at ___ center. Noted to be sweating, tired, and vomited x2 so he did not get HD. His fasting glucose was 287 on the morning of admission before breakfast, took 10u Humalog. His blood sugar was running in the 300s yesterday with recent systolic blood pressures in the 150s. He reports compliance with insulin and home blood pressure medications. Recently he has felt generally fatigued, but at dialysis center he was sweating and more tired. He denies recent lows other than the hypoglycemic seizure he had ___ while at HD, which resulted in a tounge laceration but no other complications. He denies any prior history of seizures. He denies recent illness, cough, dysuria, rash, HA, diarrhea, CP, or vomiting prior to today. Of note he has had multiple complications of Type1DM and HTN, including total blindness in L eye secondary to retinopathy and nephropathy requiring dialysis. He has no known coronary disease or peripheral vascular disease though head MRI in ___ was found to be consistent with multiple hypertensive infarcts. In the ED: - blood glucose elevated to > 700 -K+ was elevated at 5.4. -VBG w/ pH 7.2 -8 units bolus insulin, then insulin gtt at 7u/h. -2L NS Also noted to have elevated troponins to 0.83 (baseline 0.6-0.8 in the setting of poor renal clearance) thought to be due to demand ischemia given elevated HR and BP > 200 systolic. Baseline EKG (___): LAD, ___, TWI in lateral leads, delayed R-wave progression possibly due to anteroseptal infarct. EKG on admission: All of the same in addition to peaked TW in V2,V3 and possible 2mm ST elevations in V2/V3. Chest pain free. VS T 97.8 HR 105 BP 211/113 RR 16 Sa02 100% r/a Past Medical History: - Diabetes, type 1 - admitted for hyperglycemia DKA from ___ to ___ and again from ___ to ___. Most recent A1c 8.0 ___. - Hypertension - h/o malignant HTN since ___ on multiple meds - Nephropathy - CKD stage V, PD failure ___ s/p HD line placement in the setting of metabolic encephalopathy -> now on TTS HD - UGIB: s/p D with clipping, injection and cautery of a bleeding duodenal ulcer EGD ___ - MRI w/likely hypertensive infarcts discovered ___ - Jejunitis/c. diff infection ___ - Anemia of chronic disease - Hyperlipidemia - Depression, not currently on therapy - Blindness in L eye ___ diabetic retinopathy - Vitrectomy R eye w/laser therapy ___ - Erectile dysfunction Social History: ___ Family History: Hypertension in mother and father, and hypercholesterolemia in mother. No family hx of DM, renal disease, MI or CVA. Physical Exam: ICU ADMISSION EXAM Vitals: T 97.8 HR 105 BP 211/113 RR 16 Sa02 100% r/a General: Healthy-appearing, pleasant man lying in bed in NAD HEENT: Anicteric sclerae, R tongue with 3cm linear laceration with white fibrinous tissue at base. No surrounding suppuration, swelling. Neck: JVP non-elevated CV: RRR, loud S2, ___ SEM Lungs: Coarse breath sounds R>L, otherwise no rales, wheezes Abdomen: PD catheter, soft, NT, ND, non-obese GU: No foley Ext: Warm, 2+ DP pulses, no edema Neuro: A&Ox3. CNII-XII intact. ___ in UE and ___ bilaterally. Normal DTRs throughout. Gait not evaluated Pertinent Results: ___ 03:10PM BLOOD Glucose-787* UreaN-58* Creat-12.4*# Na-125* K-6.4* Cl-82* HCO3-11* AnGap-38* ___ 06:16PM BLOOD Glucose-722* UreaN-58* Creat-12.1* Na-133 K-4.3 Cl-91* HCO3-15* AnGap-31* ___ 12:32AM BLOOD Glucose-256* UreaN-62* Creat-12.7* Na-138 K-3.7 Cl-99 HCO3-24 AnGap-19 ___ 04:57AM BLOOD Glucose-85 UreaN-64* Creat-13.1* Na-141 K-4.3 Cl-101 HCO3-26 AnGap-18 ___ 03:10PM BLOOD WBC-6.1 RBC-4.56* Hgb-12.5* Hct-41.4 MCV-91# MCH-27.4 MCHC-30.2*# RDW-14.3 Plt ___ ___ 03:10PM BLOOD ALT-42* AST-56* AlkPhos-79 TotBili-0.2 ___ 03:10PM BLOOD cTropnT-0.83* ___ 06:16PM BLOOD CK-MB-8 ___ 12:32AM BLOOD CK-MB-7 cTropnT-0.85* ___ 04:57AM BLOOD CK-MB-6 cTropnT-0.89* ___ 03:10PM BLOOD %HbA1c-9.5* eAG-226* ___ 03:17PM BLOOD ___ pO2-84* pCO2-35 pH-7.20* calTCO2-14* Base XS--13 Comment-GREEN TOP ___ 06:33PM BLOOD ___ Temp-36.6 pO2-45* pCO2-39 pH-7.26* calTCO2-18* Base XS--8 Intubat-NOT INTUBA ___ 12:45AM BLOOD ___ pO2-58* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 ___ 03:17PM BLOOD Glucose->500 Lactate-2.2* Na-129* K-5.4* Cl-89* calHCO3-13* ___ 05:09PM BLOOD Glucose-GREATER TH K-4.8 ___ 12:45AM BLOOD Lactate-2.0 K-3.7 --------------- IMAGING ___ CXR: FRONTAL AND LATERAL VIEWS OF THE CHEST: No pleural effusion, pneumothorax or focal airspace consolidation. Heart size is normal. The mediastinal and hilar structures are unremarkable. The pulmonary vascularity is normal. A right double-lumen dialysis catheter terminates in the right atrium. IMPRESSION: No acute cardiopulmonary process --------------- EKG showed LAD, peaked Tw in precordial leads compared to baseline, as well as ?ST changes in V2/V3 with apparent old anteroseptal infarct given poor Rwave progression Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO BID 2. Aspirin 81 mg PO DAILY 3. CloniDINE 0.2 mg PO BID 4. Lisinopril 40 mg PO DAILY 5. Minoxidil 2.5 mg PO BID 6. Nephrocaps 1 CAP PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. sevelamer CARBONATE 2400 mg PO TID W/MEALS 9. Simethicone 40-80 mg PO QID:PRN gas 10. Torsemide 100 mg PO DAILY 11. Glargine 25 Units Bedtime 12. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: 1. DKA 2. Malignant hypertension 3. ESRD on HD Secondary diagnoses: 1. DM type I 2. Anemia 3. Hyperlipidemia 4. Duodenal ulcer s/p bleed and cauterization 5. Diabetic retinopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Diabetes on hemodialysis with fevers and chills. Evaluate for pneumonia or an acute infectious process. COMPARISON: Chest radiographs ___ and ___. FRONTAL AND LATERAL VIEWS OF THE CHEST: No pleural effusion, pneumothorax or focal airspace consolidation. Heart size is normal. The mediastinal and hilar structures are unremarkable. The pulmonary vascularity is normal. A right double-lumen dialysis catheter terminates in the right atrium. IMPRESSION: No acute cardiopulmonary process. Radiology Report REASON FOR EXAMINATION: Diabetes mellitus, hemodialysis, fever. Portable AP radiograph of the chest was reviewed in comparison to ___. The central vein catheter tip terminates at the level of the right atrium. Heart size and mediastinum are unremarkable. Lungs are essentially clear. No pleural effusion or pneumothorax is seen. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: HYPERGLYCEMIA Diagnosed with DIAB KETOACIDOSIS IDDM temperature: 98.0 heartrate: 104.0 resprate: 18.0 o2sat: 100.0 sbp: 190.0 dbp: 110.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted for elevated blood sugars >700 and very high blood pressure at your HD appointment on ___ last week. You were treated with insulin, fluids and IV blood pressure medicines in the ICU until your blood sugar and blood pressure stabilized. You were then transferred to the general medicine floor for continued monitoring. Your sugars ranged from 400 to 100 on insulin. Your blood pressure remained stable on your home dosing of blood pressure medications. You received dialysis on ___ and ___. You should go to your regular dialysis appointment next ___. Please be sure to take your insulin and blood pressure medications as prescribed at home. If you develope headache, shakes, feelings of weakness, feeling like you are having difficulty staying awake, palpitations, nausea, vomiting, lightheadedness or fainting please check your blood sugar quickly. Call your doctor or go to the emergency room if your blood sugar goes above 300 for more than 24 hours or below 70 more than twice in a row. You have a follow up appointment scheduled with your regular nurse practitioner at the ___ on ___ at 2:00 ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Doxycycline / Amoxicillin / Penicillins / Tetracyclines Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ M w/ COPD, alcohol induced chronic pancreatitis w/ pseudocyst s/p Whipple, and chronic pain presenting with tachypnea. Patient developed productive cough with clear sputum 4 days prior to admission associated with tachypnea, dyspnea on exertion, and squeezing chest pressure (___) radiating to the back. He also had chills, nausea, and a loose stool this morning. Patient is usually on prednisone 10mg daily and was using his albuterol inhaler more frequently. ROS negative for fever, abdominal pain, vomitting/diarrhea, and dysuria, ___ edema, PND, orthopnea, or sick contacts In the ED, initial vitals: Temp. 97.8, HR 121, BP 186/126, RR 16 Labs showed: WBC 8.7, Hg 14.9, Hct 43.8, platelets 157. Trop 0.01, D-dimer 242, lactate 1.6. Patient given total of 13 mg morphine, 500 mg azithromycin, 125 mg methylprednisone X 1, and nebulizer treatment. CXR obtained without any acute cardiopulmomary process. Patient was placed on non-rebreather initially with marginal sats at which time bipap was placed with improvement of tachypnea. No ABG available. On transfer, vitals were: Temp 98.2, HR 112, BP 120/75, RR 19, 97% RA On arrival to the MICU, breathing comfortably on BiPAP. Past Medical History: S/P WHIPPLE PROCEDURE pylorus sparing Dr ___ ___ -none since early ___ CHRONIC OBSTRUCTIVE PULMONARY DISEASE TOBACCO ABUSE DEPRESSION NARCOTICS AGREEMENT *S/P CHOLECYSTECTOMY *S/P PNEUMOTHORAX AND RIB FRACTURES traumatic HEARING LOSS traumatic CELIAC DISEASE LUNG NODULES Social History: ___ Family History: Mother ALZHEIMER'S DISEASE Father COLON CANCER Brother ALCOHOLIC CIRRHOSIS Sister ALCOHOLIC CIRRHOSIS Physical Exam: ADMISSIONS PHYSICAL: ==================== Temp 98.2, HR 112, BP 120/75, RR 19, 97% RA GENERAL: Head bobbing and weaving but alert and attentive, unable to complete sentences due to SOB HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Little air movement with end expiratory wheezing intermittently CV: Difficult to appreciate heart sounds ABD: 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: Alert and attentive, moving all extremities DISCHARGE PHYSICAL: =================== Vitals: 97.7 125/74 85 18 95% on RA General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: marked expiratory wheezes throughout less prominent on ___ AM vs ___ ___, no rales or ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSIONS LABS: ================ ___ 08:00PM BLOOD WBC-8.7# RBC-4.84 Hgb-14.9 Hct-43.8 MCV-91 MCH-30.8 MCHC-34.0 RDW-12.3 RDWSD-40.5 Plt ___ ___ 08:00PM BLOOD WBC-8.7# RBC-4.84 Hgb-14.9 Hct-43.8 MCV-91 MCH-30.8 MCHC-34.0 RDW-12.3 RDWSD-40.5 Plt ___ ___ 08:00PM BLOOD Neuts-86.7* Lymphs-6.2* Monos-6.1 Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.52* AbsLymp-0.54* AbsMono-0.53 AbsEos-0.00* AbsBaso-0.02 ___ 08:00PM BLOOD ___ PTT-29.0 ___ ___ 08:00PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-135 K-4.4 Cl-93* HCO3-31 AnGap-15 ___ 08:00PM BLOOD ALT-31 AST-42* AlkPhos-93 TotBili-0.3 ___ 03:14AM BLOOD CK(CPK)-58 ___ 08:00PM BLOOD cTropnT-<0.01 ___ 03:14AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 01:42AM BLOOD cTropnT-<0.01 ___ 08:00PM BLOOD Albumin-4.8 ___ 03:14AM BLOOD Calcium-9.0 Phos-4.5# Mg-2.9* ___ 01:42AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.3 ___ 08:00PM BLOOD D-Dimer-242 ___ 05:01AM BLOOD Type-ART Rates-/14 pO2-179* pCO2-48* pH-7.40 calTCO2-31* Base XS-4 Intubat-NOT INTUBA ___ 08:08PM BLOOD Lactate-1.6 ___ 05:01AM BLOOD Lactate-1.5 IMAGING AND OTHER STUDIES: ========================== CXR ___: No acute cardiopulmonary process. COPD. ECG ___: Sinus rhythm with premature atrial contractions. Compared to the previous tracing of ___ the P wave voltage appears to be less. There remainsdelayed R wave transition in the mid-precordial leads. Other findings are similar to ___. DISCHARGE LABS: =================== ___ 06:55AM BLOOD WBC-8.0 RBC-3.86* Hgb-11.8* Hct-36.1* MCV-94 MCH-30.6 MCHC-32.7 RDW-12.3 RDWSD-42.7 Plt ___ ___ 06:55AM BLOOD Glucose-114* UreaN-7 Creat-0.7 Na-134 K-3.8 Cl-94* HCO3-30 AnGap-14 ___ 06:55AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1 MICROBIOLOGY: =============== ___ Blood cultures: pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Creon 12 1 CAP PO TID W/MEALS 3. Dronabinol 5 mg PO BID 4. Mirtazapine 45 mg PO QHS 5. Omeprazole 40 mg PO DAILY 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H 7. Sertraline 25 mg PO DAILY 8. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 11. Tiotropium Bromide 1 CAP IH DAILY 12. Atorvastatin 20 mg PO QAM 13. PredniSONE 10 mg PO DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY For PCP prophylaxis RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 3. Atorvastatin 20 mg PO QAM 4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 5. Tiotropium Bromide 1 CAP IH DAILY 6. Azithromycin 250 mg PO Q24H Duration: 4 Days Last day ___. RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY 8. Creon 12 1 CAP PO TID W/MEALS 9. Dronabinol 5 mg PO BID 10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 11. Mirtazapine 45 mg PO QHS 12. Omeprazole 40 mg PO DAILY 13. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H 14. Sertraline 25 mg PO DAILY 15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 16. PredniSONE 40 mg PO DAILY Duration: 2 Doses Take 40 mg on ___ and ___ then 20 mg on ___, and ___ then resume 10 mg daily. Tapered dose - DOWN RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 17. PredniSONE 20 mg PO DAILY Duration: 3 Doses Take 40 mg on ___ and ___ then 20 mg on ___, and ___ then resume 10 mg daily. Tapered dose - DOWN 18. PredniSONE 10 mg PO DAILY Take 40 mg on ___ and ___ then 20 mg on ___, and ___ then resume 10 mg daily. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: =================== COPD 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 copd // sob TECHNIQUE: Single frontal view of the chest COMPARISON: ___ FINDINGS: Lungs remain hyperinflated, consistent with chronic obstructive pulmonary disease. No focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable and unremarkable. IMPRESSION: No acute cardiopulmonary process. COPD. Gender: M Race: WHITE - EASTERN EUROPEAN Arrive by WALK IN Chief complaint: Chest pain, Dyspnea Diagnosed with CHEST PAIN NOS temperature: 97.8 heartrate: 121.0 resprate: 36.0 o2sat: 97.0 sbp: 186.0 dbp: 126.0 level of pain: 9 level of acuity: 1.0

Dear Mr. ___, It was a pleasure caring for you during your hospitalization at ___. You were admitted for severe shortness of breath/low oxygen level due to a COPD exacerbation. You were treated with steroids, an antibiotic (azithromycin), and nebulizers. Please continue the steroid taper and antibiotic as prescribed. You were also started on Bactrim, which is an antibiotic to prevent infections while on steroids. You should continue this until directed otherwise by your doctor. Please continue to use your inhalers as prescribed and keep yourself well-hydrated. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: Bacitracin / Ampicillin Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: ___ - open splenectomy ___ - L S1 screw, ant column screw ___ - bedside tracheostomy History of Present Illness: Ms. ___ is a ___ year old Female who presented to the ___ in the setting of an MVC. She was initially intubated at the OSH, and was found on pan-scan imaging to have small bilateral pneumothoraces, multiple rib fractures, a splenic laceration, L5 transverse process fracture, and pelvic fractures. Past Medical History: ___:(from old notes and from HCP, needs to be reconfirmed) -Osteoarthritis -Depression -Chronic Back Pain -HTN -HLD -Obesity -Hyperthyroidism (benign thyroid mass) -Insulin Dependent DM2 -Hx of osteomyelitis -Asthma -? Pulm fibrosis (was o2 dependent at one time and on steroids per pulm) Social History: ___ Family History: noncontributory Physical Exam: General: alert and oriented, x3, NAD, awake, oriented x1 Cardiac: RRR, mild tachycardia, sinus rhythm Respiratory: mildly tachypneic, on trach collar GI: large left sided incision w/ steri-strips intact, healing well GU: foley d/c'd MSK: moving all extremity, no obvious trauma Medications on Admission: lantus 42 qpm, levothyroxine 100', gabapentin 600'', amlodipine 10', metoprolol 25', lexapro 20', mirtazapine 30', aspirin 81', magnesium oxide 250', hctz 25' Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Polytrauma following MVC Discharge Condition: stable Followup Instructions: ___ Radiology Report INDICATION: ___ female status post ___ with extensive splenic laceration. COMPARISON: CTA torso ___. PHYSICIANS: Dr. ___ (resident), Dr. ___ (fellow) and Dr. ___ (attending, present and supervising throughout). ANESTHESIA: The patient arrived to the angiography suite intubated and sedated. Fentanyl and Versed infusions were maintained throughout the procedure. 1% lidocaine was administered for local anesthetic. FLUOROSCOPY: 395 mGy, 32.3 minutes. CONTRAST: 90 mL Visipaque. PROCEDURES: 1. Right common femoral artery access. 2. Splenic arteriogram and cone beam CT. 3. Coil embolization of third order and second order branches of the splenic artery. 4. Proximal splenic artery embolization with a 6mm Amplatzer plug device. PROCEDURE DETAIL: After discussion of the risks, benefits and alternatives to the procedure with the patient's next of kin, verbal informed consent was obtained and witnessed. The patient was brought to the angiography suite and placed supine on the imaging table. The right groin was prepped and draped in the usual sterile fashion. A preprocedure timeout and huddle was performed as per ___ protocol. Initial scout image demonstrated delayed nephrogram in the right kidney consistent with impaired excretion of contrast from the prior CTA. Under fluoroscopic and palpatory guidance, the right common femoral artery was accessed using local anesthesia and the standard micropuncture technique at the level of the mid femoral head. A 6 ___ ___ sheath was advanced over the ___ wire and parked in the mid abdominal aorta. Next, a glide catheter and Glidewire were advanced through the sheath and used to select the celiac axis and then advanced further into the splenic artery. The sheath was then brought further into the splenic artery to secure the celiac ostial access. A digital subtraction angiogram was performed with cone beam CT demonstrating multiple abnormalities in the splenic parenchyma consistent with multiple pseudoaneurysms. There was no definite active extravasation. A decision was made to further sub-select the branches supplying two largest pseudoaneurysms in the upper and lower splenic poles. A third order branch supply the upper pole of the spleen using a ___ Renegade microcatheter and double-angled Glidewire. After hand injection to confirm the desired position, three 2 mm x 1 cm Hilal coils were deployed. Injection of contrast confirmed stasis of flow. Next, the microcatheter was withdrawn and used to select a second order branch of the splenic artery supplying the lower pole and supplying multiple large parenchymal abnormalities. After hand injection of contrast to confirm position of the microcatheter one 2 mm x 1 cm Hilal coil and two 3 mm x 2 cm Hilal coils were deployed. There was near-complete stasis of flow. Approximately 0.5 cc of a gelfoam slurry was injected with resulting stasis of flow. The microcatheter was withdrawn and the glide catheter exchanged for a 6 ___ guiding catheter which was placed in the proximal splenic artery. A 6 mm Amplatzer plug was deployed. Hand injection of contrast following deployment confirmed absence of antegrade flow to the spleen with reflux into the celiac axis and common hepatic arteries. The guide catheter and 6 ___ sheath were removed over a wire. Manual pressure was held for 25 minutes for optimal hemostasis. The patient tolerated the procedure well without immediate complication. FINDINGS: 1. Incidental note of a delayed right nephrogram. 2. Multiple splenic parenchymal abnormalities consistent with pseudoaneurysms. No definite active extravasation. IMPRESSION: 1. Uncomplicated proximal and selective distal splenic embolization. 2. Delayed right nephrogram consistent with renal insufficiency. Findings were discussed by phone with Dr. ___ at the completion of the procedure at approximately 8:20 p.m. on ___. Radiology Report INDICATION: Multiple rib fractures. ___ at 533am. FINDINGS: There is subcutaneous emphysema in the left chest wall. There is a consolidation in the left mid and lower lung, which likely represents a combination of hemothorax and atelectasis and contusion from prior injury. Multiple continuous posterior rib fractures are seen in the left, as seen on prior CT. ET tube ends 3.4 cm from the carina. The enteric tube ends in the stomach. No pleural effusion is identified. The right lung is grossly clear. The mediastinal and hilar contours are within normal limits. IMPRESSION: Left mid and lower lung opacity likely represents combination of pleural hemothorax and atelectasis and contusion. Multiple rib fractures on the left. No pneumothorax is identified. Radiology Report INDICATION: Increasing abdominal distention status post MVC. Evaluate for free air. COMPARISON: ___ at 5:33 a.m. FINDINGS: Enteric tube ends in the stomach; however the last side port is likely above the GE junction. ET tube is stable in position. The left mid and lower lung opacities are unchanged. The right lung is clear. Left pleural effusion is unchanged. There is no evidence of free air. No pneumothorax. IMPRESSION: No evidence of free air. No significant change compared to ___ at 5:33 a.m. Enteric tube ends in the stomach; however the last side port is likely above the GE junction. Recommend advancement. These findings were discussed with Dr. ___ by Dr. ___ at 940am on ___ by phone at time of discovery. Radiology Report EXAMINATION: CYSTOGRAM INDICATION: ___ year old woman with pelvic fracture, concern for bladder injury, rule out bladder injury. COMPARISON: CTA torso from ___. FINDINGS: Initial AP and oblique scout images prior to administration of contrast show a Foley catheter within the bladder, a right total hip arthroplasty, and fractures of the left acetabular column and inferior pubic ramus previously seen on CT torso. Intermittent fluoroscopy was performed while approximately 300 cc of Cysto-Conray water soluble contrast was instilled through the patient's catheter into the bladder. With a distended bladder, imaging was performed in AP and oblique projections. The patient's catheter was then reconnected to the urinary bag, and the patient was able to evacuate the bladder through the catheter. Post-evacuation images were then obtained. There is no evidence of contrast extravasation from the bladder. Intermittent excretion of IV contrast from bilateral ureters were noted during the exam. IMPRESSION: No evidence of bladder leak. Radiology Report CHEST RADIOGRAPH. INDICATION: Multiple rib fractures, intubation, evaluation. COMPARISON: Chest radiograph from ___. FINDINGS: As compared to the previous radiograph, there is unchanged evidence of rib fractures. The effusion on the left has substantially decreased. However, on the right, a new effusion has occurred. As a consequence, the areas of basal atelectasis have changed accordingly. On the current image, there is no evidence for the presence of pneumothorax. In the interval, a right internal jugular vein catheter has been newly introduced. No other relevant changes. Radiology Report INDICATION: New NG tube placement. COMPARISONS: Chest radiograph from ___ at 5:40. FINDINGS: An endotracheal tube is in unchanged position, 5.3 cm from the carina. A right internal jugular sheath is present with the tip in the upper SVC. An enteric tube courses below the diaphragm with the tip in the stomach. Since the prior exam, moderate right and small left pleural effusion appear grossly stable. There is no new opacity or pulmonary edema. There is no pneumothorax. The cardiomediastinal silhouette is unchanged. Left-sided rib fractures are again noted. IMPRESSION: Enteric tube with the tip in the stomach. Otherwise, no significant change from the prior exam. Radiology Report CHEST RADIOGRAPH INDICATION: Motor vehicle accident, pneumonia. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, no relevant change is seen. Moderate bilateral pleural effusions. Areas of atelectasis at both lung bases. Borderline size of the cardiac silhouette with mild fluid overload. No pneumothorax. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ year old woman s/p mvc s/p splenectomy, w/pelvic fx, RUE swelling // RUE DVT? TECHNIQUE: Grey scale, color and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the subclavian veins bilaterally. Normal flow, compression and augmentation is seen in the right internal jugular, axillary and brachial veins. Normal color flow is seen in the right basilic vein. Occlusive thrombus is seen within a segment of the right cephalic vein at the level of the antecubital fossa. Normal flow and compression is seen within the cephalic vein in the upper arm. IMPRESSION: 1. No evidence of deep vein thrombosis. 2. Occlusive thrombus seen within a segment of the right cephalic vein at the level of the antecubital fossa. Radiology Report INDICATION: Polytrauma, status post MVC requiring intubation. COMPARISON: Chest radiograph dated ___. TECHNIQUE: Portable semi-erect frontal radiograph of the chest. FINDINGS: There is improved aeration of the left upper lobe from ___. Increased retrocardiac opacification and hazy opacification at the left costophrenic angle likely reflects a pleural effusion with worsening left lower lobe atelectasis. A small right pleural effusion is also seen. There is no definitive evidence of pneumothorax on this semi-erect radiograph. The tip of the endotracheal tube abuts the tracheal wall. An enteric tube and right internal jugular catheter are unchanged. The cardiomediastinal silhouette is prominent in part related to low lung volumes and AP technique. IMPRESSION: 1. Resolved left upper lobe collapse but worsened left lower lobe atelectasis from ___. 2. Small bilateral pleural effusions, left greater than right. 3. ET tube tip abuts the tracheal wall. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST. REASON FOR EXAM: Hypoxemia. Comparison is made with prior study performed seven hours earlier. New increased widespread opacity in the left lung is consistent with left upper lobe collapse . There is also marked decrease of volume in the left lower lobe. The amount of pleural effusion cannot be assessed. Improved opacity in the right lung due to redistribution of a large pleural effusion. Cardiomediastinum is shifted towards the left. The ET tube, right IJ catheter tip and NG tube are in unchanged standard positions. Findings were discussed with Dr. ___ by phone on ___ at 1:50 p.m., two minutes after the discovery of the finding. Radiology Report CHEST RADIOGRAPH INDICATION: Intubation, evaluation for interval change. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, no relevant change is seen. The monitoring and support devices are constant. Low lung volumes with retrocardiac atelectasis. The pre-existing blunting of the costophrenic sinuses is constant. Constant known rib fractures. No pneumothorax. Radiology Report STUDY: Pelvis intraoperative study, ___. CLINICAL HISTORY: Patient with left acetabular fracture ORIF. FINDINGS: Several fluoroscopic images of the pelvis from the operating room demonstrate placement of a screw and washer within the left superior pubic rami. There has also been subsequent placement of a screw and washer projecting over the left sacroiliac joint. There are no signs for hardware-related complications. The total intraservice fluoroscopic time was 193.5 seconds. Please refer to the operative note for additional details. Radiology Report INDICATION: MVC status post splenectomy and ORIF of the hip, now intubated, with fever. COMPARISON: ___. TECHNIQUE: Portable semi-erect frontal radiograph of the chest. FINDINGS: The endotracheal tube, enteric tube and right IJ central venous catheter are unchanged in position. The lung volumes are unchanged. Retrocardiac opacification is again seen, likely reflecting atelectasis. There is mild right basilar atelectasis. Blunting of the right costophrenic angle may reflect small right pleural effusion. The left costophrenic angle remains visible. There is no significant pneumothorax. The cardiomediastinal contours are within normal limits and stable. Known rib fractures are re-demonstrated. IMPRESSION: 1. Unchanged position of support devices. 2. Persistent low lung volumes and bibasilar atelectasis. Possible small right pleural effusion. Radiology Report PORTABLE CHEST FILM ___ AT 6:06 A.M. CLINICAL INDICATION: ___ with presumed VAP, evaluate for pneumonia. Comparison to prior study dated ___ at 1330. A portable AP upright chest film ___ at 6:06 a.m. is submitted. IMPRESSION: 1. Endotracheal tube continues to have its tip approximately 5 cm above the carina. A nasogastric tube is seen coursing below the diaphragm with the tip just below the esophageal gastric junction. Advancement of the tube by approximately 5 cm would be recommended to ensure that the side port is subdiaphragmatic. The cardiac and mediastinal contours are stable. Lung volumes remain low with improved aeration at the right base but interval appearance of retrocardiac opacity suggestive of atelectasis, although pneumonia cannot be entirely excluded. Possible layering left effusion. No evidence of pulmonary edema although the vasculature is crowded. No pneumothorax. Results were communicated to the patient's nurse, ___, by phone on ___ at 11:38 a.m. at the time of discovery. Radiology Report INDICATION: New left PICC placement, here to evaluate PICC position. COMPARISON: Chest radiograph performed earlier the same day at 05:14 a.m. TECHNIQUE: Portable semi-erect frontal radiograph of the chest. FINDINGS: There has been interval placement of a left PICC ending at the confluence of the left brachiocephalic vein and SVC. An endotracheal tube, enteric tube, and right internal jugular transducer catheter are unchanged. Aeration of the right lung base is improved from the most recent prior study. The appearance of the chest is otherwise unchanged from the study performed earlier the same day with persistent low lung volumes. IMPRESSION: 1. Left PICC ending at the upper SVC. 2. Improved aeration of the right lung base. NOTIFICATION: Finding #1 was communicated by Dr. ___ to IV nurse, ___, via pager at 1:45 p.m. on ___. Radiology Report STUDY: AP chest ___. CLINICAL HISTORY: ___ woman with difficulty weaning off the respirator. Evaluate for interval change. FINDINGS: Comparison is made to prior study from ___. Endotracheal tube, feeding tube and left-sided central line are again seen in unchanged position. There is cardiomegaly. Several minimally displaced left lateral rib fractures are seen. A left retrocardiac opacity is seen and the small left side pleural effusion is present. There is minimal prominence of the pulmonary interstitial markings without overt pulmonary edema. Overall, these findings are relatively stable. Radiology Report INDICATION: ___ status post splenectomy for splenic laceration. Spiking fevers and rising white blood cell count. Rule out intra-abdominal abscess. COMPARISON: Prior CT scan of ___. TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen and pelvis after the administration of IV contrast. Multiplanar axial, coronal, and sagittal images were generated. A TOTAL BODY DLP: 1077.5 mGy-cm. FINDINGS: LUNG BASES: There are bilateral small pleural effusions, larger on the right. Bibasilar airspace opacities are noted, which may represent atelectasis but superinfection cannot be excluded. There is a residual small right lower lobe pneumothorax. Calcifications of the coronary arteries and aorta. No left-sided pneumothorax noted on the provided images. No pericardial effusion. CT OF THE ABDOMEN WITH CONTRAST: A gastric bypass with gastrojejunostomy anastomosis is noted. The patient is status post splenectomy with postoperative changes at the splenectomy bed. A left abdominal drain with the tip terminating in the left upper quadrant is seen. There is no intra-abdominal or pelvic collection noted. No liver lesion is noted. There is a new, likely dystrophic calcification along the infero-lateral edge of the liver. No intra- or extra-hepatic biliary tree dilatation. Curvilinear area of hyperdensity is noted in the dependent portion of the gallbladder which may represent layering stones or contrast reflux. Stable 9-mm fatty lesion in the left adrenal gland in keeping with a myelolipoma. The right kidney and adrenal gland are unremarkable. There is atrophy of the pancreas which is likely age appropriate. The appendix is unremarkable as is the small bowel and colon. An enteric tube is noted which terminates at the most proximal aspect of the gastric remnant. There is a 41 x 51 cm oval-shaped left adnexal lesion which may be of ovarian origin. A second oval-shaped structure is noted in the right adnexal region which may represent the uterus which is slightly deviated to measures 23 x 36 cm. The right ovary is not well visualized. The abdominal aorta is of normal caliber with moderate calcified atherosclerotic disease within the aorta and iliac arteries. There is a left abdominal drain with the tip terminating in the splenectomy bed. OSSEOUS STRUCTURES: Redemonstration of the known bilateral rib fractures of the left, five, six, seven, eight, nine, ten, and twelfth rib and right seventh rib. Status-post open reduction internal fixation of pelvic ring fracture with sacroiliac screw, fully threaded, and retrograde anterior column screw. Stable right hip prosthesis. IMPRESSION: 1. Status-post splenectomy with post-surgical changes in the splenectomy bed. 2. No intra-abdominal or pelvic collection noted. 3. Small residual right lower lobe pneumothorax. 4. Bilateral small-to-moderate pleural effusions. 5. Indeterminate left adnexal mass for which an elective ultrasound is recommended when the patient is stabilized. Radiology Report INDICATION: Status post MVC with multiple orthopedic injuries, splenic laceration, and increased white count, evaluate for acalculous cholecystitis. COMPARISON: CT abdomen and pelvis on ___. FINDINGS: The liver is normal in echogenicity. No focal hepatic lesions. No intrahepatic or extrahepatic biliary duct dilatation. The common bile duct measures 4 mm. The portal vein is patent with hepatopetal flow. The gallbladder is only moderately dilated. There is cholelithiasis and on some images the gallbladder wall appears mildly edematous. No pericholecystic fluid. No sonographic ___ sign. A midline well-circumscribed pocket of fluid is consistent with excluded stomach after gastric bypass, as shows on the prior CT. IMPRESSION: Cholelithiasis. On some images the gallbladder wall appears mildly edematous, but without other signs specific for cholecystitis. Radiology Report PORTABLE CHEST X-RAY, ___ COMPARISON: Chest x-ray of one day earlier. FINDINGS: Nasogastric tube has been exchanged for a feeding tube, terminating in the proximal stomach. Exam otherwise appears similar to the prior study of one day earlier, except for apparent slight increase in pleural effusions, left greater than right. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ year old woman s/p MVA with no initial head trauma with altered mental status evaluate for intracranial pathology such is bleed or edema pre TECHNIQUE: Noncontrast multi sequence, multiplanar brain MRI is performed utilizing the following sequences: Sagittal T1, axial T2, axial FLAIR, axial FLAIR propeller, axial T2 GRE, and axial T2 trace. COMPARISON: Noncontrast head CT dated ___. FINDINGS: Some of the sequences are degraded by motion artifact. Within this confines: There is no infarct, hemorrhage, or mass effect. The ventricles and sulci are prominent indicative of mild parenchymal volume loss. There are extensive nonspecific periventricular and subcortical white matter confluent areas of FLAIR hyperintensity likely sequela of chronic small vessel ischemic disease. The principal intracranial flow voids are present. There are bilateral lens implants. There is fluid within the mastoid air cells bilaterally, left greater than right. IMPRESSION: No acute infarct, hemorrhage or mass effect. Extensive nonspecific white matter abnormalities, likely sequela of chronic small vessel ischemic disease. Radiology Report AP CHEST, 8:27 A.M. HISTORY: Newly replaced Dobbhoff tube. IMPRESSION: AP chest compared to ___: Three serial chest radiographs show initial positioning of the Dobbhoff tube in the distal right lower lobe bronchial tree, then at the gastroesophageal junction, finally in the upper stomach. None of the chest radiographs shows right pneumothorax, or evidence of bleeding in the right lung. Presumed right pleural effusion is small. Previous consolidation in the right lung laterally has improved since ___. Left lower lobe, however, is more consolidated today with greater volume loss, indicating worsening of a component of atelectasis, despite at least a small left pleural effusion. Followup for possible complications of the bronchial intubation and possible left lower lobe pneumonia. No pneumothorax. Tracheostomy tube in standard placement. Left PIC line ends in the upper SVC. Radiology Report CHEST RADIOGRAPH INDICATION: Nasogastric tube, Dobbhoff placement. COMPARISON: ___, 8:27. FINDINGS: As compared to the previous radiograph, Dobbhoff tube is in unchanged position. The tip of the tube projects 2-3 cm within the stomach. The tube has not changed in position since the previous examination. All other monitoring and support devices are also in constant position. Unchanged appearance of the heart and the known small left pleural effusion. Radiology Report CHEST RADIOGRAPH INDICATION: Dobbhoff placement. COMPARISON: ___, 2:27. FINDINGS: As compared to the previous radiograph, the Dobbhoff catheter appears to be pulled back. The tip of the catheter is coiled. The last images of the series show the catheter within the proximal parts of the stomach. The decision of repositioning the device should be made on the grounds of clinical criteria. Radiology Report AP CHEST, 5:35 A.M., ___ HISTORY: ___ woman after polytrauma with a new Dobbhoff feeding tube. IMPRESSION: AP chest compared to ___: Feeding tube with a wire stylet initially placed in the lower esophagus is on the second image advanced into the upper stomach. Moderate left pleural effusion changed in distribution but not in overall size. Pulmonary vascular congestion, more readily assessed in the right lung, has progressed. Heart size top normal. Tracheostomy tube in standard placement. Left PIC line ends at the origin of the SVC. No pneumothorax. Radiology Report INDICATION: ___ year old woman with dobboff and past gastric bypass. Advanced tube into the small bowel per ACS recs FINDINGS: Patient's existing catheter is found with tip in the distal esophagus/ remnant proximal stomach. This was exchanged for an 8 ___ ___ catheter as the existing catheter was 12 ___ and the team requested a bridle. No bridle is available in a ___ size. As a result, the 8 ___ ___ was advanced into the stomach. After repeated attempts, the tip was not able to be advanced past the gastrojejunostomy and was left with a small amount of slack within the stomach with hope of passage through peristalsis. This was discussed with the patient's nurse upon completion of the study who then placed the bridle. IMPRESSION: 8 ___ ___ catheter left within the stomach. Despite repeated attempts, unable to be advanced past the gastrojejunostomy. Please note when ordering this study in the future with instructions to bridle, only 8 and 10 ___ tubes can be successfully bridled. Radiology Report AP CHEST, 6:14 A.M., ___ HISTORY: ___ woman after motor vehicle collision and tracheostomy. Attempting to wean. IMPRESSION: AP chest compared to ___ through ___: Mild pulmonary edema has improved, moderate left pleural effusion has increased. Mild-to-moderate cardiomegaly stable. Feeding tube ends in the stomach. Tracheostomy tube in standard placement. Left PICC line ends in the upper-to-mid SVC. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with dobhoff, ? pulled back inadvertantly // ___ year old woman with dobhoff, ? pulled back inadvertantly TECHNIQUE: Portable chest COMPARISON: ___ FINDINGS: Tracheostomy tube and left-sided PICC line are unchanged. There is worsening appearance of the lungs with increased ill-defined vasculature and increased alveolar infiltrates left greater than right. There is dense retrocardiac opacity. The heart is moderately enlarged. There is bilateral pleural effusions. IMPRESSION: Worsened fluid status. An underlying infectious infiltrate can't be excluded Radiology Report INDICATION: Trauma. Rib fractures, splenic injury, pelvic fractures on outside hospital exam. COMPARISON: CT torso performed subsequently after this exam. FINDINGS: PORTABLE AP CHEST: There are at least five contiguous rib fractures on the left from the fourth to the eighth ribs although several other rib fractures bilaterally are better evaluated on concurrent CT torso. There is subcutaneous emphysema in the left chest wall. There is opacity in the left lung, likely a combination of lung parenchymal contusion and hemothorax. The right lung is relatively clear, but low in volume. The cardiomediastinal silhouette and hilar contours are difficult to evaluate given portable technique but grossly normal. The ET tube terminates approximately 2.5 cm from the carina. Enteric tube courses through the esophagus and appears to course to the right at the EG junction and out of view. There is possible small left pneumothorax with lucency along the left heart border. PORTABLE AP PELVIS: There are fractures of the superior and inferior pubic rami on the left with inferior displacement of the medial fracture components. There is communited left sacral alar fracture. There is no evidence of pubic symphysis or SI joint diastasis. There is total right hip arthroplasty. The left hip appears intact. IMPRESSION: 1. Numerous left rib fractures with left hemothorax and possible left pneumothorax. Other known right rib fractures and right pneumothorax are better seen on concurrent CT of the chest. 2. Left superior and inferior pubic rami fractures and comminuted left sacral alar fracture Radiology Report INDICATION: Trauma. Motor vehicle collision with left rib fractures, splenic laceration, pelvic fractures. COMPARISON: Outside CT of the torso without contrast the same day. TECHNIQUE: Contiguous helical MDCT images were obtained through the torso after administration of Omnipaque IV contrast, followed by additional delayed images through the torso. Multiplanar axial, coronal, and sagittal images were generated. TOTAL BODY DLP: 2237 mGy-cm. FINDINGS: OSSEOUS STRUCTURES: There are posterior and lateral displaced fractures of the left 3, 4, 6, 7, 8, 9, 10 ribs, as well as fractures laterally in the left second rib, laterally in the left fifth rib, and anteriorly in the left first rib. There is a lateral second right rib fracture, lateral/anterior right fourth rib fracture, and lateral right seventh rib fracture. Left L5 tranverse process fracture is minimally displaced (2A:115). There are acute fractures of the left inferior pubic ramus (2B:446). There is a comminuted fracture of the left acetabular column involving the left superior pubic ramus (2B:427). There is also comminuted fracture of the left sacral ala (2B:386). There is no evidence of pubic symphysis or SI joint diastasis. Total right hip prosthesis is incidentally noted. CT CHEST WITH CONTRAST: Included portions of the thyroid are unremarkable. There is no supraclavicular, axillary, hilar, or mediastinal lymphadenopathy. The heart is not enlarged, and there is only trace likely physiologic pericardial fluid. There are calcifications of the coronary arteries and aorta. There are very small bilateral pneumothoraces (2A:1). There is a moderate left hemothorax with atelectasis of the left lower lobe. A small peripheral area of probable lung contusion is evident in the lingula (2A:3). Very small right hemothorax is also noted with adjacent atelectasis in the lower lobe. Subcutaneous emphysema is noted within the left chest wall adjacent to the fractures. The thoracic aorta is normal in caliber without intramural hematoma, aneurysm, or dissection. The great vessels are unremarkable. CT ABDOMEN WITH CONTRAST: The liver enhances normally without focal lesions, intra- or extra-hepatic biliary duct dilation. The portal vein is patent. The gallbladder contains small dependently layering stones. There is thickening at the fundus of the gallbladder, likely reflecting adenomyomatosis (2B:319). Fatty lesion in the left adrenal gland is compatible with a myelolipoma. The pancreas and right adrenal gland are unremarkable. The kidneys excrete contrast symmetrically without hydronephrosis or worrisome mass. There are scattered subcentimeter hypodensities. The largest in the interpolar region of the right kidney measures 1.2 cm with internal density of 15 Hounsfield units, compatible with a simple cyst. Other smaller hypodensities are too small to characterize but may also be simple cysts. The ureters are normal throughout their visualized course. The spleen contains several lacerations, the largest a 3.1-cm laceration within the upper pole (2B:269). There are several arterially enhancing foci, most likely reflecting pseudoaneurysms; for example, 1.6 cm focus superiorly (2A:18) and several smaller scattered foci more inferiorly. The most inferior focus (2A:40) may have a component of active extravasation, but if present, this is small. There is small to moderate hemoperitoneum, with a hematoma seen surrounding the spleen. Additional small volume hemorrhage tracks along the retroperitoneum on the left along the psoas. The patient is status post gastric bypass. Enteric tube passes into the gastric remnant. The excluded portion of the stomach is unremarkable. Small and large bowel are normal in caliber without evidence of wall thickening or abnormal enhancement. There is no mesenteric or retroperitoneal lymphadenopathy and no abdominal wall hernia. No free air is present. Abdominal aorta is normal in caliber with moderate calcified atherosclerotic disease within the aorta and iliac arteries. CT PELVIS WITH CONTRAST: Streak artifact from right total hip arthroplasty limits evaluation of the lower pelvis. However, within these limitations, there is small to moderate amount of blood in the pelvis. Two more well-circumscribed foci in the lower pelvis measuring 4.5 and 3.3 cm also likely reflect hematomas (2A:157). The rectum and is unremarkable. A foley is noted in a collapsed bladder. Extraperitoneal hematoma surrounds the left pubic rami fracture; extraperitoneal bladder rupture is unlikely given the normal appearance of the bladder on the prior CT. IMPRESSION: 1. Splenic lacerations (AAST grade 3) with several pseudoaneurysms, the largest measuring 1.6 cm. The small inferior-most pseudoaneurysm may have a tiny component of active extravasation. 2. Moderate left hemothorax with small bilateral pneumothoraces. 3. Small left lung contusion at the lingula. 4. Small hemoperitoneum with hemorrhage also in the left retroperitoneum and pelvis. 5. Comminuted left acetabular column and left inferior pubic ramus fracture. Comminuted left sacral alar fracture. 6. Fracture of the left L5 transverse process. Numerous left segmental rib fractures as detailed above and several nonsegmental right rib fractures. 7. Cholelithiasis and adenomyomatosis of the gallbladder fundus. 8. Left adrenal myelolipoma. These results were communicated to the surgery team immediately at the time of discovery in person by ___, approximately 3:30 p.m., ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: MVC Diagnosed with SPLEEN PARENCHYMA LACER, FRACTURE OF PUBIS-CLOSED, FX SACRUM/COCCYX-CLOSED, FX LUMBAR VERTEBRA-CLOSE, TRAUM HEMOTHORAX-CLOSED, FX MULT RIBS NOS-CLOSED, MV COLLISION NOS-DRIVER temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

1. continue weaning the ventilator as tolerated 2. ambulate daily with assistance 3. staples from back removed, staples from LUQ removed 4. suction as needed/routine tracheostomy care 5. turn/reposition q2 hours when in bed 6. pain control

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Vicodin / Seroquel Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with history of multiple GI surgeries, now presenting with persistent abdominal pain s/p ERCP with stent placement. She has had recurrent abdominal pain and "issues" over the past year. She went to ___ for initial evaluation of abdominal pain and was found to have a UTI. She had a subsequent evaluation with EGD/ERCP with stent placement. She was reportedly found to have pancreatitis and treated with bowel rest. She had minimal improvement during this hospitalization. She was eventually discharged yesterday but pain has persisted and she is unable to care for her children at home, so she is presenting now for further evaluation. In the ED, initial VS were: 98.2 87 125/85 18 97%. Exam notable for moderate tenderness to palpation to RUQ. LFTs and lipase normal with only mild ALT elevation. Given recent stent placement, CT abd/pelvis done and only showed lymphandenopathy with stent in place. She was given 1L NS, ondansetron, and morphine with minimal improvement. With her persistent pain and intolerance to PO, she is being admitted for pain control and observation. On arrival to the floor, pt feels well. She has no complaints aside from constipation and decreased po intake. Past Medical History: - ulcers and gastritis - congenital abnormalities "heterotaxy syndrome" - lap band removed due to complications - cholecystectomy - pancreatitis - malrotation corrected age ___ - asplenic (congenital) - hysterectomy for bleeding, cysts - pregnancy Social History: ___ Family History: noncontributory Physical Exam: ADMISSION AND DISCHARGE VS - 98.0 125/82 99 18 96/RA wt 76.8kg GENERAL - well-appearing obese female in NAD, comfortable, appropriate HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout LABS: see below Pertinent Results: ADMISSION AND DISCHARGE LABS ___ 04:30PM BLOOD WBC-11.8* RBC-4.49 Hgb-13.3 Hct-39.8 MCV-89 MCH-29.7 MCHC-33.4 RDW-12.5 Plt ___ ___ 04:30PM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-142 K-3.5 Cl-105 HCO3-26 AnGap-15 ___ 04:30PM BLOOD ALT-51* AST-38 AlkPhos-99 TotBili-0.2 ___ 06:05AM BLOOD Calcium-9.1 Phos-5.7* Mg-2.0 ___ 04:30PM BLOOD Albumin-4.1 U/A - SpecGr 1.020, pH 5.5, Leuk Sm, Bld Neg, Prot Tr, RBC 3, WBC 5, Bact Few, Yeast None, Epi 1 ___ Lipase 40 IMAGING 1. No acute intrapelvic process. 2. Post-operative anatomy compatible with history of heterotaxy and malrotation. 3. Several nodular enhancing soft tissue densities at the celiac axis measuring up to 1.5 cm in short axis. These may represent lymph nodes of unknown significance. In addition, thes could represent an atypical location of splenosis. Given the patient's altered anatomy, the celiac axis is adjacent to the splenic tail. No normal spleen is visualized. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. Clonazepam 1 mg PO BID 4. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral daily 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Venlafaxine XR 150 mg PO DAILY 7. BuPROPion 200 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain RX *oxycodone-acetaminophen 5 mg-500 mg 1 capsule(s) by mouth q8 Disp #*21 Capsule Refills:*0 3. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral daily 4. BuPROPion 200 mg PO DAILY 5. Clonazepam 1 mg PO BID 6. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. Venlafaxine XR 150 mg PO DAILY 10. Bisacodyl 10 mg PO DAILY:PRN constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 11. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth q8 Disp #*90 Tablet Refills:*0 12. Senna 1 TAB PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a ___ Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Post procedural abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ woman with history of heterotaxy and repaired malrotation now status post recent ERCP with abdominal pain. TECHNIQUE: MDCT data were acquired through the abdomen and pelvis after the administration of intravenous contrast. Images were displayed in multiple planes. COMPARISON: None at this institution FINDINGS: Abdomen: The visualized lung bases are clear. The liver is enhances homogeneously. Attenuation of the liver is low, but there is no spleen for comparison. The portal and hepatic veins are patent. There is no intra or extrahepatic biliary dilatation. There is a stent from the left-sided biliary ducts into the duodenum. Gallbladder is surgically absent. The anatomic relationships at the porta hepatis are severely distorted. The pancreas is small and enhances homogeneously. The splenic to terminates around the celiac axis. The spleen is absent. Mildly enhancing soft tissue densities are visible at the celiac axis. The largest measures 1.5 x 2.4 cm (601b:037, 2:23). The adrenal glands are normal. The kidneys enhance symmetrically and excrete contrast promptly. The stomach, small bowel, and large bowel are normal caliber and wall thickness. There is a relative paucity of small bowel in the left upper quadrant, compatible with history of malrotation. There is azygos continuation of the IVC. In addition, the left renal vein drains into a hemi azygous vein which courses from the abdomen up into the chest. Pelvis: The remainder of the bowel is unremarkable. There is no pelvic free pelvic fluid. The uterus and bladder are within normal limits. There is no free pelvic fluid. There is no inguinal or pelvic adenopathy. There are no concerning lytic or sclerotic bone lesions. IMPRESSION: 1. No acute intrapelvic process. 2. Post-operative anatomy compatible with history of heterotaxy and malrotation. 3. Several nodular enhancing soft tissue densities at the celiac axis measuring up to 1.5 cm in short axis. These may represent lymph nodes of unknown significance. In addition, thes could represent an atypical location of splenosis. Given the patient's altered anatomy, the celiac axis is adjacent to the splenic tail. No normal spleen is visualized. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN RUQ, NAUSEA WITH VOMITING temperature: 98.2 heartrate: 87.0 resprate: 18.0 o2sat: 97.0 sbp: 125.0 dbp: 85.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, Thank you for choosing us for your care. You were admitted for abdominal pain. We performed blood tests look for dangerous causes of pain and there were no concerning findings. A CT scan was done and showed changes consistent with your previous surgeries, but nothing dangerous. Given your recent ERCP, it is likely that this is residual pain from that procedure. Your lipase, a marker for pancreatitis, is normal. We have made no changes to your medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / latex Attending: ___. Chief Complaint: Pulled G-tube, abdominal distention Major Surgical or Invasive Procedure: G-tube placement ___ PICC line placement ___ History of Present Illness: ___ with hx CVAs (relatively nonverbal), HTN, HLD, AFib, G-tube, and atonic colon with several recent admissions for concern of obstruction who presented from rehab after pulling out G-tube and with significant abdominal distention. Patient has had multiple recent admissions with diagnosis of atonic colon most recently ___ of this year for distended abdomen during which time she was decompressed with a rectal tube and flex sig showed atonic colon thought to be due to enteric nerve damage in setting of previous CVAs. Her bowel regimen was increased at that time and she began passing stool on her own. Patient was noted to have significant abdominal distention at rehab the day prior to admission but did have a small BM the day of admission. The same day the patient pulled her G-tube with ballon inflated. Temporary foley was placed and patient was brought to ED for evaluation and g-tube replacement. In the ED, initial vital signs: 98.6 64 148/117 20 100% RA. Labs were notable for WBC of 2.7, platelets of 123, INR of 1.7 (goal ___. KUB showed colonic dilation to 11cm. Patient was admitted for g-tube replacement and management of abdominal distention. VS on transfer 97.9 92 157/101 14 99% RA. Past Medical History: History of thromboembolic strokes (L hemiplegia and nonverbal), seizures, atrial fibrillation, hypertension, hyperlipidemia. Social History: ___ Family History: Daughter and son are HCP Physical Exam: *Admission Physical* Vitals: T: 97.9 BP: 152/89 P: 87 R: 32 O2: 100%RA Pain: Unable to assess General: Comfortable, frequent mouth movements, attempts to speak but not understandable HEENT: MMM, chapped lips, OP clear, sclera anicteric Neck: Supple, no JVD appreciated, no LAD CV: Irregularly irregular, mildly tachycardic, no murmurs appreciated Lungs: CTAB, unable to listen posteriorly as patient unwilling to move Abdomen: normoactive bowel sounds, moderately distended but soft without tenderness to palpation, tympanic, tube in place at previous G-tube site Ext: WWP, 1+ DP pulses bilaterally, no edema Neuro: Unable to assess as patient nonverbal, makes some words but not coherent. Skin: No rashes appreciated DISCHARGE PHYSICAL: 98.3 124/68 109 18 100% RA General: confortable, alert HEENT: MMM, sclera anicteric CV: irregularly irregular, mildy tachycardic, no m/r/g Lungs: CTAB Abd: soft, non-tender to palpation, non-distended, NABS, G-tube in place Ext: warm, no edema Neuro: patient nonverbal Pertinent Results: ADMISSION LABS: ___ 10:15AM BLOOD WBC-2.7* RBC-4.41 Hgb-13.7 Hct-40.8 MCV-93 MCH-31.1 MCHC-33.6 RDW-17.8* Plt ___ ___ 10:15AM BLOOD Neuts-31* Bands-0 Lymphs-64* Monos-3 Eos-0 Baso-0 Atyps-2* ___ Myelos-0 ___ 05:05PM BLOOD ___ ___ 10:15AM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-145 K-3.8 Cl-105 HCO3-28 AnGap-16 ___ 08:38PM BLOOD ALT-24 AST-45* CK(CPK)-150 AlkPhos-97 TotBili-0.8 ___ 10:15AM BLOOD Calcium-9.2 Phos-2.2* Mg-2.4 BANDEMIA: ___ 05:43AM BLOOD Neuts-34* Bands-0 Lymphs-43* Monos-10 Eos-2 Baso-0 ___ Myelos-1* Blasts-10* NRBC-2* ___ 05:16AM BLOOD Neuts-57 Bands-2 ___ Monos-7 Eos-0 Baso-0 Atyps-3* ___ Myelos-1* Blasts-5* NRBC-1* Other-0 DISCHARGE LABS: ___ 05:35AM BLOOD WBC-3.1* RBC-2.73* Hgb-8.8* Hct-26.2* MCV-96 MCH-32.3* MCHC-33.7 RDW-18.7* Plt ___ ___ 05:35AM BLOOD ___ PTT-40.3* ___ ___ 05:35AM BLOOD Glucose-95 UreaN-18 Creat-0.8 Na-142 K-4.2 Cl-109* HCO3-28 AnGap-9 STUDIES: KUB ___: IMPRESSION: Prominent colonic distention to a maximum of 11 cm, increased compared to prior examination. This is fairly similar in appearance to some of the patient's prior examinations including one dated from ___ and is most likely chronic, secondary to dysmotility CXR ___: FINDINGS: Status post G-tube placement. Only a part of the device is visible on the current chest x-ray. There are clearly hyperexpanded parts of the colon visible both under the left and the right hemidiaphragm. On the right, however, there could also be a small amount of post-procedural free air. CXR ___: IMPRESSION: AP chest compared to ___, 8:47 p.m.: ET tube in standard placement, nasogastric tube passes into non-distended stomach. Right internal jugular line ends in the right atrium, approximately 9 cm below the level of the carina, would need to be withdrawn 5 cm to reposition it in the low SVC. Opacification in the right upper lobe has improved suggesting it was due in large part to atelectasis. Followup advised. Moderate cardiomegaly has improved. Left lung is clear. No pneumothorax or pleural effusion. The intestines in the upper abdomen remain moderately-to-severely distended EKG ___: Atrial fibrillation with a rapid ventricular response with frequent ventricular premature beats or aberrant conduction. Left ventricular hypertrophy with repolarization changes. Inferolateral ST segment changes are probably due to left ventricular hypertrophy. Compared to the previous tracing of ___ the findings are similar. CXR ___: IMPRESSION: Right IJ line has been withdrawn, probably ends in the upper atrium since it is still 7 cm below the level of the carina, and would need to be further withdrawn 3 cm to reposition it low in the SVC. No pneumothorax or pleural effusion. Right upper lobe atelectasis has almost entirely cleared. Mild cardiomegaly is stable. ET tube in standard placement. Upper enteric drainage tube passes into a non-distended stomach. Intestinal segments in the upper abdomen are still moderately-to-severely distended. CXR ___: FINDINGS: As compared to the previous radiograph, the sidehole of the nasogastric tube is now in the middle to distal parts of the stomach. The tip of the device is not included on the image. No evidence of complications, notably no pneumothorax. Massive intestinal overdistention, unchanged to the prior image. Minimal plate-like atelectasis at the right lung bases. Moderate cardiomegaly. Thickening of the minor fissure. The right internal jugular vein catheter, the endotracheal tube are in correct position. KUB ___: FINDINGS: Diffuse colonic distension is again demonstrated, with individual loops of bowel measuring up to 9 cm in diameter. A moderate amount of residual stool is present within the colon, particularly in the ascending and distal rectosigmoid regions. Overall similar appearance to ___, though the extent of bowel distention has slightly decreased since that time. Similar pattern of colonic distension is present on older abdominal radiographs ___, possibly due to a history ___ syndrome. Nasogastric tube and G-tube overlie the stomach. KUB ___: IMPRESSION: Persistent colonic dilatation, substantially increased, now with a maximal dilatation of 14 cm. This is compatible with known pseudoobstruction, but volvulus is not excluded in this current study. If clinical concern for obstruction persists, a gastrograffin enema or CT may be considered. Otherwise, short-term follow-up radiographs are recommended. The degree of dilatation may pose a risk of perforation and close follow-up is suggested. KUB ___: IMPRESSION: Gas throughout the colon largely unchanged since 1 day prior consistent with excessive ileus. No evidence of obstruction. MICRO: Urine culture ___: ___. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ___ CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- 2 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Blood cx x4: No growth Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium (Liquid) 100 mg PO BID 2. LACOSamide 100 mg PO BID 3. Metoprolol Tartrate 25 mg PO TID 4. Glycerin Supps ___AILY constipation 5. Polyethylene Glycol 34 g PO DAILY 6. Atorvastatin 80 mg PO DAILY 7. Ezetimibe 10 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Ramipril 10 mg PO BID 10. Simethicone 80 mg PO TID 11. Warfarin 3.5 mg PO DAILY16 12. Acetaminophen 650 mg PO Q8H Discharge Medications: 1. Atorvastatin 80 mg PO DAILY 2. Glycerin Supps ___AILY constipation 3. Ramipril 10 mg PO BID 4. Polyethylene Glycol 34 g PO DAILY 5. Ezetimibe 10 mg PO DAILY 6. LACOSamide 100 mg PO BID 7. Simethicone 80 mg PO TID 8. Omeprazole 20 mg PO DAILY 9. Senna 1 TAB PO DAILY 10. Warfarin 3 mg PO DAILY atrial fibrillation 11. Metoprolol Tartrate 50 mg PO TID 12. Acetaminophen 650 mg PO Q6H:PRN pain/fever 13. Docusate Sodium (Liquid) 200 mg PO BID 14. Enoxaparin Sodium 60 mg SC BID Start: ___, First Dose: Next Routine Administration Time Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Abdominal distention to to atony, pulled G-tube, UTI, atrial fibrillation with aberrancy, respiratory failure Secondary: CVA, myleoproliferative disorder Discharge Condition: Activity Status: Bedbound. Level of Consciousness: Lethargic but arousable. Mental Status: Confused, non-verbal. Followup Instructions: ___ Radiology Report HISTORY: Colonic dysmotility, presenting after pulling a G-tube which is now replaced, now with significant abdominal distention. COMPARISON: ___. TECHNIQUE: Abdominal radiograph, three views. FINDINGS: There is prominent dilatation of the large bowel up to roughly 11 cm without noted wall thickening. Small bowel loops are difficult to evaluate; however, do not appear dilated. There is no evidence of pneumoperitoneum or pneumatosis, although evaluation is limited given prominent dilatation of the colon. G-tube projects over the left upper quadrant. IMPRESSION: Prominent colonic distention to a maximum of 11 cm, increased compared to prior examination. This is fairly similar in appearance to some of the patient's prior examinations including one dated from ___ and is most likely chronic, secondary to dysmotility. Radiology Report CHEST RADIOGRAPH INDICATION: G-tube placement. COMPARISON: ___. FINDINGS: Status post G-tube placement. Only a part of the device is visible on the current chest x-ray. There are clearly hyperexpanded parts of the colon visible both under the left and the right hemidiaphragm. On the right, however, there could also be a small amount of post-procedural free air. CC7 was called at the time of dictation and observation, 8:46 a.m., on ___. In addition, a wet read was entered into the system. Low lung volumes. Borderline size of the cardiac silhouette without evidence of pneumonia or pulmonary edema. Radiology Report AP CHEST, 8:47 P.M. ON ___ HISTORY: Clogged G-tube. V-tach. Check ET tube. IMPRESSION: AP chest compared to ___: Previous large pneumoperitoneum no longer visible. New opacification in the right upper lung with volume loss could be largely atelectasis but raises concern for pneumonia. ET tube is in standard position, with the chin flexed. Upper enteric drainage tube passes into a non-distended stomach. The gut in the upper abdomen remains moderately to severely distended. Heart is moderately enlarged, unchanged, but there is no vascular congestion, edema or appreciable effusion. Radiology Report AP CHEST 11:38 P.M. ON ___ HISTORY: New right IJ line and NG tube. IMPRESSION: AP chest compared to ___, 8:47 p.m.: ET tube in standard placement, nasogastric tube passes into non-distended stomach. Right internal jugular line ends in the right atrium, approximately 9 cm below the level of the carina, would need to be withdrawn 5 cm to reposition it in the low SVC. Opacification in the right upper lobe has improved suggesting it was due in large part to atelectasis. Followup advised. Moderate cardiomegaly has improved. Left lung is clear. No pneumothorax or pleural effusion. The intestines in the upper abdomen remain moderately-to-severely distended. Radiology Report AP CHEST, 3:34 A.M., ___ HISTORY: Right IJ line partially withdrawn. IMPRESSION: Right IJ line has been withdrawn, probably ends in the upper atrium since it is still 7 cm below the level of the carina, and would need to be further withdrawn 3 cm to reposition it low in the SVC. No pneumothorax or pleural effusion. Right upper lobe atelectasis has almost entirely cleared. Mild cardiomegaly is stable. ET tube in standard placement. Upper enteric drainage tube passes into a non-distended stomach. Intestinal segments in the upper abdomen are still moderately-to-severely distended. Radiology Report CHEST RADIOGRAPH INDICATION: New nasogastric tube placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the sidehole of the nasogastric tube is now in the middle to distal parts of the stomach. The tip of the device is not included on the image. No evidence of complications, notably no pneumothorax. Massive intestinal overdistention, unchanged to the prior image. Minimal plate-like atelectasis at the right lung bases. Moderate cardiomegaly. Thickening of the minor fissure. The right internal jugular vein catheter, the endotracheal tube are in correct position. Radiology Report INDICATION: History of a 20 ___ MIC G-tube in place, which fell out, for replacement. PHYSICIAN: Dr. ___, the attending radiologist, performed the procedure. PROCEDURE: 1. Tube study (injection through existing Foley in place). 2. Replacement with a 20 ___ MIC G-tube. SEDATION: Moderate sedation was provided by administering dividing doses of fentanyl throughout the total intraprocedure time of 15 minutes (50 mcg) during which patient's hemodynamic parameters were continuously monitored by a trained radiology nurse. PROCEDURE: Prior to initiation of procedure, written informed consent was obtained and preprocedure timeout was performed. The site was prepped and draped in a sterile manner. Contrast injection was performed through the existing Foley to confirm that the tip was positioned within the stomach. Next, a 4 ___ dilator and ___ wire advanced alongside the Foley, and the wire was coiled within the stomach. The Foley balloon was deflated and the catheter was removed. A Kumpe catheter was advanced into the stomach, and contrast injection confirmed appropriate location. Over the ___ wire, a 20 ___ MIC G-tube was placed, and the balloon was inflated within the stomach and pulled back to the ostomy site. The retention disc was advanced, and the catheter was secured in place. Contrast injection confirmed placement and the catheter was flushed. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: Foley catheter in place within the patent tract, with the tip positioned in the stomach. Successful exchange for a 20 ___ MIC G-tube. IMPRESSION: Successful replacement of 20 ___ MIC G-tube. Radiology Report PORTABLE ABDOMEN, ___ COMPARISON: ___. FINDINGS: Diffuse colonic distension is again demonstrated, with individual loops of bowel measuring up to 9 cm in diameter. A moderate amount of residual stool is present within the colon, particularly in the ascending and distal rectosigmoid regions. Overall similar appearance to ___, though the extent of bowel distention has slightly decreased since that time. Similar pattern of colonic distension is present on older abdominal radiographs ___, possibly due to a history ___ syndrome. Nasogastric tube and G-tube overlie the stomach. Radiology Report HISTORY: ___ female with colonic distention. COMPARISON: Abdominal plain film on ___. FINDINGS: Supine images through the abdomen demonstrate increased dilatation of large bowel. Redomonstration of diffuse colonic distention with maximum dimension measured to be 14 cm; this is considerably more dilated than on prior examination when dilation measured 7 cm. The orientation of the dilation has changed slightly as well, now more horizontal. Air is seen within nondilated loops of small bowel. Re- demonstration of G tube and interval removal of nasogastric tube. IMPRESSION: Persistent colonic dilatation, substantially increased, now with a maximal dilatation of 14 cm. This is compatible with known pseudoobstruction, but volvulus is not excluded in this current study. If clinical concern for obstruction persists, a gastrograffin enema or CT may be considered. Otherwise, short-term follow-up radiographs are recommended. The degree of dilatation may pose a risk of perforation and close follow-up is suggested. Radiology Report HISTORY: ___ female with colonic distention. COMPARISON: Abdominal plain film obtained ___. FINDINGS: Supine frontal images through the abdomen demonstrate gas filled loops distended large bowel which appears stable-slightly improved when compared to prior day. Gas is seen throughout loops of small bowel. No evidence of obstruction. No free intraperitoneal air identified. Gastric tube noted. Surgical clips noted in the epigastric region. IMPRESSION: Gas throughout the colon largely unchanged since 1 day prior consistent with excessive ileus. No evidence of obstruction. Radiology Report HISTORY: IV access needed for antibiotics. OPERATORS: Dr. ___ and Dr. ___ resident). The attending, Dr. ___, was present during key portions of the procedure. TECHNIQUE: A preprocedure time out was performed per hospital protocol. Using sterile technique and local anesthesia, the patent right basilic vein was punctured under direct ultrasound guidance using a micropuncture set. Hard-copy ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guidewire and a single-lumen PICC measuring 35 cm in length was placed through the peel-away sheath with its tip positioned in the superior vena cava under fluoroscopic guidance. Position of the catheter was confirmed by 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 was applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single-lumen PICC via the right basilic vein. The final internal length is 35 cm with its tip positioned in the low superior vena cava. The line is ready for use. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: GTUBE REPLACEMENT Diagnosed with FLATUL/ERUCTAT/GAS PAIN temperature: 98.6 heartrate: 64.0 resprate: 20.0 o2sat: 100.0 sbp: 148.0 dbp: 117.0 level of pain: 13 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you during your stay. You were admitted for abdominal distention and a pulled G-tube. During your admission your abdominal distention improved with a flexiseal, laxatives, and positioning. In addition, your G-tube was replaced. During your admission you had an episode of respiratory compromise, possibly due to aspiration, for which you were briefly intubated and in the ICU. You recovered quickly and were extubated. In addition, you had an exacerbation of your atrial fibrillation with rapid heart rates. Your heart rate was controlled with medications and at discharge is within normal limits. You were started on lovenox for coagulation because your INR was low. You will go to the nursing home on ___ until your INR is between ___. Your INR should be monitored at the nursing home. You were also treated for a urinary tract infection. You received a full course of antibiotics for the infection. In addition, it was noted that you had an increased number of blasts, or immature white blood cells, in your labs. This should be monitored as it may represent a disease process or malignancy.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine Attending: ___. Chief Complaint: Surgical Site Infection, UTI Major Surgical or Invasive Procedure: JP drain removal History of Present Illness: ___ year old Female sent from her SNF for concern that her JP drain fell out the morning of admission. There is concern for a surgical site infection. In brief she underwent a ___ laminectomy for spinal stenosis in ___ which was complicated by wound dehiscence and a spinal leak, and was admitted in ___ for debridement and irrigation, with subsequent planned debridement and paraspinus muscle flaps by PRS recently (discharged ___ who was discharged with a JP-drain in place which apparently became discharged the morning, and this prompted transfer to ___ ED. Of note she also was noted with a pneumonia at her SNF 2 days prior to transfer for which she was placed on augmentin. The SNF notes purulent drainage in the JP drain output. Initial vitals in the ___ were 97.7, 64, 144/47, 20, 97%2LNC, and the ED resident notes he was able to express purulent material from the surgical site, but of course when the ___ consult saw the patient there was none to be expressed (since it had already been expressed). The patient received IV NS and was given a dose of Zosyn for concern for a deep surgical wound infection. The remaining JP drain was removed by the PRS team. Of note the patient presents with an indwelling foley catheter from the SNF. Past Medical History: - Type 2 Diabetes - CKD Stage 3 - Primary Hypertension - HFpEF - hypothyroidism - urinary retention - GERD - Hx ischemic CVA with question of residual mild aphasia - Hx L3-L5 hemilaminectomy/foraminotomy and repair of spinal leak (___) - Hx L3 hemilaminectomy and repair of CSF leak with irrigation and debridement (___) Social History: ___ Family History: Mother: ___ Cancer Father: MI Physical ___: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache Remainder of 10 point ROS negative except as noted PHYSICAL EXAM: VSS: 98.2, 188/68, 74, 18, 92% GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3 although slightly confused [at 1:30am], Non-Focal DERM: Surgical Site with erythema with sutures in place, without drainage (see photo in OMR uploaded by ___ team) Pertinent Results: ADMISSION LABS: ___ 03:26PM BLOOD WBC-8.0 RBC-2.75* Hgb-7.8* Hct-26.4* MCV-96 MCH-28.4 MCHC-29.5* RDW-17.4* RDWSD-60.2* Plt ___ ___ 03:26PM BLOOD Neuts-69.2 Lymphs-18.1* Monos-8.8 Eos-2.9 Baso-0.5 Im ___ AbsNeut-5.56 AbsLymp-1.45 AbsMono-0.71 AbsEos-0.23 AbsBaso-0.04 ___ 03:26PM BLOOD Glucose-81 UreaN-27* Creat-1.6* Na-141 K-4.4 Cl-108 HCO3-23 AnGap-10 ___ 07:43PM BLOOD Lactate-0.9 ___ 05:38PM URINE Color-Yellow Appear-HAZY* Sp ___ ___ 05:38PM URINE Blood-NEG Nitrite-NEG Protein-70* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-5.5 Leuks-LG* ___ 05:38PM URINE RBC-86* WBC->182* Bacteri-MOD* Yeast-MANY* Epi-1 TransE-<1 ___ 05:38PM URINE CastHy-8* ___ 06:00PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG ___ 7:30 pm BLOOD CULTURE - pending ___ 5:38 pm URINE CULTURE - pending CHEST (PA & LAT) Study Date of ___ 4:33 ___ IMPRESSION: Cardiomegaly with pulmonary edema though improved since prior and persistent bilateral pleural effusions. CT L-SPINE W/ CONTRAST Study Date of ___ 8:33 ___ IMPRESSION: 1. Status post L3-4 and L4-___s recent paraspinous muscle flap repair of dehisced lumbar surgical wound. Expected postsurgical changes are seen within the midline soft tissues extending from the L1-L5 levels. Specifically, ill-defined enhancement throughout the surgical bed may be postsurgical, but early developing phlegmon would be difficult to exclude. Additionally, a 2.9 cm region of air within the midline wound at the L1-2 level may also be postsurgical, although abscess formation would be difficult to exclude. 2. Sigmoid diverticulosis. Small volume pelvic free fluid surrounding the sigmoid colon is nonspecific but limits evaluation for acute diverticulitis. 3. Bilateral pleural effusions. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Acetaminophen 650 mg PO TID 2. amLODIPine 10 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Escitalopram Oxalate 10 mg PO DAILY 7. Heparin 5000 UNIT SC BID 8. HydrALAZINE 25 mg PO TID 9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Metoprolol Tartrate 25 mg PO BID 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 17.2 mg PO BID 15. Tamsulosin 0.8 mg PO QHS 16. Torsemide 20 mg PO DAILY 17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 18. Vitamin D 1000 UNIT PO DAILY 19. Lidocaine 5% Patch 1 PTCH TD QPM 20. Lisinopril 30 mg PO DAILY 21. Gabapentin 300 mg PO BID 22. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 23. TraZODone 50 mg PO QHS:PRN insomnia 24. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. Acetaminophen 650 mg PO TID 3. amLODIPine 10 mg PO DAILY 4. Ascorbic Acid ___ mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Escitalopram Oxalate 10 mg PO DAILY 8. Gabapentin 300 mg PO BID 9. Heparin 5000 UNIT SC BID 10. HydrALAZINE 25 mg PO TID 11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. Levothyroxine Sodium 75 mcg PO DAILY 15. Lidocaine 5% Patch 1 PTCH TD QPM 16. Lisinopril 30 mg PO DAILY 17. Metoprolol Tartrate 25 mg PO BID 18. Polyethylene Glycol 17 g PO DAILY 19. Senna 17.2 mg PO BID 20. Tamsulosin 0.8 mg PO QHS 21. Torsemide 20 mg PO DAILY 22. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 23. TraZODone 50 mg PO QHS:PRN insomnia 24. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Status post spinal surgery 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 fever // PNA? TECHNIQUE: AP and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: There is persistent pulmonary edema though improved since prior exam. There are small to moderate pleural effusions, larger on the left. Cardiac silhouette is enlarged, similar to prior. Azygos fissure again noted. No acute osseous abnormalities. IMPRESSION: Cardiomegaly with pulmonary edema though improved since prior and persistent bilateral pleural effusions. Radiology Report EXAMINATION: CT L-SPINE W/ CONTRAST INDICATION: ___ with recent JP drainNO_PO contrast // sacral region for abscess? sacral region for abscess? TECHNIQUE: Non-contrast helical multidetector CT was performed after the intravenous administration of mL of Omnipaque contrast agent. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 15.8 s, 30.3 cm; CTDIvol = 30.3 mGy (Body) DLP = 868.0 mGy-cm. Total DLP (Body) = 882 mGy-cm. COMPARISON: CT L-spine ___ FINDINGS: Status post L3-4 and L4-5 hemilaminectomies and foraminotomies as well as recent local paraspinous muscle flap repair of dehisced lumbar surgical wound. Expected postsurgical changes are seen within the midline soft tissues superficial to the spinous processes extending from the L1-L5 levels. At the L1-L2 level, there is a 2.9 x 1.0 cm region of air which may be postsurgical. Ill-defined enhancement throughout the surgical bed is likely postsurgical, although early developing phlegmon can not be excluded. Mild right lateral listhesis of L3 on L4 is unchanged. Alignment of the lumbar spine is otherwise preserved. No acute fractures. There is moderate sigmoid diverticulosis. Small amount of pelvic free fluid is nonspecific. Bilateral pleural effusions are partially visualized. IMPRESSION: 1. Status post L3-4 and L4-5 hemilaminectomies as well as recent paraspinous muscle flap repair of dehisced lumbar surgical wound. Expected postsurgical changes are seen within the midline soft tissues extending from the L1-L5 levels. Specifically, ill-defined enhancement throughout the surgical bed may be postsurgical, but early developing phlegmon would be difficult to exclude. Additionally, a 2.9 cm region of air within the midline wound at the L1-2 level may also be postsurgical, although abscess formation would be difficult to exclude. 2. Sigmoid diverticulosis. Small volume pelvic free fluid surrounding the sigmoid colon is nonspecific but limits evaluation for acute diverticulitis. 3. Bilateral pleural effusions. Gender: F Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by AMBULANCE Chief complaint: Wound eval Diagnosed with Pneumonia, unspecified organism temperature: 97.7 heartrate: 64.0 resprate: 20.0 o2sat: 97.0 sbp: 144.0 dbp: 47.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You came to the hospital after the JP drain in your spinal surgical wound became dislodged. You were evaluated by our Plastic Surgeons who removed the drain. The Plastic Surgery team believes that your surgical wound is healing well and not showing any signs of infection.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Bactrim / Epinephrine / amlodipine / labetalol / prazosin / hydrochlorothiazide Attending: ___. Chief Complaint: Right femoral neck fracture Major Surgical or Invasive Procedure: Right hip hemiarthroplasty ___, ___ History of Present Illness: ___ female medical history of hypertension presents with the above injury s/p mechanical fall. Patient denies numbness, tingling, weakness, head strike, LOC, or other injuries. She is accompanied by her sister who she lives with. She is reportedly very active and still works. Outside hospital obtained CT of the head which did not show any acute cerebral hemorrhage. Past Medical History: Hypertension Hyperlipidemia Diverticulosis Depression Social History: ___ Family History: Sister -ductal carcinoma in situ Family history of colon cancer in father and distant cousins. Father died in ___ because of colon cancer complications, also had MI Grandmother and mother with diabetes Physical Exam: General: Well-appearing, breathing comfortably MSK: Right hip with clean and intact dressings with minimal strikethrough with no surrounding skin changes. Right foot warm and well perfused with intact sensory and motor function. Pertinent Results: ___ 07:18AM BLOOD WBC-10.6* RBC-2.70* Hgb-8.2* Hct-25.8* MCV-96 MCH-30.4 MCHC-31.8* RDW-14.0 RDWSD-48.8* Plt ___ ___ 07:18AM BLOOD Glucose-118* UreaN-14 Creat-0.7 Na-143 K-4.2 Cl-109* HCO3-22 AnGap-12 ___ 07:18AM BLOOD Calcium-8.2* Mg-2.1 Medications on Admission: Active Medication list as of ___: Medications - Prescription ATENOLOL - Dosage uncertain - (Prescribed by Other Provider) ATORVASTATIN - atorvastatin 20 mg tablet. tablet(s) by mouth once a day - (Prescribed by Other Provider) CLONIDINE HCL - clonidine HCl 0.2 mg tablet. 1 tablet(s) by mouth once a day - (Pt was on 0.3) FLUOXETINE - fluoxetine 10 mg capsule. capsule(s) by mouth once a day - (Prescribed by Other Provider) HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) LABETALOL - labetalol 200 mg tablet. 2 tablet(s) by mouth three times a day - (Not Taking as Prescribed) LOSARTAN [COZAAR] - Cozaar 100 mg tablet. tablet(s) by mouth once a day - (Prescribed by Other Provider) NYSTATIN - nystatin 100,000 unit/gram topical powder. apply to affected area twice daily as needed for yeast - (Not Taking as Prescribed) PRAZOSIN - prazosin 1 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 81 mg chewable tablet. Tablet(s) by mouth once a day - (Prescribed by Other Provider) (Not Taking as Prescribed) CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 2,000 unit capsule. 1 capsule(s) by mouth once a day - (OTC) (Not Taking as Prescribed) CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000 mcg tablet. tablet(s) by mouth once a day - (Prescribed by Other Provider) DOCUSATE SODIUM - docusate sodium 100 mg capsule. Capsule(s) by mouth once a day - (Prescribed by Other Provider) (Not Taking as Prescribed) MULTIVITAMIN - multivitamin tablet. Tablet(s) by mouth once a day - (Prescribed by Other Provider) (Not Taking as Prescribed) Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 30 mg SC DAILY RX *enoxaparin 30 mg/0.3 mL 30 mg SC daily Disp #*26 Syringe Refills:*0 4. Ramelteon 8 mg PO QHS:PRN insomnia Should be given 30 minutes before bedtime 5. Senna 8.6 mg PO BID 6. TraMADol 25 mg PO TID:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 7. TraZODone 25 mg PO QHS:PRN insomnia backup 8. Vitamin D ___ UNIT PO DAILY 9. Losartan Potassium 50 mg PO DAILY Can increase to the home dose after blood pressure monitoring 10. Atenolol 25 mg PO DAILY 11. Atorvastatin 20 mg PO QPM 12. FLUoxetine 10 mg PO DAILY 13. NIFEdipine (Extended Release) 30 mg PO DAILY 14. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right femoral neck 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: HIP 1 VIEW INDICATION: Right hemi fracture TECHNIQUE: Single AP view of the right hip obtained in the OR without radiologist present COMPARISON: Pelvis and right hip radiographs ___ FINDINGS: The single available image shows interval placement of a right hip hemiarthroplasty. Alignment appears appropriate on this single projection. No fracture seen. Please see the operative report for further details. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: R Leg pain, s/p Fall Diagnosed with Fracture of unsp part of neck of right femur, init, Fall on same level, unspecified, initial encounter temperature: 98.1 heartrate: 61.0 resprate: 18.0 o2sat: 95.0 sbp: 194.0 dbp: 64.0 level of pain: 8 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: -Weightbearing as tolerated right lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. 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. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever < 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE < 30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. Physical Therapy: Weightbearing as tolerated bilateral lower extremity, range of motion as tolerated Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ presents to ED with abdominal pain. She felt sudden onset lower middle abdominal pain around 130pm. It became significantly worse and was accompanied by nausea and sweating. She went to urgent care and had rebound tenderness on exam. Given this she was advised to present to ___. She had pain in the car ride when going over bumps. She describes it as "feeling sensitive". At ___, she had CT scan showing no evidence of appendicitis but questionable torsion. She then had a PUS which showed a dilated fallopian tube and complex material with possible torsion. Recommendation made for OB/GYN consultation. Now, patient states her pain has improved and is ___. She has not required pain meds in the ED. She is ambulating without difficulty. No fevers, chills, emesis. No recent weight loss. Of note, patient had a similar episode of pain in ___. She had acute onset pain and discomfort that lasted ___ hours then spontaneously resolved. That pain episode was accompanied by nausea but no emesis. She did not seek care as she was on vacation. ROS negative except as noted above. Past Medical History: POBHx: G4P3 - 1 SAB - 3 SVD PGynHx - menarche at ~age ___ with regular menses prior to IUD -> now amenorrheic - contraception: ___ IUD for ___ years total ___ years for one, new one in place ___ years) - h/o abnormal pap smears, last normal in ___ - denies h/o STIs - sexually active w/ ___ male partner, husband PMH: hypertension PSH: L hip replacement Meds: red yeast rice 600mg, glucosamine 500mg, turmeric, lisinopril, Vitamin D2, fish oil All: NKDA Social History: ___ Family History: Non-contributory Physical Exam: Physical Exam on Admission: 98.4, 67, 126/89, 16, 95% RA Gen: NAD Lungs: No resp distress Abd: soft, mild tenderness to palpation in lower abdomen, no rebound or guarding SSE: normal external genitalia, cervix with IUD strings visible, no discharge or blood in vault SVE: small uterus, + R adnexal tenderness, no adnexal masses palpated Physical Exam on Discharge: 24 HR Data (last updated ___ @ 253) Temp: 98.4 (Tm 98.4), BP: 122/78, HR: 84, RR: 18, O2 sat: 95%, O2 delivery: RA Fluid Balance (last updated ___ @ 254) Last 8 hours Total cumulative 0ml IN: Total 0ml OUT: Total 0ml, Urine Amt 0ml Last 24 hours Total cumulative 0ml IN: Total 0ml OUT: Total 0ml, Urine Amt 0ml *one unmeasured void General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, mild tenderness to palpation, greatest in right lower quadrant. Marked rebound tenderness, right>left. No guarding. Extremities: no edema, no TTP Pertinent Results: ___ 05:10PM BLOOD WBC-14.6* RBC-4.84 Hgb-15.1 Hct-44.7 MCV-92 MCH-31.2 MCHC-33.8 RDW-11.9 RDWSD-40.2 Plt ___ ___ 05:10PM BLOOD Neuts-84.1* Lymphs-7.5* Monos-7.4 Eos-0.4* Baso-0.3 Im ___ AbsNeut-12.26* AbsLymp-1.10* AbsMono-1.08* AbsEos-0.06 AbsBaso-0.04 ___ 01:10PM BLOOD WBC-11.4* RBC-4.14 Hgb-12.9 Hct-38.7 MCV-94 MCH-31.2 MCHC-33.3 RDW-11.8 RDWSD-40.5 Plt ___ ___ 01:10PM BLOOD Neuts-77.1* Lymphs-13.7* Monos-7.9 Eos-0.6* Baso-0.3 Im ___ AbsNeut-8.79* AbsLymp-1.56 AbsMono-0.90* AbsEos-0.07 AbsBaso-0.03 ___ 05:10PM BLOOD Glucose-105* UreaN-18 Creat-0.9 Na-140 K-4.4 Cl-101 HCO3-28 AnGap-11 ___ 05:10PM BLOOD ALT-13 AST-18 AlkPhos-72 TotBili-0.4 ___ 05:10PM BLOOD Lipase-25 ___ 05:10PM BLOOD Albumin-4.4 ___ 05:18PM BLOOD Lactate-1.4 ___ 06:10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM* ___ 06:10PM URINE RBC-4* WBC-6* Bacteri-FEW* Yeast-NONE Epi-1 ___ 06:10PM URINE Mucous-MOD* ___ 06:10PM URINE Hours-RANDOM ___ 06:10PM URINE UCG-NEGATIVE ___ 5:10 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 12:20 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 6:10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. CT Abdomen/Pelvis (___): IMPRESSION: Heterogeneous cystic mass in the cul de sac concerning for adnexal mass or hydrosalpinx. Associated small volume ascites. Torsion difficult to exclude and pelvic ultrasound is advised. U/S Pelvis (___): IMPRESSION: 1. Findings are concerning with left hydrosalpinx containing complex material. Currently there is no evidence of torsion though intermittent torsion not excluded. 2. Mild to moderate free fluid. U/S Pelvis (___): IMPRESSION: 1. No substantial change in findings likely reflecting left hematosalpinx. 2. Unchanged hyperemia of the normal size left ovary. Normal arterial and venous flow without evidence of torsion. 3. Moderate volume complex pelvic free fluid. Medications on Admission: Lisinopril 10 mg PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever Reason for PRN duplicate override: Alternating agents for similar severity Do not take more than 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild take with food. Alternate every three hours with Tylenol for pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 3. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Hematosalpinx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with dilated left fallopian tube, r/o ovarian torsion, free fluid// evaluate for torsion, free fluid TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Pelvic ultrasound ___. CT abdomen and pelvis ___. FINDINGS: The uterus is retroverted and measures 8.2 x 3.5 x 5.9 cm. The endometrium is homogenous and measures 6 mm. An IUD is likely in the appropriate position. The right ovary measures 1.9 x 2.4 x 1.5 cm. Again seen is a dilated tubular structure within the left adnexa, demonstrating complex fluid, likely reflecting hematosalpinx. An adjacent left ovary measures 1.2 x 3.2 x 1.4 cm and appears hyperemic. Normal arterial and venous flow is demonstrated within the bilateral ovaries. A moderate amount of complex free fluid has probably not substantially changed. IMPRESSION: 1. No substantial change in findings likely reflecting left hematosalpinx. 2. Unchanged hyperemia of the normal size left ovary. Normal arterial and venous flow without evidence of torsion. 3. Moderate volume complex pelvic free fluid. NOTIFICATION: The findings were discussed with Dr. ___ by ___, M.D. on the telephone on ___ at 3:29 pm, 1 minutes after discovery of the findings. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Lower abdominal pain Diagnosed with Torsion of left ovary and ovarian pedicle temperature: 97.3 heartrate: 88.0 resprate: 17.0 o2sat: 100.0 sbp: 126.0 dbp: 81.0 level of pain: 8 level of acuity: 3.0

Dear ___ ___ were admitted to the gynecology service at ___ for pain management and observation of a possible ovarian torsion and hematosalpinx (blood and fluid in the fallopian tube). We repeated imaging on the second day of your stay, which demonstrated that the fluid collection in your fallopian tube and your abdomen was unchanged since ___ were admitted. Your blood counts remained stable as well, indicating that ___ were likely not continuing to bleed into your abdomen or fallopian tube. Your pain was well controlled on Tylenol and your vital signs remained stable. The team has determined that ___ are stable for discharge with close outpatient follow up with your primary OBGYN for further evaluation and definitive treatment. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where ___ are unable to keep down fluids/food or your medication

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 abdominal pain and distention Major Surgical or Invasive Procedure: Diagnostic/therapeutic paracentesis ___ Diagnostic paracentesis ___ Diagnostic/therapeutic paracentesis ___ with ___ Therapeutic paracentesis ___ with ___ History of Present Illness: Mr. ___ is a ___ y/o man with a PMH of alcoholic cirrhosis c/b ascites, esophageal varices (s/p banding ___ HCC (s/p TACE), who presents with abdominal pain. The abdominal pain is diffuse, intermittent, crampy in nature, approximately 4 out of 10. It is been associated with significant abdominal distention and accumulation of "fluid" in his abdomen. He denies any associated fevers, nausea, vomiting. He denies any urinary symptoms. He denies any chest pain or shortness of breath. He denies any cough, sore throat, runny nose Notably, admitted to ___ from ___ to ___ for strep bovis bacteremia and ___ progression s/p TACE, admissions complicated by tremors and c. diff colitis. In the ___, initial VS were: 6 97.7 70 101/59 18 98% RA Exam notable for: Large abdominal distention. Positive fluid wave. Reducible umbilical hernia present. No CVAT. Minimal left-sided focal abdominal tenderness. No rebound, no guarding. Labs showed: Na 133, Cr 2.1, TBili 2.0, INR 1.6 (MELD 24) Diagnostic paracentesis: 158 WNC, 3% PMNs Imaging showed: RUQUS: 1. Cirrhotic liver with large volume ascites and multiple hypoechoic masses, as better seen on prior MR. ___. Edematous gallbladder wall likely secondary to chronic liver disease. 3. The spleen is top-normal in size. CXR: Final read pending, preliminarily no acute cardiopulmonary process Consults: Liver "Has intermittent tenderness to palpation on exam. Had diagnostic paracentesis done in the ___ need to f/u that to evaluate for SBP. For now, I would recommend empirically treating for SBP with ceftriaxone and giving albumin 1.5mg/kg. Would also check blood cultures. Also has ___. Is getting albumin as per above, so we can see if the creat improves after albumin infusion. If creat does not improve, would check urine electrolytes. As long as LFTs are stable, can admit to ___ under Dr. ___ Patient received: ___ 19:00 IV CefTRIAXone Transfer VS were: 67 95/58 16 97% RA On arrival to the floor, patient reports he was experiencing ___ abdominal pain and distension at rehab. His pain has now improved and is ___ in severity. His other complaint is cough with phlegm that has been present for several weeks. Denies fevers, chills, chest pain, shortness of breath, dysuria, leg swelling. Past Medical History: - Alcoholic cirrhosis (complicated by ascites/esophageal varices s/p banding ___ - Hepatocellular carcinoma (s/p TACE in ___ - Hepatitis C - Weakly positive antibody I n2015; antibody and viral load were repeated during ___ admission and both were negative - Depression - GERD Social History: ___ Family History: Brother- ___ disease, Father- passed away from heart attack at age ___, no known liver disease or malignancies in family Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9 97/63 67 16 94Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS:24 HR Data (last updated ___ @ 008) Temp: 98.0 (Tm 98.9), BP: 110/70 (110-128/62-77), HR: 53 (52-56), RR: 18, O2 sat: 95% (94-98), O2 delivery: ra, Wt: 179.2 lb/81.29 kg GENERAL: Elderly man sitting up in bed, distended abdomen, NAD HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM HEART: RRR, S1/S2, II/VI holosystolic murmur at LUSB, no gallops or rubs LUNGS: Crackles at bilateral bases.Breathing comfortably without use of accessory muscles. ABDOMEN: Normoactive bowel sounds. Abdomen distended, somewhat tense, nontender. Reducible umbilical hernia. No guarding or rebound. EXTREMITIES: No cyanosis, clubbing. No peripheral edema. PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. No asterixis but visible intention tremor. SKIN: Warm and well perfused, no lesions or eruptions. Pertinent Results: ADMISSION LABS: ================ ___ 04:25PM BLOOD WBC-4.1 RBC-2.41* Hgb-9.2* Hct-26.8* MCV-111* MCH-38.2* MCHC-34.3 RDW-16.2* RDWSD-66.1* Plt ___ ___ 04:25PM BLOOD Neuts-61.6 ___ Monos-12.8 Eos-2.5 Baso-0.2 Im ___ AbsNeut-2.50# AbsLymp-0.89* AbsMono-0.52 AbsEos-0.10 AbsBaso-0.01 ___ 04:25PM BLOOD ___ PTT-37.7* ___ ___ 04:25PM BLOOD Glucose-132* UreaN-52* Creat-2.1* Na-133* K-4.9 Cl-95* HCO3-25 AnGap-13 ___ 04:25PM BLOOD ALT-36 AST-58* AlkPhos-194* TotBili-2.0* ___ 04:25PM BLOOD Albumin-3.1* Calcium-8.4 Phos-4.0 Mg-2.4 IMAGING AND STUDIES: ==================== LIVER/GALLBLADDER US ___: IMPRESSION: 1. Cirrhotic liver with large volume ascites and multiple hypoechoic masses, as better seen on prior MR. 2. Edematous gallbladder wall likely secondary to chronic liver disease. 3. The spleen is top-normal in size. CT ABD/PELV W/O CONT ___: IMPRESSION: 1. Small amount of hyperdense blood layering in ascites in the posterior right abdomen, measuring approximately 5.3 x 3.6 x 5.4 cm. 2. Similar volume large ascites, now measures slightly higher than simple fluid density, likely due to mixture with blood products. 3. Colonic diverticulosis. 4. Bilateral gynecomastia. 5. Cirrhotic liver morphology with post treatment changes. DISCHARGE LABS: =============== ___ 05:03AM BLOOD WBC-5.2 RBC-2.76* Hgb-10.3* Hct-29.9* MCV-108* MCH-37.3* MCHC-34.4 RDW-21.1* RDWSD-82.3* Plt Ct-93* ___ 05:03AM BLOOD Neuts-66.8 ___ Monos-11.5 Eos-1.5 Baso-0.4 Im ___ AbsNeut-3.48 AbsLymp-0.99* AbsMono-0.60 AbsEos-0.08 AbsBaso-0.02 ___ 05:03AM BLOOD Plt Ct-93* ___ 05:03AM BLOOD Glucose-114* UreaN-49* Creat-1.8* Na-138 K-5.3* Cl-102 HCO3-24 AnGap-12 ___ 05:03AM BLOOD ALT-52* AST-104* LD(LDH)-175 AlkPhos-214* TotBili-4.6* ___ 05:03AM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.5 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Thiamine 100 mg PO DAILY 5. Gabapentin 300 mg PO TID 6. MetroNIDAZOLE 500 mg PO Q8H 7. Ondansetron ODT 8 mg PO Q8H nausea 8. Spironolactone 50 mg PO TID 9. TraMADol 50 mg PO Q4H:PRN Pain - Moderate 10. Lactulose 30 mL PO TID constipation 11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 12. GuaiFENesin ER 600 mg PO Q12H 13. Fentanyl Patch 50 mcg/h TD Q72H Discharge Medications: 1. Megestrol Acetate 400 mg PO BID RX *megestrol 400 mg/10 mL (10 mL) 400 mg by mouth twice a day Disp #*1 Package Refills:*1 2. Midodrine 15 mg PO TID RX *midodrine 5 mg 3 tablet(s) by mouth three times per day Disp #*270 Tablet Refills:*0 3. Gabapentin 300 mg PO BID RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 6. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Lactulose 30 mL PO TID constipation RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth three times per day Disp #*4 Package Refills:*0 8. Multivitamins 1 TAB PO DAILY 9. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. HELD- Spironolactone 50 mg PO TID This medication was held. Do not restart Spironolactone until discussing with Dr. ___ ___ Disposition: Home With Service Facility: ___ Discharge Diagnosis: Alcoholic cirrhosis Hepatocellular carcinoma Post-TACE decompensation of cirrhosis Acute kidney injury Hepatorenal syndrome C difficile infection Chronic neuropathy QT Prolongation Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with HCC, developed ascites in 3 days w/ significant abdominal distention + worsening pain.// PVT? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MR abdomen ___. Abdominal ultrasound ___ and ___.. FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is nodular, consistent with cirrhosis. There are multiple hypoechoic masses within the liver, the largest measuring 2.7 x 2.7 x 2.8 cm, likely corresponding to the exophytic lesion seen on recent MR. ___ main portal vein is patent with hepatopetal flow. There is large volume ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm. GALLBLADDER: The gallbladder wall is edematous and thickened, consistent with chronic liver disease. The gallbladder is not distended. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 13.0 cm. KIDNEYS: Limited views of the bilateral kidneys show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhotic liver with large volume ascites and multiple hypoechoic masses, as better seen on prior MR. 2. Edematous gallbladder wall likely secondary to chronic liver disease. 3. The spleen is top-normal in size. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: ___ with HCC, ascites, new hypoxia.// New SpO2 93% ISO, ascites. Hepatic Hydrothorax? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph ___ and ___. FINDINGS: There is new opacity at the of the right lung base. Opacities in the left lung base appears minimally improved compared to ___ but is still more extensive compared to ___. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: Interval progression of probable atelectasis of the right lung base. Left lung opacity appears improved compared to most recent chest radiograph from ___. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST INDICATION: ___ year old man with etoh cirrhosis and hcc, u/s showing new large volume ascites. Also has c diff// assess for bowel distension, abscess, ascites TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.3 s, 57.2 cm; CTDIvol = 20.3 mGy (Body) DLP = 1,159.1 mGy-cm. Total DLP (Body) = 1,159 mGy-cm. COMPARISON: CT abdomen and pelvis ___. MRI ___. FINDINGS: LOWER CHEST: There is linear left basilar atelectasis. There is severe coronary artery calcifications. Relative low signal intensity of the blood pool suggests underlying anemia. ABDOMEN: HEPATOBILIARY: Cirrhotic liver morphology. High density lipiodol centered in segment VIII and V including three discrete lesions in segment VIII are consistent with post TACE change. Evaluation for additional focal liver lesions is limited on this non contrast examination. There is large volume ascites measuring simple density which has increased from ___. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are symmetric in size. There is a partially exophytic simple cyst in the right lower pole measuring 1.1 x 1.1 cm. There is no hydronephrosis. GASTROINTESTINAL: There is no hiatal hernia. There is no small bowel obstruction. Oral contrast is seen extending to the proximal colon. No colonic wall thickening is seen. There is no intra-abdominal free air. PELVIS: Limited views of the pelvis due to streak artifact. Bladder is grossly unremarkable. No pelvic sidewall or inguinal adenopathy is seen. REPRODUCTIVE ORGANS: Prostate contains coarse calcifications but is normal in size. 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 are multilevel degenerative changes of the lumbar spine most pronounced at L4-5 where there is vertebral body fusion. Partially imaged right hip prosthesis noted. No aggressive bony lesions are seen. SOFT TISSUES: There is an umbilical hernia containing simple fluid. IMPRESSION: 1. Cirrhotic liver morphology with increasing large volume ascites. 2. Lipiodol in segments VIII and V post recent TACE. 3. No intra-abdominal fluid collections. 4. Unremarkable non-contrast appearance of the small and large bowel. Radiology Report INDICATION: ___ year old man with EtOH cirrhosis now with decompensation. Acutely short of breath.// Intrapulmonary process? TECHNIQUE: AP portable chest radiograph COMPARISON: ___ IMPRESSION: Low bilateral lung volumes. New pulmonary vascular congestion without overt pulmonary edema. Bibasilar atelectasis is noted, right greater than left. No pleural effusion or pneumothorax. The size of the cardiac silhouette is within normal limits. Degenerative changes are present around the left shoulder. Radiology Report EXAMINATION: Ultrasound-guided paracentesis INDICATION: ___ year old man with etoh cirrhosis, hcc, new worsening ascites// lvp TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: None. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated moderate ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 3 L of clear, straw-colored fluid were removed. Fluid samples were submitted to the laboratory for cell count, differential, and culture. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 3 L of fluid were removed. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 INDICATION: ___ year old man with etoh cirrhosis, aggressive HCC// assess for intracranial mass, acute process 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 = 747.4 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. Periventricular and subcortical white matter hypodensities are nonspecific but likely sequelae of chronic small vessel ischemic disease. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. There is mild right maxillary sinus mucosal thickening and minimal patchy ethmoid air cell opacification. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No evidence of an intracranial mass within the limitations of noncontrast CT. No evidence of an acute intracranial abnormality. Radiology Report EXAMINATION: ULTRASOUND-GUIDED PARACENTESIS INDICATION: ___ year old man with etoh cirrhosis, hcc, new worsening ascites// Please perform LVP TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: Ultrasound-guided paracentesis dated ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a large amount of ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 3 L of clear yellow fluid were removed. Fluid samples were submitted to the laboratory for chemistry, cell count, differential, and culture. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 3 L of fluid were removed. Radiology Report EXAMINATION: ULTRASOUND-GUIDED PARACENTESIS INDICATION: ___ year old man with etoh cirrhosis, large volume ascites, hcc, ___// diagnostic and therapeutic paracentesis TECHNIQUE: Ultrasound guided diagnostic paracentesis. COMPARISON: Paracentesis ___. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a small amount of ascites. A suitable target in the deepest pocket in the right upper quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right upper quadrant and 20 cc of radial fluid were removed. Fluid samples were submitted to the laboratory for chemistry, cell count, differential, and culture. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Technically successful ultrasound guided diagnostic paracentesis. 2. 22 cc of fluid were removed. Radiology Report INDICATION: ___ year old man with cirrhosis, now with new oxygen requirement. Example notable for diffuse crackles and wheezes.// Evaluate for pulmonary edema TECHNIQUE: Frontal radiograph of the chest. COMPARISON: ___. IMPRESSION: Increased hazy opacity of bilateral lungs, right greater than left, could represent worsening moderate pulmonary edema. Infection cannot be excluded. This could be followed on subsequent exams. Likely small right pleural effusion. Cardiac silhouette appears unchanged. Degenerative changes of bilateral shoulders. Radiology Report EXAMINATION: Ultrasound paracentesis INDICATION: ___ year old man with etoh cirrhosis, large volume ascites// diagnostic and therapeutic paracentesis TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: Ultrasound ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated moderate ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 2.5 L of serosanguinous fluid were removed. Fluid samples were submitted to the laboratory for cell count, differential, and culture. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 2.5 L of fluid were removed. Radiology Report INDICATION: ___ year old man s/p paracentesis on ___, with low hemoglobin, did not respond to 1U RBC// Evaluate for bleeding? Hematoma? Please page ___ if evidence for active extravasattion TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 55.7 cm; CTDIvol = 19.8 mGy (Body) DLP = 1,103.1 mGy-cm. Total DLP (Body) = 1,103 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: There is mild to moderate bibasilar atelectasis. Otherwise, visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates cirrhotic liver morphology with high density lipiodol centered in segment 8 and 5 with post TACE treatment changes. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. There is large volume ascites, similar to prior volume but now measures slightly higher than simple fluid density, likely due to mixture with blood products. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is a stable sized right renal cyst. Otherwise, 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: There is a small amount of hyperdense blood layering in ascites in the posterior right abdomen. Overall this blood spans approximately 5.3 x 3.6 x 5.4 cm (2:40). The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is partially calcified within normal limits otherwise. The seminal vesicles are normal. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Stable multilevel degenerative changes of the visualized thoracolumbar spine are noted, including unchanged partial fusion of the L4 and L5 vertebral bodies. There is a right hip prosthesis. SOFT TISSUES: There is a small ascites filled umbilical hernia (2:60). There is bilateral gynecomastia. There is asymmetric soft tissue edema in fat stranding along the right lower quadrant abdominal subcutaneous tissue, likely inflammation from recent procedure (2:68). IMPRESSION: 1. Small amount of hyperdense blood layering in ascites in the posterior right abdomen, measuring approximately 5.3 x 3.6 x 5.4 cm. 2. Similar volume large ascites, now measures slightly higher than simple fluid density, likely due to mixture with blood products. 3. Colonic diverticulosis. 4. Bilateral gynecomastia. 5. Cirrhotic liver morphology with post treatment changes. Radiology Report EXAMINATION: Ultrasound-guided paracentesis INDICATION: ___ year old man with ETOH cirrhosis with large volume ascites and HRS.// paracentesis TECHNIQUE: Ultrasound guided therapeutic paracentesis COMPARISON: CT abdomen and pelvis from ___. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a large amount of ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 3 L of bloody fluid were removed. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Successful therapeutic paracentesis, with the patient being hemodynamically stable at the end of the procedure. 2. 3 L of serosanguineous fluid were removed. No samples were sent. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Abdominal distention, Ascites Diagnosed with Alcoholic cirrhosis of liver with ascites temperature: 97.7 heartrate: 70.0 resprate: 18.0 o2sat: 98.0 sbp: 101.0 dbp: 59.0 level of pain: 6 level of acuity: 3.0

Dear Mr. ___, It was a pleasure to participate in your care. WHY WAS I ADMITTED TO THE HOSPITAL? You were brought to the hospital from your rehab facility because you were experiencing worsening abdominal pain and swelling. WHAT HAPPENED WHILE I WAS HERE? - You were found to have fluid in your abdomen called ascites, which was drained multiple times. - You were found to have a kidney injury for which you received medicine called midodrine and octreotide. - You finished your course of treatment for your C. difficile infection. WHAT SHOULD I DO WHEN I GET HOME? - Please take all of your medicines as prescribed. - Weigh yourself every day and call your liver doctor if your weight increases by 3 pounds. - Go to all of your followup appointments. - Go to ___ next ___ and get a paracentesis. It was a pleasure caring for you and we wish you the best. Sincerely, Your ___ Liver 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: Falls Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ with past medical history of central-line associated aortic valve endocarditis (s/p porcine aortic valve replacement with course c/b periprocedural stroke and residual left-sided deficits), MI (on aspirin), and gastric lap banding (___) who presents with two separate episodes of syncope and pre-syncope. The patient describes 2 distinct episodes which lead to the present hospitalization. The first occurred on ___ (5 days prior to presentation) while at work. She was at desk working when she had total LOC. Patient states that her coworkers told her that she had passed out but the patient herself is entirely amnestic to the event. She felt "fine" immediately after the episode, ate something, and returned to work for the rest of the day. She denies bowel/bladder incontinence, tongue biting, or associated chest pain/palpitations. The second episode occurred on ___ while at her mother's house. As she was preparing to leave, the patient became acutely dizzy characterized by the sensation that "the room was spinning." She had the feeling of "falling to the left" and noted "dark spots" in her visual field, particularly on the right (unclear if right eye vs. right visual field). She subsequently fell to the floor without LOC. Her body "felt limp" and she was unable to get back up for a few minutes. She again denies associated chest pain, SOB, incontinence, or other associated symptoms. The patient then presented to the hospital at the request of her family. In the ED, initial vitals were T 98.3 BP 193/100 HR 64 RR 14 O2 100% on RA. Exam was notable for grade III SEM. Neurological exam notable for stable mild LLE weakness, LUE weakness, sensory loss on L leg, ataxia on L side. Labs notable for a HgB 10.9 (most recent baseline 12.6 in Atrius records) and WBC 5.3. Past Medical History: - Infective endocarditis - MI - CVA - Aortic valve replacement - S/p gastric banding (___) Social History: ___ Family History: Mother: SLE, ___ syndrome, sarcoidosis, MGUS. Had "angina" in her late ___. Father: deceased ___ grandmother: CHF, ESRD Paternal grandmother: Multiple myeloma ___ aunt: ___ disorder ___ aunt: Multiple myeloma (died from complications) Physical Exam: ========================= ADMISSION PHYSICAL EXAM ========================= VITALS: T 98.7 BP 172/113 L Sitting HR 71 RR 18 Sa 100 Ra GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CARDIOVASCULAR: Grade ___ SEM heard best at the left sternal border. Regular rate and rhythm, normal S1 + S2, no rubs or gallops LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi ABDOMEN: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: Mental status - oriented to place, day, date, month year. Naming intact. Calculations intact. Remote history intact. CNs II-XII - within normal limits. Motor - Mildly decreased bulk in the interossei of the left hand compared to left. Orbits around the left finger. Sensation - Decreased sensation along medial surface of left palm and left foot. Coordination - FNF intact in the ___ upper extremities. Decreased speed with rapid fine motor movements in the left hand compared to the right. ========================= DISCHARGE PHYSICAL EXAM ========================= Vitals: 99.0 PO 137 / 71 R Lying 64 18 99 Ra GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, neck supple, JVP not elevated, CARDIOVASCULAR: Systolic ejection murmur heard best at the left sternal border. Regular rate and rhythm, normal S1 + S2, no rubs or gallops LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, non-tender, non-distended GU: No foley EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . NEURO: Mental status - A/O x 3. Moves all four extremities purposefully. Able to stand unassisted and without dizziness/lightheadedness. Pertinent Results: ================== ADMISSION LABS ================== ___ 05:38AM URINE HOURS-RANDOM ___ 05:30AM URINE HOURS-RANDOM ___ 05:30AM URINE UCG-NEGATIVE ___ 05:30AM URINE COLOR-Straw APPEAR-Hazy* SP ___ ___ 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 03:35AM cTropnT-<0.01 ___ 03:35AM TSH-2.9 ___ 12:25AM COMMENTS-GREEN TOP ___ 12:25AM K+-4.8 ___ 11:53PM ___ PTT-30.5 ___ ___ 10:10PM GLUCOSE-71 UREA N-15 CREAT-0.8 SODIUM-140 POTASSIUM-6.2* CHLORIDE-103 TOTAL CO2-24 ANION GAP-13 ___ 10:10PM estGFR-Using this ___ 10:10PM cTropnT-<0.01 ___ 10:10PM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-2.0 ___ 10:10PM WBC-5.3 RBC-4.38 HGB-10.9* HCT-34.7 MCV-79* MCH-24.9* MCHC-31.4* RDW-18.6* RDWSD-53.5* ___ 10:10PM NEUTS-39.4 ___ MONOS-11.0 EOS-7.4* BASOS-0.6 IM ___ AbsNeut-2.08# AbsLymp-2.15 AbsMono-0.58 AbsEos-0.39 AbsBaso-0.03 ___ 10:10PM PLT COUNT-331 ================== IMAGING ================== ___ CHEST X-RAY 1. Increased haziness of the right lung as compared with the left likely relates to foci of right upper lobe ground-glass, better visualized same-day CT head and neck, incompletely assessed on that exam. No focal lung consolidation, pulmonary edema, or other acute cardiopulmonary process. ___ ECHOCARDIOGRAM Conclusions The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal inferior and lateral walls. The remaining segments contract normally (biplane LVEF = 52 %). The estimated cardiac index is high (>4.0L/min/m2). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve homograft appears well seated, with normal leaflet motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate (___) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction. Well seated aortic valve bioprosthesis with normal gradient and no aortic regurgitation. Mild-moderate mitral regurgitation. Compared with the prior study (images reviewed) of ___, trace aortic regurgitation is not seen on the current study. Regional systolic function is similar. ___ CTA HEAD AND CTA NECK (wet read): 1. Patent anterior/posterior circulation, circle of ___, and major tributaries. 2. Incidental 1-2 mm left paraclinoid internal carotid aneurysm/infundibulum (3:201). 3. Findings suggest sarcoidosis, including interstitial/perifissural micronodules in the lung apices and a calcified mediastinal lymph node (3:4, 03:14). 4. Ground-glass opacity in the right lung apex with ___ morphology may suggest infection. 5 mm and 3 mm right upper lobe nodules noted incidentally. 5. 5 mm left thyroid nodule which by ACR recommendations does not require follow-up unless there is additional clinical concern given size and patient age. ================== DISCHARGE LABS ================== ___ 06:00AM BLOOD WBC-3.9* RBC-4.17 Hgb-10.2* Hct-32.3* MCV-78* MCH-24.5* MCHC-31.6* RDW-18.3* RDWSD-50.5* Plt ___ ___ 06:00AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-142 K-3.9 Cl-105 HCO3-25 AnGap-12 ___ 03:35AM BLOOD cTropnT-<0.01 ___ 06:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.9 ___ 03:35AM BLOOD TSH-2.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: - Syncope SECONDARY DIAGNOSIS: - Elevated blood pressure without diagnosis of hypertension - Pulmonary nodules and micronodules - Thyroid nodule Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ woman presenting with dizziness. Evaluation for stroke. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7 mGy-cm. 3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 119.8 mGy (Head) DLP = 59.9 mGy-cm. 4) Spiral Acquisition 4.7 s, 37.2 cm; CTDIvol = 30.9 mGy (Head) DLP = 1,148.6 mGy-cm. Total DLP (Head) = 2,014 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. There is evidence of right frontal encephalomalacia. The ventricles are normal in size and configuration. There is mucosal thickening of the bilateral ethmoid air cells. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without dissection, stenosis, or occlusion. There is an incidentally noted 1-2 mm aneurysm at the left para clinoid internal carotid (3:201). There is fetal configuration of the right PCA. 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: There is evidence of interstitial micronodules in the lung apices (3:4), as well as a calcified mediastinal lymph node (03:14), which may be suggestive of sarcoidosis. A 5 mm nodule and a 3 mm nodule are incidentally noted within the right upper lobe. There is also evidence of a ground-glass opacity with ___ morphology at the right apex, which may be suggestive of infection. A 5 mm left thyroid nodule is incidentally noted, which does not require follow-up by ___ guidelines unless there is additional clinical concern given the size and patient's age. IMPRESSION: 1. No evidence of hemorrhage or infarction. 2. No evidence of dissection, occlusion, or stenosis. Incidentally noted 1-2 mm aneurysm at the left paraclinoid internal carotid artery. 3. Interstitial micronodules in the lung apices and a calcified mediastinal lymph node, which may be suggestive of sarcoidosis. 4. 5 mm nodule and 3 mm nodule incidentally noted within the right upper lobe. Please see ___ society guidelines as outlined below. 5. Incidentally noted 5 mm left thyroid nodule, which does not require follow-up by ___ guidelines unless there is additional clinical concern given the size and patient's age. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Syncope Diagnosed with Syncope and collapse temperature: 98.3 heartrate: 64.0 resprate: 14.0 o2sat: 100.0 sbp: 193.0 dbp: 100.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at the ___ ___. WHY WAS I SEEN IN THE HOSPITAL? - You had two episodes of falling and losing (or near-losing) consciousness. WHAT WAS DONE WHILE I WAS IN THE HOSPITAL? - We looked at your brain and the blood vessels of your head and neck using a CT scan. We did not find any problems with your brain or blood vessels. - We watched the electrical activity of your heart overnight. You did not have any bad heart rhythms. - We looked at the strength and structure of your heart using an echocardiogram. This is roughly unchanged from the last time you had an echocardiogram with Atrius. WHAT SHOULD I DO WHEN I AM OUT OF THE HOSPITAL? - Please follow up with your primary care doctor and cardiologist as scheduled. - Please ask about your referral for a longer "event monitor" to look at the electrical activity of your heart over a month. We have placed an order through ___, but you may need other information from your ___ team. We wish you the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base / Tetracyclines / Augmentin / Zofran / iron Attending: ___. Chief Complaint: Urinary retention Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx DM, HTN, Depression, Gastric bypass, and ___ tylenol overdose presents from ___ with oliguria. Per the pt and her son, on ___ she had a tylenol overdose, for which she was taken to ___, and found to have a tylenol level of >400, and DKA. Presumably she was treated with NAC and insulin gtt. During her stay she was started on HCTZ and cymbalta. She was discharged on ___ to ___. Since ___ of this week, the pt felt like she couldn't urinate much, just small trickles that were cloudy and occasionally pink. She endorsed some chronic lower back pain, chronic n/v, and new suprapubic pain. She denied fevers/chills. Her facility was concerned re: urinary retention and so sent her into the ED. In the ED, initial vs were: T 96.4 P 67 BP 116/49 R18 O2 sat 97% RA. Given history thought c/w UTI, the pt was given Bactrim DS x1. Cr noted to be 6.0 from 0.7 on d/c from ___ 3.0 on ___ Foley flushed but still no urine draining, US showed collapsed bladder. Glucose 53, given ___ amp D5. Pt received 3L ns. On the floor, she was 98.2 120/60 72 18 98%RA. She complained of some chronic LBP, and increased subprapubic pain with the foley. She denied taking any non-prescribed medications, denied NSAIDs, denied current SI. Past Medical History: Asthma HTN Stroke ___ yrs ago with some residual L sided weakness. DM Gastric bypass ___ (leading to chronic diarrhea, vomiting) Social History: ___ Family History: NC Physical Exam: Admission Physical Exam: Vitals: 98.2 120/60 72 18 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes Neuro: non focal Discharge Physical Exam: Pertinent Results: ADMISSION LABS: ___ 04:17PM BLOOD WBC-8.9 RBC-3.74* Hgb-11.1* Hct-31.9* MCV-85 MCH-29.8 MCHC-34.9 RDW-14.3 Plt ___ ___ 04:17PM BLOOD Neuts-64.5 ___ Monos-5.8 Eos-1.9 Baso-0.5 ___ 11:04PM BLOOD ___ ___ 04:17PM BLOOD Glucose-55* UreaN-51* Creat-6.3* Na-138 K-4.0 Cl-96 HCO3-24 AnGap-22* Pertinent Labs: ___ 08:32PM URINE Color-Straw Appear-Clear Sp ___ ___ 08:32PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG ___ 02:26AM URINE RBC-128* WBC->182* Bacteri-MANY Yeast-NONE Epi-<1 ___ 02:26AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Micro: ___ 2:26 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Imaging: Renal ultrasound (___): Normal kidney ultrasound. Echogenic liver. Discharge Labs: Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 3. Aspirin 81 mg PO DAILY 4. Clonazepam 0.5 mg PO TID 5. CloniDINE 0.2 mg PO BID 6. Duloxetine 60 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 8. GlyBURIDE 2.5 mg PO BID 9. Hydrochlorothiazide 25 mg PO DAILY 10. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO TID:PRN heartburn 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Milk of Magnesia 30 mL PO DAILY 13. Metoprolol Tartrate 50 mg PO BID 14. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking 15. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 16. Omeprazole 20 mg PO DAILY 17. Sertraline 100 mg PO BID 18. Zolpidem Tartrate 10 mg PO HS Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO TID:PRN heartburn 3. Amlodipine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Clonazepam 0.5 mg PO TID 6. CloniDINE 0.2 mg PO BID 7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 8. Sertraline 100 mg PO BID 9. Zolpidem Tartrate 10 mg PO HS 10. Metoprolol Tartrate 50 mg PO BID 11. Milk of Magnesia 30 mL PO DAILY 12. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking 13. Omeprazole 20 mg PO DAILY 14. Hydrochlorothiazide 25 mg PO DAILY 15. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute Kidney Injury Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Tylenol overdose and increased creatinine. COMPARISON: None available. FINDINGS: The right kidney measures 12.4 cm and there is no hydronephrosis, stone or mass seen. The left kidney measures 10.8 cm and no hydronephrosis, stone or mass seen. The liver is overall increased in echogenicity. IMPRESSION: Normal kidney ultrasound. Echogenic liver. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: URINARY RETENTION Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 96.4 heartrate: 67.0 resprate: 18.0 o2sat: 97.0 sbp: 116.0 dbp: 49.0 level of pain: 7 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. You were admitted because you had damage to your kidneys. We gave you IV fluids and encouraged you to eat and drink and your kidney function improved. It is very important that you continue to drink plenty of water to prevent dehydration. We also treated you with antibiotics for a urinary tract infection. You will need to see your doctor within one week to recheck your electrolytes (including kidney function). We made the following changes to your medications: Restart: 1. Metformin 1000mg twice per day Stop: 1. glyburide since your blood sugar level was very low 2. duloxetine, please discuss restarting this medication with your mental health provider if it is still needed. 3. oxycodone

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Fever, Headaches, Confusion Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ year old gentleman with a history of HTN, DM, lumbar microdisectomy s/p spinal stimulator, and chronic pain on narcotics contract presenting with fevers, headaches, and confusion. Patient reports four days of headache and fever to 102. His headache is frontal, throbbing. He denies neck pain or stiffness. He reports photophobia and nausea associated. Mild nonproductive cough as well. He initially presented to ___ ___ on ___ with these symptoms. Review of records from outside hospital indicates patient had negative flu swab, negative UA. At the OSH, he had a leukocytosis to 16 and was treated empirically for meningitis/encephalitis with IV Vancomycin/CTX/Acyclovir. NCHCT did not have any acute abnormalities. LP was not performed was he had a spinal cord device implanted. He eventually left AMA. He presented to the ___ on ___ for further management given ongoing symptoms. -In the ED, initial vitals were: T 98.9 HR 58 BP 97/60 RR 16 SpO2 96% RA - Exam notable for: Normal mental status, no neck stiffness - Labs notable for: WBC 12.6, H/H 11.8/33.3, Na 132, Cr 1.0, lactate 1.6 -No further imaging was performed in the ED -Patient was given: 1 L IV NS, Azithromycin 500 mg IV, Zofran 4 mg IV, Dilaudid 0.25 mg IV -No LP was performed in the ED due to implanted spinal cord device -Decision was made to admit patient to medicine for further management -Vitals prior to transfer: T 99.8 HR 64 BP 133/83 RR 25 SpO2 100% RA Upon arrival to the floor, the patient was alert and oriented x3, mentating well and appropriately answering questions. He denied any neck stiffness. He endorses headaches, nausea, and productive cough. He denied any chest pain, dyspnea, visual changes, weakness, or numbness. He was continued on IV Vanc/CTX/Acyclovir for empiric coverage of meningitis/acyclovir. He otherwise was continued on his home medications. Past Medical History: -Diabetes Mellitus -Hypertension -Tobacco Abuse -Gout -Insomnia -Depression -Chronic Pain/Narcotics Contract -Lumbar microdiscectomy, ___: facet fusion, ___: transforaminal lumbar interbody fusion at ___, ___: Removal of posterior and interbody instrumentation L5-S1, revision. ___: SCS implant (___). Social History: ___ Family History: Mother and Father with high blood pressure. Brothers and one sister with HTN as well. Grandmother with MI. Grandfather old age. Mother with breast CA. Physical Exam: ADMISSION: VS T 98.3 BP 141/86 HR 67 RR 18 SpO2 97 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple, no neck stiffness or meningeal signs. Negative Kernig's and Brudzinski's sign. No cervical lymphadenopathy CV: RRR. Normal S1+S2, no murmurs, rubs, gallops. Lungs: R base inspiratory crackles, no wheezing or rhonci Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert and oriented x3. Moving all extremities with purpose, no facial asymmetry, gait deferred. DISCHARGE: General: Alert, oriented, no acute distress Neck: Supple, no neck stiffness or meningeal signs. No cervical lymphadenopathy CV: RRR. Normal S1+S2, no murmurs, rubs, gallops. Lungs: CTAB Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CN II-XII intact, sensation grossly intact, ___ strength all extremities Pertinent Results: ADMISSION: ___ 06:47PM BLOOD WBC-12.6* RBC-3.99* Hgb-11.8* Hct-33.3* MCV-84# MCH-29.6 MCHC-35.4 RDW-14.1 RDWSD-43.2 Plt ___ ___ 06:47PM BLOOD Neuts-71.8* Lymphs-15.8* Monos-11.1 Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.02* AbsLymp-1.99 AbsMono-1.40* AbsEos-0.02* AbsBaso-0.04 ___ 07:09PM BLOOD ___ PTT-31.7 ___ ___ 06:47PM BLOOD Glucose-91 UreaN-8 Creat-1.0 Na-132* K-3.5 Cl-95* HCO3-23 AnGap-18 ___ 06:47PM BLOOD ALT-38 AST-62* AlkPhos-64 TotBili-0.2 ___ 06:47PM BLOOD Albumin-3.2* Calcium-8.2* Phos-2.7 Mg-2.2 ___ 06:47PM BLOOD Lactate-1.6 DISCHARGE: ___ 08:50AM BLOOD WBC-12.2* RBC-4.06* Hgb-11.9* Hct-34.6* MCV-85 MCH-29.3 MCHC-34.4 RDW-14.6 RDWSD-45.8 Plt ___ ___ 08:50AM BLOOD ___ PTT-31.3 ___ ___ 08:50AM BLOOD Glucose-115* UreaN-8 Creat-0.8 Na-140 K-4.3 Cl-106 HCO3-24 AnGap-14 ___ 08:50AM BLOOD ALT-66* AST-37 LD(LDH)-251* AlkPhos-68 TotBili-0.2 ___ 08:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 STUDIES: RUQ US ___: 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Hepatic cysts. MICRO: ___ Blood Cultures PENDING ___ CSF Spinal Cx PENDING + ENTEROVIRUS HSV PCR NEGATIVE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Trandolapril 2 mg PO BID 2. Pregabalin 300 mg PO TID 3. Mirtazapine 45 mg PO QHS 4. Allopurinol ___ mg PO BID 5. Lidocaine 5% Patch 1 PTCH TD BID:PRN Pain 6. QUEtiapine Fumarate 50 mg PO QAM 7. QUEtiapine Fumarate 100 mg PO QHS 8. MetFORMIN XR (Glucophage XR) 750 mg PO BID 9. CloNIDine 0.1 mg PO BID 10. Baclofen 10 mg PO TID:PRN Pain - Moderate 11. Spironolactone 25 mg PO DAILY 12. Fentanyl Patch 75 mcg/h TD Q72H 13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 14. Sertraline 50 mg PO DAILY 15. TraZODone 100 mg PO QHS 16. Verapamil SR 180 mg PO Q24H 17. Docusate Sodium 100 mg PO DAILY:PRN constipation Discharge Medications: 1. Narcan (naloxone) 4 mg/actuation nasal ONCE TO REVERSE OPIOID OVERDOSE IF USED CALL ___ RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal ONCE Disp #*1 Spray Refills:*0 2. Allopurinol ___ mg PO BID 3. Baclofen 10 mg PO TID:PRN Pain - Moderate 4. CloNIDine 0.1 mg PO BID 5. Docusate Sodium 100 mg PO DAILY:PRN constipation 6. Fentanyl Patch 75 mcg/h TD Q72H 7. Lidocaine 5% Patch 1 PTCH TD BID:PRN Pain 8. MetFORMIN XR (Glucophage XR) 750 mg PO BID 9. Mirtazapine 45 mg PO QHS 10. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 11. Pregabalin 300 mg PO TID 12. QUEtiapine Fumarate 50 mg PO QAM 13. QUEtiapine Fumarate 100 mg PO QHS 14. Sertraline 50 mg PO DAILY 15. Spironolactone 25 mg PO DAILY 16. Trandolapril 2 mg PO BID 17. TraZODone 100 mg PO QHS 18. Verapamil SR 180 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: Primary: Community Acquired Pneumonia Transaminitis Secondary: Hypertension Diabetes 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: ___ year old man with elevated LFTs// biliary pathology, cirrhosis findings? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. Multiple hepatic cysts are demonstrated. 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 6 mm. GALLBLADDER: Gallbladder is contracted. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 11.1 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. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Hepatic cysts. Gender: M Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Confusion, Fever, Headache, Transfer Diagnosed with Pneumonia, unspecified organism, Headache, Dehydration temperature: 98.9 heartrate: 58.0 resprate: 16.0 o2sat: 96.0 sbp: 97.0 dbp: 60.0 level of pain: 9 level of acuity: 2.0

Mr. ___, You were admitted to ___ because you had confusion and a headache. WHILE YOU WERE HERE: - We did some labs on your spinal fluid and found that you do not have meningitis - We found that you have pneumonia and we treated this with antibiotics WHEN YOU GO HOME: - Please continue all medications as directed - Please follow-up with the doctors listed below - ___ any shortness of breath, confusion, or worsening headache, please call your doctor or return to the emergency department immediately We wish you the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Oxycodone / Balmex / miconazole / Keflex / SilvaSorb / lidocaine patch Attending: ___. Chief Complaint: bilateral leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: ___ presents for bilateral knee pain after she played tennis for ___ hours . Pt has some developmental delay and participates in sports and recently flew to ___ for a tennis tournament. She felt her both ankles were swollen after the long plane ride. She also complains of cough which started last ___ for which she took a 8 day course of doxycycline which ended yesterday. She ___ shortness of breath, or chest pain or calf tenderness. Past Medical History: PAST MEDICAL HISTORY: - Peripheral nerve sheath tumor - Borderline diabetes mellitus - Hypothyroidism - Bilateral knee osteoarthritis - Developmental delay PAST SURGICAL HISTORY: - Tympanostomy tubes in ear at the age of ___ - Tonsillectomy at ___ years - Wide tumor bed excision, right elbow area for intermediate grade soft tissue sarcoma Social History: ___ Family History: Grandfather: colon cancer in grandfather Father: DM2, CAD Physical Exam: General: NAD VITAL SIGNS:98.2f PO 144 / 79 91 18 98 RA HEENT: nc/at CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, soft, LIMBS: very minimal non pitting edema. no erythema or rashes. SKIN: No rashes or skin breakdown Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Benzonatate 100 mg PO TID 2. Gabapentin 600 mg PO TID 3. Levothyroxine Sodium 75 mcg PO DAILY 4. PAZOPanib 600 mg oral DAILY 5. Clindamycin 450 mg PO Q8H Discharge Medications: 1. Enoxaparin Sodium 100 mg SC Q12H Duration: 3 Months Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 100 mg/mL 100 mg SC twice daily Disp #*60 Syringe Refills:*2 2. Benzonatate 100 mg PO TID 3. Gabapentin 600 mg PO TID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. HELD- PAZOPanib 600 mg oral DAILY This medication was held. Do not restart PAZOPanib until you discuss with your oncologist. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right posterior Tibial Vein clot Community acquired pneumonia Discharge Condition: Stable Alert and communicative Independent Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with dyspnea, metastatic sarcoma // Eval for pulm edema, acute process TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from outside hospital dated ___. CT chest dated ___. FINDINGS: A left chest wall Port-A-Cath terminates in the right atrium. Numerous pulmonary metastatic lesions are seen within the lungs bilaterally. Given the size and number of these lesions, it is difficult to exclude an underlying pneumonia. Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: 1. Numerous pulmonary metastatic lesions bilaterally. Given the size and number of these lesions, it is difficult to exclude an underlying pneumonia. 2. No evidence of pulmonary edema. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with sarcoma, bilateral leg swelling, recent long-distance flight // Eval for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is completely occlusive clot within a right posterior tibial vein. There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the left posterior tibial and peroneal veins. The right peroneal vein was not well visualized. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Completely occlusive clot within a right posterior tibial vein. 2. Nonvisualized right peroneal vein. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with sarcoma, + dimer // 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: Total DLP (Body) = 397 mGy-cm. COMPARISON: CT chest dated ___. FINDINGS: This examination is limited due to patient's body habitus and motion artifact. HEART AND VASCULATURE: A Port-A-Cath terminates in the right atrium. Pulmonary vasculature is well opacified to the segmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: The right peritracheal mediastinal lymph node measuring 10 mm in short axis is new (series 2, image 26) a paraesophageal lymph node is stable measuring 12 mm in short axis (series 2, image 79) the right hilar lymph node conglomerate and has increased in size measuring 3.6 x 2.5 cm on today's examination (series 2, image 55), previously measuring 2.9 x 2.3 cm, and causes mass effect on the right hepatic veins. The left hilar lymph node conglomerate has also increased in size (series 2, image 57). No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Patient is status post right upper lobe resection with adjacent scarring and pleural thickening, which is stable. There is increasing thickening of the right chest wall soft tissues, concerning for metastatic involvement. For instance, a right chest wall nodule measures 2.0 x 1.9 cm on today's examination (series 2, image 30), previously measuring 1.5 x 1.4 cm. There are numerous pulmonary metastatic lesions bilaterally, which may have also increased in size and distribution. In addition, there are numerous foci of peribronchial ground-glass opacities and consolidations within the lower lobes bilaterally, which are new since ___, and raise concern for multifocal pneumonia. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: The right lobe of the thyroid is atrophic. The remaining thyroid is within normal limits. Otherwise, visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. Limited examination due to the patient's body habitus and motion artifact. 2. Within these limitations, no evidence of large central pulmonary embolism. 3. Extensive hilar lymphadenopathy, which has progressed compared to ___. Numerous pulmonary metastatic lesions bilaterally, which seem to have increased. Right chest wall involvement, which has also progressed. 4. New peribronchial ground-glass opacities and consolidations within the lower lobes bilaterally, which raise concern for superimposed multifocal pneumonia in the appropriate clinical setting. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Leg swelling, Transfer Diagnosed with Pneumonia, unspecified organism temperature: 98.4 heartrate: 86.0 resprate: 18.0 o2sat: nan sbp: 141.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

Dear ___, It was a pleasure taking care of you. You were admitted here because you had a blood clot in right leg. You were treated with subcutaneous lovenox injections for the blood clot. You need to continue this treatment for three months at least. Please follow up with your other appointments as outpatient. Sincerely, ___ MD

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Paracentesis - ___ G-Tube Replacement - ___ History of Present Illness: ___ PMH of Diarrhea predominant IBS, Oropharyngeal dysphagia (c/b aspiration now s/p GTube for nutrition), Stage IV pancreatic cancer (c/b malignant ascites on protocol ___, presents with vomiting. As per review of outpatient notes, NP was called by patient's wife in light of persistent vomiting, that was dark brown, and was associated with more coughing and white mucus. Reported low grade fever so was referred to ED. On arrival to the medical ward, pt and wife provided history. They noted that he received chemotherapy last week and had 2 asymptomatic days afterward then developed nausea/vomiting which is similar to how he reacted to prior chemotherapy administration. Reglan, Zofran, and Compazine was given to good effect but 1 day later he kept vomiting despite such medications, and further doses withheld as they wouldn't stay down. Vomit was noted to be thin/watery/brown without coffee grounds or bright red blood. He was stooling daily during this time and passing gas. Denied significant abdominal distension or pain but noted that he had generalized discomfort when vomiting. Reported no fevers at home, but temperature was 99 (increased from baseline of around 97). As a result of vomiting tubefeeds had been held. Patient also reported increase in chronic cough with thicker mucus but noted that it is still clear and breathing was unlabored. On arrival to medical ward patient reported feeling much improved. In the ED, initial VS were: 98.0 103 ___ 99% RA. Patient remained afebrile in ED. CBC with WBC of 2.7, Hgb 7.8, plt 372, CHEM wnl, lactate wnl, flu negative. CXR with small pleural effusions but no pneumonia. CT A/P revealed: 1. Pancreatic body mass with upstream dilation and tail atrophy, similar to prior. 2. Interval increase in now moderate sized right nonhemorrhagic pleural effusion. 3. No dilated loops of bowel or free air. 4. Position of the G tube balloon appears slightly retracted and is not definitively within the stomach lumen; this could be positioning or incomplete distension of the stomach on this exam. Correlate with clinical assessment and consider imaging after injecting G-tube with enteric contrast. 5. 7 x 3.3 cm collection along the left lateral lobe of the liver with mild mass effect on the stomach is new or more conspicuous compared to the prior exam. Multiple other intraperitoneal and pelvic fluid collections persist, some overall unchanged, others perhaps slightly smaller. 6. Multiple hepatic hypodensities and extensive omental caking, consistent with metastases are overall unchanged. GTube check performed and revealed: Enteric contrast administered via patient's PEG is noted within the stomach. No extraluminal contrast identified. ED team performed bedside U/S and could not identify a tappable pocket of ascites for diagnostic para. Patient was given IVF and admitted to the hospital. ___ was consulted and noted that they would change patient's GTube tomorrow morning. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ CT Abdomen/Pelvis: Within the pancreatic body, there is a 3cm hypodense mass. The tail is atrophied and the main PD is dilated in that region. There are multiple scattered hypodense masses with both lobes of the liver c/w metastases. Within the R lobe anterior segment, there is a 3cm lesion. In the posterior segment, there is a 2cm lesion. Most of the other lesions in both lobes measure between 1-2cm. There is abnormal soft tissue stranding and nodularity within the omental c/w carcinomatosis. There is a small amount of free fluid in the pelvis. - ___ Pathologic Diagnosis: Liver, targeted needle core biopsies: Ductal adenocarcinoma, which in the provided clinical context likely represents metastatic ductal adenocarcinoma of the pancreas. - ___ Peritoneal Fluid Cytology: Positive for malignant cells. - ___: Right cephalic vein port placement (single-lumen BARD ClearVUE PowerPort; deemed MRI safe). - ___: Cycle 1 Protocol ___: A Phase 3, Randomized, Double-Blind,Placebo-Controlled, Multicenter Study of PEGylated Recombinant Human Hyaluronidase (PEGPH20) in Combination with nab-Paclitaxel Plus Gemcitabine Compared with Placebo Plus nab-Paclitaxel and Gemcitabine in Subjects with Hyaluronan-High Stage IV Previously Untreated Pancreatic Ductal Adenocarcinoma TREATMENT: - PEGPH20/placebo: ___ mcg/kg IV over ___ minutes (approx. 1mL/min) on day 1, 8, 15 of cycle 2 and beyond. -Nab-paclitaxel: 125mg/m2 IV over ___ minutes on day 1, 8, 15 of cycle 2 and beyond; administered ___ hours after PEGPH20/placebo infusion. - Gemcitabine: 1000mg/m2 IV over 30 minutes on day 1, 8, 15 of cycle 2 and beyond after nab-paclitaxel infusion. - Dexamethasone: 8mg PO within 2 hours prior to the beginning of PEGPH20/placebo infusion AND ___ hours after the completion of PEGPH20/placebo infusion (at home). This comes from research supply. - Enoxaparin: 1mg/kg administered subcutaneously once daily. On dosing days, enoxaparin will be administered prior to infusion of study medication by treatment RN and will be administered by patient at home all other days. This comes from research supply. - Other pre-medication per provider discretion and ordered in OMS. CURRENT TREATMENT SUMMARY: - ___: C1D1 - ___: Delay C2D1 d/t clinical concern for PNA. - ___: C2D1, no dose modifications. - ___: C2D8 Tx HELD due to gr 3 diarrhea, enoxaparin also on hold - ___: C3D1 - resume treatment of all 3 drugs post-hospitalization. No dose modification" PAST MEDICAL HISTORY: - s/p R shoulder melanoma (removed in ___ - R hearing loss (spontaneous loss ___ years ago s/p steroid injections in ear drum with 90% back) - R hand Dupuytren contracture - Diarrhea-predominant inflammatory bowel syndrome - Low back pain with radiculopathy - Adenomatous polyps - s/p L IH repair - s/p remote tonsillectomy - Stage IV pancreatic cancer c/b malignant ascites - Oropharyngeal dysphagia c/b aspiration now s/p GTube for nutrition - Likely OSA Social History: ___ Family History: Mother with alcoholism. Father with prostate CA and adenomatous polyps, died age ___. MGM with "woman-related" cancer, died age ___. One sister with glioblastoma, died age ___. Her son (patient's nephew), also with glioblastoma, died <___. Physical Exam: ======================== Admission Physical Exam: ======================== Vitals: Temp: 98.8, BP: 119/74, HR: 97, RR: 18, O2 sat: 95%, O2 delivery: Ra, Wt: 157.3 lb/71.35 kg GENERAL: Laying in bed, wife at bedside, appears comfortable, NAD. EYES: PERRLA, anicteric. HEENT: MMM, OP Clear. NECK: Supple. LUNGS: CTA b/l, no wheezes/rales/rhonchi. CV: RRR normal distal perfusion, no edema ABD: G-tube in LUQ with dressing c/d/I, no tenderness, rebound, or guarding, normoactive BS, no distension, no flank tenderness. GENITOURINARY: No foley. EXT: No deformity, no rash. SKIN: Warm, dry, no rash. NEURO: AOx3, fluent speech. ACCESS: Port in right upper chest, dressing c/d/i. ======================== Discharge Physical Exam: ======================== VS: 98.8 ___ 18 96%RA General: Chronically ill-appearing gentleman, pleasant, lying in bed, in no acute distress. HEENT: MMM, OP clear of thrush or ulcerations. CV: RRR, normal s1/s2, no m/r/g. PULM: CTAB, respirations unlabored but diminished at right base. ABD: BS+, soft, distended with fluid shift, non-tender to palpation. LIMBS: No ___, non-pitting at the ankles. SKIN: Faint discrete scattered pink macules on back. NEURO: Speech is clear, thought process logical, linear, future oriented. ACCESS: Right chest wall port without erythema. Pertinent Results: =============== Admission Labs: =============== ___ 02:38PM BLOOD WBC-2.7* RBC-2.65* Hgb-7.8* Hct-24.8* MCV-94 MCH-29.4 MCHC-31.5* RDW-18.2* RDWSD-60.6* Plt ___ ___ 02:38PM BLOOD Neuts-74.0* ___ Monos-5.1 Eos-0.4* Baso-0.7 NRBC-0.7* Im ___ AbsNeut-2.01 AbsLymp-0.52* AbsMono-0.14* AbsEos-0.01* AbsBaso-0.02 ___ 02:38PM BLOOD Glucose-104* UreaN-16 Creat-0.4* Na-135 K-4.4 Cl-99 HCO3-26 AnGap-10 ___ 02:45PM BLOOD Lactate-1.1 =============== Discharge Labs: =============== ___ 05:32AM BLOOD WBC-8.1 RBC-3.16* Hgb-9.3* Hct-29.2* MCV-92 MCH-29.4 MCHC-31.8* RDW-19.1* RDWSD-61.4* Plt ___ ___ 04:35AM BLOOD Neuts-67.6 Lymphs-18.7* Monos-9.0 Eos-0.3* Baso-0.3 NRBC-1.3* Im ___ AbsNeut-2.64 AbsLymp-0.73* AbsMono-0.35 AbsEos-0.01* AbsBaso-0.01 ___ 05:32AM BLOOD Glucose-122* UreaN-15 Creat-0.4* Na-134* K-4.6 Cl-98 HCO3-23 AnGap-13 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough 2. Benzonatate 200 mg PO TID:PRN cough 3. Mirtazapine 30 mg PO QHS 4. LOPERamide 2 mg PO Q4H:PRN diarrhea 5. Ondansetron 8 mg PO Q8H:PRN as needed for severe nausea 6. Prochlorperazine ___ mg PO Q6H:PRN nausea r/t chemotherapy 7. Enoxaparin Study Med 80 mg Subcutaneous DAILY 8. Metoclopramide 5 mg PO QID 9. Zenpep (lipase-protease-amylase) 3 tabs oral qmeals 10. LORazepam 0.5-1 mg PO Q6H:PRN nausea, vomiting, anxiety 11. GuaiFENesin ___ mL PO Q6H:PRN cough 12. Dexamethasone 8 mg PO ASDIR Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*6 Tablet Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough 3. Benzonatate 200 mg PO TID:PRN cough 4. Dexamethasone 8 mg PO ASDIR 5. Enoxaparin Study Med 80 mg Subcutaneous DAILY 6. GuaiFENesin ___ mL PO Q6H:PRN cough 7. LOPERamide 2 mg PO Q4H:PRN diarrhea 8. LORazepam 0.5-1 mg PO Q6H:PRN nausea, vomiting, anxiety 9. Metoclopramide 5 mg PO QID 10. Mirtazapine 30 mg PO QHS 11. Ondansetron 8 mg PO Q8H:PRN as needed for severe nausea 12. Prochlorperazine ___ mg PO Q6H:PRN nausea r/t chemotherapy 13. Zenpep (lipase-protease-amylase) 3 tabs oral qmeals 14.Tube Feeds Jevity 1.5 at 110 ml/hr over 16 hours. Dispense 1 month supply. Refills: 11. Free water 150 mL Q4H. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: - Nausea/Vomiting - Malignant Ascites - Bacterial Peritonitis - Diarrhea - Cough - Oropharyngeal Dysphagia with Aspiration - Severe Protein-Calorie Malnutrition - Metastatic Pancreatic Cancer - Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ man with a history of pancreatic cancer who presents with nausea, vomiting and inability to tolerate po. TECHNIQUE: Chest PA and lateral COMPARISON: Chest CT dated ___. Chest radiograph dated ___. FINDINGS: Slightly low lung volumes. No focal pneumonia, pulmonary edema, or pneumothorax. Right Port-A-Cath tip ends in the right atrium. Cardiomediastinal silhouette is unchanged. Pleural effusions are small. Trace pleural fluid in the minor fissure. Tortuous thoracic aorta. No evidence of pneumomediastinum or subdiaphragmatic free air. IMPRESSION: 1. No pneumonia. 2. Small pleural effusions. Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: ___ man with a history of pancreatic cancer, presenting with nausea, vomiting, inability to tolerate p.o. Evaluate for small bowel obstruction. NO_PO contrast. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 634 mGy-cm. COMPARISON: CT abdomen and pelvis and CT chest dated ___. FINDINGS: LOWER CHEST: Nonhemorrhagic right pleural effusion is now moderate in size, larger since the prior exam. Associated homogeneously enhancing relaxation atelectasis in the right lower lung is mild. A left pleural effusion is trace and also nonhemorrhagic, overall unchanged from prior. No focal pneumonia in the partially imaged lower lungs. No evidence of a pericardial effusion. Coronary artery calcifications are moderate, incompletely imaged. The tip of a central venous catheter is only partially imaged near the SVC-RA junction. ABDOMEN: HEPATOBILIARY: Multiple hepatic hypodensities throughout the liver are compatible with known metastases, probably overall similar in size to the prior exam when accounting for differences in measurement technique. No evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. Multiple large perihepatic fluid collections with fluid attenuation and enhancing wall persist. 2 closely approximated fluid collections along the left lateral lobe with mild mass effect on the stomach wall measures 7 x 3.3 cm, new from the prior (series 2, image 27). The largest fluid collection is bilobed along the anterior surface of the liver. Compared to the prior exam the inferior lobe of this fluid collection may be slightly smaller, now 16.2 x 9.7 cm on axial images, previously 17.3 x 10.9 cm (series 2, image 71; series 602, image 39). A 5.2 x 1.6 cm fluid collection along the anterior liver surface is unchanged (series 2, image 20). A 5.3 x 7 cm fluid collection along the posterior aspect of the liver is also overall unchanged (series 2, image 25). PANCREAS: The known hypoattenuating mass in the pancreatic body is difficult to accurately measure. Severe dilation of the main pancreatic duct with marked atrophy of the pancreatic tail persists, overall unchanged. The pancreatic head and uncinate process are within normal limits without main pancreatic ductal dilation in these regions. Small amount of ascites in the peripancreatic region is unchanged and of simple attenuation (series 2, image 30). SPLEEN: The spleen is normal in size and attenuation without evidence of a focal lesion. A fluid collection with fluid-fluid level of proteinaceous debris and/or old blood products may be slightly smaller, now measuring 14.3 x 9.9 cm, previously 16.8 x 11.2 cm (series 2, image 22). This fluid collection exerts mass effect on the spleen. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. No evidence of focal renal lesions or hydronephrosis. No perinephric abnormality. GASTROINTESTINAL: The stomach is not markedly distended. The patient has a G-tube. Position of the G-tube appears slightly retracted relative to the prior exam however there may still be connect to be with the stomach lumen (series 2, image 29, 28). Small bowel loops are normal in caliber, wall thickness, enhancement throughout. The colon and rectum are within normal limits. The appendix is not seen. No small bowel obstruction. No pneumoperitoneum. Caking in the omentum from metastases is probably overall similar to the prior exam when accounting for differences in measurement technique (series 2, image 44). An 2.8 x 1.9 cm fluid collection in the mid right abdomen is unchanged (series 2, image 47). A 3.7 x 2.7 cm fluid collection in the right lower quadrant is unchanged (series 2, image 75). PELVIS: The urinary bladder is moderately distended and unremarkable. The distal ureters are unremarkable. An 1.8 x 2.6 cm fluid collection in the central pelvis is also unchanged (series 2, image 79; series 602, image 39). REPRODUCTIVE ORGANS: The prostate gland is not enlarged. LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or inguinal lymphadenopathy. A 6 mm left external iliac lymph node is smaller from the prior exam (series 2, image 76). VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic disease is noted. The main, left common right portal veins appear patent. The splenic vein and SMV appear patent. BONES: No evidence of worrisome osseous lesions or acute fracture. Multilevel degenerative changes in the spine are similar to the prior exam, moderate to severe. Mild retrolisthesis of L2 on L3 and L3 on L4 is likely degenerative, unchanged. SOFT TISSUES: The patient has a G-tube. No soft tissue gas or fluid collections in the abdominal or pelvic wall. IMPRESSION: 1. Pancreatic body mass with upstream dilation and tail atrophy, similar to prior. 2. Interval increase in now moderate sized right nonhemorrhagic pleural effusion. 3. No dilated loops of bowel or free air. 4. Position of the G tube balloon appears slightly retracted and is not definitively within the stomach lumen; this could be positioning or incomplete distension of the stomach on this exam. Correlate with clinical assessment and consider imaging after injecting G-tube with enteric contrast. 5. 7 x 3.3 cm collection along the left lateral lobe of the liver with mild mass effect on the stomach is new or more conspicuous compared to the prior exam. Multiple other intraperitoneal and pelvic fluid collections persist, some overall unchanged, others perhaps slightly smaller. 6. Multiple hepatic hypodensities and extensive omental caking, consistent with metastases are overall unchanged. RECOMMENDATION(S): Correlate with clinical assessment and consider imaging radiograph after injecting G-tube with sufficient oral contrast. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 6:33 pm, 20 minutes after discovery of the findings. Radiology Report INDICATION: ___ w/ h/o stage IV pancreatic ca on chemotherapy (third dose of third cycle finished 5 days prior), history of inguinal hernia repair, p/w n/v for the past 2 days, inability to tolerate PO, which is a generally dramatic change from his baseline. No diarrhea (chroniclaly on loperamide to assist with diarrhea). No fevers. No cough, ST, rhinorrhea. No abd pain, ST, chest pain. No leg swelling. He has a G-tube for aspiration issues and family has been providing support through this but patient continues to have emesis. Several streaks of red in the emesis; on enoxaparin. No illicits x3. TECHNIQUE: Two abdominal films were obtained, one before one following the administration of contrast via patient's PEG tube. COMPARISON: Correlation made to CT scan of the abdomen pelvis from earlier the same day. FINDINGS: Enteric contrast was administered via patient's PEG tube and is seen within the stomach. There is no extraluminal contrast identified. Excreted contrast is seen within the renal collecting system and ureters. Degenerative changes noted in the spine. Nonobstructive bowel gas pattern. IMPRESSION: Enteric contrast administered via patient's PEG is noted within the stomach. No extraluminal contrast identified. Radiology Report EXAMINATION: PARACENTESIS DIAGNOSTIC/THERAPEUTIC WITH IMAGING GUIDANCE INDICATION: ___ year old man with pancreatic ca w/loculated ascites//therapeutic and dx para please TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated moderate loculated ascites. A suitable target in the largest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 3.1 L of cloudy brown fluid were removed. Fluid samples were submitted to the laboratory for cell count, differential, and culture. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: -Technically successful ultrasound guided diagnostic and therapeutic paracentesis. -3.1 L of fluid were removed. Radiology Report INDICATION: ___ year old man with history of stage IV pancreatic cancer on chemotherapy (3rd dose of ___ cycle finished 5 days prior), N/V x 2 days. Org placed G-Tube MIC ___ Fr ___ re-admitted on ___ with 2 days N/V, G-tube check ___. Exchange planned for ___ COMPARISON: Abdominal 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: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: 35 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.1 min, 8 mGy PROCEDURE: 1. Exchange of a gastrostomy tube. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper abdomen and tube site was prepped and draped in the usual sterile fashion. A scout image was performed. The existing tube was injected with contrast and showed opacification of the gastric rugae. A ___ wire was advanced through the tube into the stomach. The existing tube was then removed using gentle traction after deflation of the balloon. Given the recent placement of the gastrostomy tube and lack of issues during tube feeding, a decision was made to use a 12 ___ MIC for replacement to err on the side of caution and prevent dehiscence of the fairly immature gastropexy. A 12 ___ gastrostomy tube was advanced over the wire into the stomach and the balloon was inflated using contrast diluted in sterile water. Contrast injection confirmed appropriate position. The retention ring of the tube was secured in place using 0 silk sutures. Sterile dressing was applied. Patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. 12 ___ MIC gastrostomy tube in the stomach. Indwelling gastrostomy tube balloon under-inflated. IMPRESSION: Successful exchange of a gastrostomy tube for a new 12 ___ MIC gastrostomy tube. The tube is ready to use. Radiology Report EXAMINATION: Video oropharyngeal swallow INDICATION: ___ year old man with pancreatic cancer and silent aspiration.// Evaluate for aspiration, interval change. 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: 04:57 min. COMPARISON: None FINDINGS: There is penetration with thin and nectar thick consistency liquids. There is intermittent aspiration with thin liquids. IMPRESSION: Intermittent aspiration with thin liquids. Penetration with nectar thick consistency liquids. 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: M Race: WHITE Arrive by WALK IN Chief complaint: Abdominal distention, Vomiting Diagnosed with Unspecified abdominal pain temperature: 98.0 heartrate: 103.0 resprate: 18.0 o2sat: 99.0 sbp: 106.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. You were admitted to the hospital with nausea and vomiting. This was likely due to chemotherapy and improved. There was concern that your feeding tube was misplaced so this was replaced. You also had a drainage of your ascites (abdominal fluid). There was concern for infection of the fluid for which you received antibiotics and will finish at home. Your tube feeds were modified to help you tolerated them better at home so as to improve your nutrition. You will start by running the tube feeds over 16 hours. You should follow-up with your outpatient Nutrition team. While on this schedule of tube feeds, you can take your Zenpep (pancreatic enzyme replacement) at bedtime and in the morning. Please continue your prior home medications. Please follow-up with your Oncologist. All the best, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: right eye pain, back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of polysubstance abuse, sciatica, and psychiatric disorder who presents with chest pain, back pain, and inability to ambulate s/p fall. . The patient states that he got into a fight at a club last night, and was hit in the right eye with a pistol. He experienced tearing chest pain that began in his left shoulder, and radiated to his right hip and across his back. He states that he was unable to ambulate, and was taken to the hospital in an ambulence. Of note, the patient states that he used cocaine, marijuana, and over 1 pint of vodka yesterday. He drinks at least a pint of vodka daily. . In the ED, initial VS: 98.4 103 ___ 99% ra. Labs were notable for Hct of 28.4 (baseline 36-38), Guaiac was negative. CT head and sinuses were negative. CT abd without RP bleed. EKG was reported to be sinus 98, NA/NI, TWF laterally. He received 2 L NS, percocet and 0.5 mg Dilaudid for the chest and back pain. VS upon transfer 97.8, 84, 18, 125/89, 100%RA. . Currently, the patient is complaining of pain in his right eye and lower back. Back pain is radiating down his right leg. He states that he did have maroon stools 2 days ago, but has not had a bowel movement since. No fevers, chills, N/V. Occasionally has lower abdominal cramping, chronic since gunshot wound to abdomen. . REVIEW OF SYSTEMS: Patient endorses urinary retention. Denies fever, chills, night sweats, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: # Osteonecrosis of L hip, s/p THR at Mt ___ ___ # Polysubstance abuse (EtOH, cocaine and opiates) with repeated ED visits for pain medications, "inability to walk" and housing -- numerous OMR notes with suspicion for malingering, narcotics seeking # Antisocial disorder. Extensive psych evaluation on ___ when patient was considered for inpatient psychiatric hospitalization. Felt to have several features consistent with psycopathy but did not meet requirements for inpatient hospitalization. History of aggressive behavior while hospitalized. Previous incarcerations. # Bipolar disorder. Unclear history. Patient has not been medicated. # Prior MI. In the ___, following cocaine use. Multiple visits to ED for CP following cocaine use. # DJD of the spine. Previous reports of sciatica with demands for pain medication on presentation to ED. He has had LBP and thigh pain for ___ years. MRI of spine showed degenerative changes and disc herniation in ___. # HTN # mTB as a child. Took medication. # H/o gunshot wound to abdomen in the ___, s/p ex-lap Social History: ___ Family History: Father had extensive alcohol abuse history and gout starting in his ___. Denies FH of CAD, DM, malignancy. Physical Exam: Admission Physical Exam: VS - Temp 98.1F, BP 131/84, HR 83, R 18, O2-sat 100% RA GENERAL - Alert, interactive, well-appearing in NAD, laying comfortably on side HEENT - right eyelid edematous and closed; eye appears mildly cloudy and patient with subjective blurred vision; MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, non-edematous NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ in upper extremities bilaterally; ___ with giveaway weakness in ankles bilaterally; otherwise will not participate in motor exam due to pain; patient states that sensation diminished in legs bilaterally L>R; decreased sensation in testicular sac; cremasteric reflex intact bilaterally . Discharge Physical Exam: 98.1 ___ ___ 100%RA GENERAL - Alert, interactive, well-appearing in NAD, laying comfortably on side HEENT - right eyelid edematous and closed; MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, non-edematous NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ in upper extremities bilaterally; 4+/5 with giveaway weakness in ankles bilaterally - however, on discharge patient was able to stand and walk comfortably with assistance of cane Pertinent Results: Labs: ___ 12:50AM BLOOD WBC-5.2 RBC-3.37*# Hgb-9.7*# Hct-28.4*# MCV-84 MCH-28.8 MCHC-34.1 RDW-16.2* Plt ___ ___ 12:50AM BLOOD Neuts-45.2* ___ Monos-5.7 Eos-6.7* Baso-2.0 ___ 06:30PM BLOOD Glucose-102* UreaN-12 Creat-1.1 Na-138 K-4.1 Cl-107 HCO3-24 AnGap-11 ___ 06:30PM BLOOD ALT-38 AST-37 AlkPhos-100 TotBili-0.5 ___ 06:30PM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.7 Mg-2.1 ___ 12:50AM BLOOD Hapto-201* ___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . CT head ___: 1. No acute intracranial process. 2. No evidence of fracture. . CT sinus ___: 1. No evidence of fracture. 2. Paranasal sinus disease. 3. Unchanged asymmetric soft tissue in the left piriform sinus, as noted on ___, to be correlated with direct visualization. . CXR PA/Lateral ___: No acute cardiopulmonary process. . Lumbosacral spine X-ray ___: No acute fracture. Stable degenerative changes. . CT abdomen/pelvis w/out contrast ___: 1. No retroperitoneal hematoma. 2. No acute intra-abdominal or intrapelvic process allowing for non-contrast technique. . MRI lumbar spine ___: Stable multifactorial degenerative changes of the lumbar spine without significant spinal canal stenosis and multilevel mild-to-moderate neural foraminal narrowing. Medications on Admission: Per discharge summary ___ (patient only able to confirm seroquel and citalopram) 1. quetiapine 100 mg Tablet Sig: One (1) Tablet PO three times a day. 2. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: On for 12 hours and off for 12 hours daily. 6. tizanidine 4 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain and muscle spasm. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain/muscle spasm. 6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Anemia, Back pain, s/p eye trauma 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: Cocaine use with chest pain status post fall with severe low back pain. ___. FINDINGS: Frontal and lateral views of the lumbar spine demonstrate five lumbar-type non-rib-bearing vertebral bodies. There is minimal if any anterolisthesis of L4 on L5 and retrolisthesis of L5 on S1. Marked disc space narrowing and endplate sclerosis with anterior spondylosis is present at L5-S1. Remainder of the lumbar spine demonstrates preservation of disc and vertebral body height. Mild compression deformity of T12 vertebral body is unchanged since ___. There is no pubic symphyseal or sacroiliac diastasis. The patient is status post left total hip arthroplasty. IMPRESSION: No acute fracture. Stable degenerative changes. Radiology Report INDICATION: ___ male with chest pain status post cocaine use, struck in the face with a pistol. ___. TECHNIQUE: Contiguous non-contrast axial images were acquired through the brain with multiplanar reformations. FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift of normally midline structures. The gray-white matter differentiation is preserved. Ventricles and sulci appear age appropriate. Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid air cells are well aerated. There is no evidence of fracture. Right frontal subgaleal thickening is longstanding. Globes and orbits are intact. IMPRESSION: 1. No acute intracranial process. 2. No evidence of fracture. Radiology Report INDICATION: ___ male with chest pain after using cocaine. COMPARISON: Radiograph dated ___ and CT dated ___. FINDINGS: Frontal and lateral views of the chest demonstrate stable low lung volumes. Allowing for such, the heart is normal in size. Mild unfolding of the thoracic aorta is unchanged. The lungs are clear. There is no vascular congestion, pleural effusion, or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ male with cocaine use, struck in the face with a pistol. COMPARISON: Same-day CT head. TECHNIQUE: MDCT of the maxillofacial bones was performed without contrast administration, with multiplanar reformations. There is no evidence of fracture. The nasal bones, zygomatic arches, lamina papyracea, anterior clinoid processes, and pterygoid plates are intact. The mandible appears intact. There is no periapical lucency. There is mucosal thickening involving the ethmoidal air cells and right maxillary sinus. Bilateral OMUs are patent. Visualized upper cervical spine demonstrates moderate multilevel degenerative disease. Globes appear intact. There is asymmetric soft tissue in the left piriform sinus, as previously seen on ___. IMPRESSION: 1. No evidence of fracture. 2. Paranasal sinus disease. 3. Unchanged asymmetric soft tissue in the left piriform sinus, as noted on ___, to be correlated with direct visualization. Radiology Report INDICATION: ___ male with low back pain status post fall with 10 point hematocrit drop. Question retroperitoneal hemorrhage. ___. TECHNIQUE: MDCT images were acquired from the lung bases through the pubic symphysis without contrast administration, with multiplanar reformations. CT ABDOMEN: The lung bases are clear with the exception of dependent atelectasis. There is no pleural effusion. The heart is normal in size without pericardial effusion. There is relative hypoattenuation of myocardium with respect to the blood pool in keeping with anemia. The liver demonstrates no focal lesion. Non-contrast technique limits assessment of solid organs. Allowing for such, the gallbladder, spleen, splenule, pancreas, and adrenal glands appear unremarkable. The kidneys demonstrate no stone or hydronephrosis. Small and large bowel loops are normal in caliber. There is no free air or free fluid. The great vessels are normal in caliber. Tiny mesenteric and retroperitoneal lymph nodes do not meet size criteria for adenopathy. CT PELVIS: The bladder, distal ureters, rectum, and prostate appear within normal limits allowing for streak artifact from a total left hip arthroplasty. There is anterior tenting of the bladder dome, with a linear structure leading to a small 7-mm possible urachal cyst (please confirm), likely congenital in origin and of doubtful clinical significance. There is no free fluid in the pelvis. BONE WINDOW: There is a left total hip arthroplasty in appropriate position. Multilevel moderate degenerative changes are seen. There is grade 1 retrolisthesis of L5 on S1. IMPRESSION: 1. No retroperitoneal hematoma. 2. No acute intra-abdominal or intrapelvic process allowing for non-contrast technique. Radiology Report INDICATION: ___ patient with known degenerative disc disease, presenting with progressive decrease of sensation in lower legs. Assessment for cord compression. COMPARISON: MR ___ dated ___. TECHNIQUE: Sagittal STIR, T1 and T2 as well as axial T2 images were obtained without contrast. FINDINGS: The lumbar spine has normal lordotic curvature, vertebral body height and alignment. Besides T1- and T2-hyperintense, STIR-hypointense lesion in L1, likely meningioma as well as ___ type 2 endplate changes at L5/S1, the bone marrow signal is unremarkable. The intervertebral discs demonstrate diffuse loss of height and T2 signal as a manifestation of degenerative disc disease. At L3/L4, a diffuse disc bulge is mildly indenting the anterior thecal sac without causing significant spinal canal stenosis. The left neural foramen is mildly narrowed due to extending disc material and facet joint arthropathy. At L4/L5, diffuse disc bulge is indenting the anterior thecal sac without causing significant spinal canal stenosis. The bilateral neural foramina are mildly narrowed due to extending disc material and facet joint arthropathy. At L5/S1, a diffuse disc bulge is indenting the anterior thecal sac. The bilateral neural foramina are moderately narrowed due to facet joint arthropathy. The conus terminates at L2 level. Conus and cauda equina demonstrate normal morphology and preserved intrinsic T2 signal. The posterior elements demonstrate multilevel facet joint arthropathy. The paraspinal soft tissues are unremarkable. IMPRESSION: Stable multifactorial degenerative changes of the lumbar spine without significant spinal canal stenosis and multilevel mild-to-moderate neural foraminal narrowing. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: CHEST PAIN Diagnosed with ANEMIA NOS, CHEST PAIN NOS, COCAINE ABUSE-UNSPEC temperature: 98.4 heartrate: 103.0 resprate: 20.0 o2sat: 99.0 sbp: 109.0 dbp: 88.0 level of pain: 10 level of acuity: 2.0

Mr. ___, . You were admitted to the hospital for back pain, eye pain, and a decrease in your blood counts after being hit by the blunt end of a pistol. We performed an MRI of your back that shows no damage to your spinal cord. You were also seen by ophthalmology who found no damage to your eye. Your eyelid will remain swollen for the next several days. We suspect that you lost blood in your stool. However, you would not allow us to follow your blood counts, or test your stool for blood. . You were discharged to home. . Medications changed this admission: STOP seroquel STOP celexa START ibuprofen every 6 hours as needed for pain

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of recurrent episodes of abdominal pain and bloating of unclear etiology, presenting with RLQ pain since yesterday at 8 ___. Patient started having some right flank pain with sudden onset that radiated to the epigastrium and to the left abdomen. Had some nausea, but no vomiting. Denies any fevers or chills. Has been having some loose stools. In the ED, pelvic exam was normal, a CTU was performed to evaluate for kidney stones, and this was negative. It did show an 8 mm appendix. Surgery is consulted for possible enlarged appendix. ROS: (+) per HPI (-) Denies fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, pruritis, jaundice, rashes, bleeding, easy bruising, dizziness, vertigo, syncope, weakness, paresthesias, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema Past Medical History: OCD, trichotillomania, depression, GERD, recurrent episodes of abdominal pain and bloating of unclear etiology. Normal gastric emptying study ___, H. pylori ___ s/p treatment, recurrent vaginitis Social History: ___ Family History: Father had CABG Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 99.6 117 130/80 18 100% GEN: A&Ox3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, minimally tender in all the right abdomen, not consistent after distraction, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused DISCHARGE PHYSICAL EXAM: VITALS T99, BP 117/83, HR 90, RR18, 99% RA GENERAL: well appearing in NAD HEENT: PERRL, EOMI, MMM, OP clear NECK: no LAD, supple LUNGS: CTAB no MRG HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, +BS, R-side TTP (perumbilical-RUQ, milder TTP RLQ), negative ___ sign, referred pain to right side with LLQ and LUQ palpation, no TTP over mcburney's point EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3, CN II-XII grossly intact, ___ strength, normal gait, normal sensation throughout Pertinent Results: ADMISSION LABS: ___ 05:45PM BLOOD WBC-9.7 RBC-5.18 Hgb-13.0 Hct-39.4 MCV-76* MCH-25.1* MCHC-32.9 RDW-13.3 Plt ___ ___ 05:45PM BLOOD Neuts-76.0* ___ Monos-4.0 Eos-1.2 Baso-0.5 ___ 05:45PM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-138 K-3.9 Cl-104 HCO3-26 AnGap-12 ___ 05:45PM BLOOD ALT-16 AST-15 AlkPhos-42 TotBili-0.3 ___ 05:45PM BLOOD Albumin-4.6 Iron-24* ___ 05:45PM BLOOD Lipase-33 DISCHARGE LABS: ___ 06:30AM BLOOD WBC-8.0 RBC-4.95 Hgb-12.3 Hct-38.0 MCV-77* MCH-24.8* MCHC-32.3 RDW-13.4 Plt ___ ___ 06:30AM BLOOD Glucose-81 UreaN-9 Creat-0.7 Na-140 K-3.6 Cl-107 HCO3-25 AnGap-12 ___ 06:30AM BLOOD ALT-9 AST-15 AlkPhos-37 TotBili-0.5 PERTINENT MICRO: ___ 7:21 pm SWAB -Chlamydia trachomatis, Nucleic Acid Probe, with Amplification PENDING AT TIME OF DISCHARGE -NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION PENDING AT TIME OF DISCHARGE PERTINENT IMAGING: CT ABD/PEL ___ NON CON TECHNIQUE: Multidetector CT through the abdomen and pelvis was performed without oral or IV contrast. Patient was scanned in the prone position and multiplanar reformations were provided. FINDINGS: The imaged lung bases are clear. ABDOMEN: The kidneys demonstrate no hydronephrosis or renal stone. A hypodensity arising from the lower pole of the left kidney is incompletely characterized on this single-phase exam though it is most compatible with a simple cyst, please note this left renal cyst has been previously characterized on an ultrasound of the abdomen dated ___. The liver, spleen, gallbladder, pancreas, and adrenal glands appear normal on this non-contrast exam. The abdominal aorta is normal in course and caliber. No significant atherosclerosis is noted. The retroperitoneal lymph nodes are not enlarged. The stomach is decompressed. The duodenum appears normal. PELVIS: Loops of small bowel demonstrate no signs of ileus or obstruction. The appendix measures up to 8 mm in diameter, though there is no periappendiceal fat stranding to suggest acute appendicitis. The colon is unremarkable without signs of colitis or obstruction. Uterus and adnexal regions appear normal. The urinary bladder appears unremarkable. No pelvic free fluid. BONES: No worrisome lytic or blastic osseous lesion is seen. IMPRESSION: 1. No hydronephrosis or renal stone. 2. 8 mm appendix which is at the upper limits of normal for size without definite signs of acute appendicitis. ___ ABDOMINAL ULTRASOUND FINDINGS: The liver has normal echotexture and there is no focal liver lesion. The main portal vein is patent and displays hepatopetal flow. The gallbladder is normal and there is no stones. There is no intra- or extra-hepatic biliary ductal dilatation and the common bile duct measures 3 mm. The right kidney measures 11.4 cm and the left kidney measures 10.8 cm. Both kidneys are normal without hydronephrosis, mass, or stone. A 4.1 cm simple cyst is noted in the lower pole of left kidney as seen on prior CT. There is a lobulation of the left kidney unchanged compared to the prior ultrasound dated ___. The visualized portions of the pancreas are normal. The tail of pancreas is not visualized, likely due to overlying bowel gas. Spleen is normal measuring 10.2 cm. The aorta is of normal caliber throughout. The visualized portions of the inferior vena cava appear normal. IMPRESSION: Left renal cyst. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. lactase *NF* 4,500 unit Oral with dairy 2. Omeprazole 20 mg PO DAILY 3. Simethicone 40-80 mg PO QID:PRN bloating Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. lactase *NF* 4,500 unit Oral with dairy 3. Simethicone 40-80 mg PO QID:PRN bloating Discharge Disposition: Home Discharge Diagnosis: Abdominal Pain, etiology unclear Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CT SCAN OF THE ABDOMEN AND PELVIS PERFORMED ON ___ COMPARISON: None. CLINICAL HISTORY: Right lower quadrant and right CVA tenderness. Assess for appendicitis or kidney stone. TECHNIQUE: Multidetector CT through the abdomen and pelvis was performed without oral or IV contrast. Patient was scanned in the prone position and multiplanar reformations were provided. FINDINGS: The imaged lung bases are clear. ABDOMEN: The kidneys demonstrate no hydronephrosis or renal stone. A hypodensity arising from the lower pole of the left kidney is incompletely characterized on this single-phase exam though it is most compatible with a simple cyst, please note this left renal cyst has been previously characterized on an ultrasound of the abdomen dated ___. The liver, spleen, gallbladder, pancreas, and adrenal glands appear normal on this non-contrast exam. The abdominal aorta is normal in course and caliber. No significant atherosclerosis is noted. The retroperitoneal lymph nodes are not enlarged. The stomach is decompressed. The duodenum appears normal. PELVIS: Loops of small bowel demonstrate no signs of ileus or obstruction. The appendix measures up to 8 mm in diameter, though there is no periappendiceal fat stranding to suggest acute appendicitis. The colon is unremarkable without signs of colitis or obstruction. Uterus and adnexal regions appear normal. The urinary bladder appears unremarkable. No pelvic free fluid. BONES: No worrisome lytic or blastic osseous lesion is seen. IMPRESSION: 1. No hydronephrosis or renal stone. 2. 8 mm appendix which is at the upper limits of normal for size without definite signs of acute appendicitis. Radiology Report INDICATION: Right-sided abdominal pain of unclear etiology. TECHNIQUE: Abdominal ultrasound (complete). COMPARISON: CT abdomen and pelvis ___. FINDINGS: The liver has normal echotexture and there is no focal liver lesion. The main portal vein is patent and displays hepatopetal flow. The gallbladder is normal and there is no stones. There is no intra- or extra-hepatic biliary ductal dilatation and the common bile duct measures 3 mm. The right kidney measures 11.4 cm and the left kidney measures 10.8 cm. Both kidneys are normal without hydronephrosis, mass, or stone. A 4.1 cm simple cyst is noted in the lower pole of left kidney as seen on prior CT. There is a lobulation of the left kidney unchanged compared to the prior ultrasound dated ___. The visualized portions of the pancreas are normal. The tail of pancreas is not visualized, likely due to overlying bowel gas. Spleen is normal measuring 10.2 cm. The aorta is of normal caliber throughout. The visualized portions of the inferior vena cava appear normal. IMPRESSION: Left renal cyst. Gender: F Race: HISPANIC OR LATINO Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN RLQ temperature: 99.6 heartrate: 117.0 resprate: 18.0 o2sat: 100.0 sbp: 130.0 dbp: 80.0 level of pain: 5 level of acuity: 3.0

Dear ___, ___ was a pleasure taking part in your care during your hospitalization at ___. You were admitted with abdominal pain, and underwent testing to investigate the cause. CT scan did NOT show appendicitis, bowel obstruction, or kidney stones, and ultrasound of the abdomen did NOT show gallstones. With ibuprofen and your usual home medications your symptoms improved and you were able to be discharged home. It is important that you follow up with your PCP as directed below to discuss your symptoms.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bradycardia and malnutrition Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old female with a history of severe eating disorder, anxiety, and hypothyroidism with a recent admission for intentional overdose of psychiatric medication now transferred from ___ for evaluation of SI and failure to follow their eating disorder protocol as well as medical clearance for bradycardia. Patient reports that the SI was a passive fleeting feeling that she wrote about in her journal and she no longer feels this way. She reports she was taking good oral intake at ___ but had declined the tube that they recommended. She would like either an inpatient psychiatric stay to address her psychiatric problems or to be transferred back to ___ as soon as possible. ROS positive only for mild intermittent constipation. Past Medical History: PMH -Anorexia nervosa with purging -ETOH abuse -Anxiety -Depression -Migraines -Hypothyroidism? -Osteopenia -Born with one kidney - One grand mal seizure at ___ years old. None since. She used anti-epileptic (Keppra) for ___ years but has not taken a medication to prevent seizures since. Social History: ___ Family History: Family history of: - Anxiety: paternal grandfather - ___: mother and maternal aunt. Mother is a ___. - One sister cuts herself - No history of suicide attempts in family Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vital Signs: T 97.4 PO BP 92 / 64 L Sitting HR48 RR16 SaO2 100RA General: Very thin young women, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Bradycardic and regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, Mild tenderness suprapubic, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly normal sensation and strength of extremities. Access: PIV DISCHARGE PHYSICAL EXAM ======================= Vitals- 98.1 | 91/59 | 80 | 16 | 100% RA Weight- 40.3kg from low weight of 38.1 KG on ___ General- cachectic, alert, oriented, no acute distress HEENT- sclera anicteric, MMM, nicotine lozenge in mouth, oropharynx clear with good dentition, PERRLA Neck- thin, supple, JVP not elevated, no LAD Lungs- clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- bradycardic with regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-distended, bowel sounds present, mild RLQ tenderness, no rebound tenderness, no organomegaly GU- no foley Ext- 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS ============== ___ 03:54PM BLOOD WBC-3.8* RBC-3.94 Hgb-10.4* Hct-33.5* MCV-85 MCH-26.4 MCHC-31.0* RDW-14.3 RDWSD-44.7 Plt ___ ___ 03:54PM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-140 K-4.2 Cl-101 HCO3-30 AnGap-13 ___ 07:25AM BLOOD ALT-19 AST-12 LD(LDH)-129 AlkPhos-66 Amylase-114* TotBili-0.2 ___ 07:25AM BLOOD TotProt-5.8* Albumin-3.8 Globuln-2.0 Calcium-9.5 Phos-3.8 Mg-1.7 UricAcd-3.2 Cholest-155 ___ 03:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging ======= CXR ___ portable AP: IMPRESSION: Comparison to ___. The patient is extubated and the nasogastric tube was removed. Otherwise the chest radiograph is stable and normal. Normal size of the cardiac silhouette. Mild scoliosis. No pneumonia, no pulmonary edema, no pleural effusions. DISCHARGE LABS ============== ___ 06:50AM BLOOD WBC-3.8* RBC-4.03 Hgb-10.7* Hct-34.1 MCV-85 MCH-26.6 MCHC-31.4* RDW-14.3 RDWSD-42.5 Plt ___ ___ 06:50AM BLOOD Glucose-64* UreaN-20 Creat-1.0 Na-137 K-4.0 Cl-98 HCO3-26 AnGap-17 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 150 mg PO BID 2. Levothyroxine Sodium 25 mcg PO DAILY 3. ClonazePAM 0.5 mg PO TID:PRN anxiety 4. FoLIC Acid 1 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Melatin (melatonin) 5 mg oral QPM 7. Polyethylene Glycol 17 g PO BID 8. Multivitamins 1 TAB PO DAILY 9. B Complete (vitamin B complex) oral DAILY 10. Gabapentin 200 mg PO TID 11. Vitamin D Dose is Unknown PO DAILY 12. Calcium Carbonate 500 mg PO Frequency is Unknown 13. OLANZapine 5 mg PO QHS 14. Pedialyte (electrolytes-dextrose;<br>sodium-potas-chloride-dextrose) 10.6-4.7 mEq/8.5 gram oral TID 15. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) unknown oral ___ 16. Simethicone 40-80 mg PO QID:PRN gas/distention 17. DiphenhydrAMINE 50 mg PO QHS:PRN sleep Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Neutra-Phos 2 PKT PO BID 4. Nicotine Lozenge 2 mg PO Q2H:PRN crave 5. Thiamine 100 mg PO DAILY 6. OLANZapine 2.5 mg PO TID W/MEALS 7. ClonazePAM 0.5 mg PO TID:PRN anxiety 8. DiphenhydrAMINE 50 mg PO QHS:PRN sleep 9. FoLIC Acid 1 mg PO DAILY 10. Gabapentin 200 mg PO TID 11. LamoTRIgine 150 mg PO BID 12. Levothyroxine Sodium 25 mcg PO DAILY 13. Melatin (melatonin) 5 mg oral QPM 14. Simethicone 40-80 mg PO QID:PRN gas/distention Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis - Anorexia nervosa - Malnutrition - Bradycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with eating disorder // Initial evaluation for eating disorder protocol. Initial evaluation for eating disorder protocol. IMPRESSION: Comparison to ___. The patient is extubated and the nasogastric tube was removed. Otherwise the chest radiograph is stable and normal. Normal size of the cardiac silhouette. Mild scoliosis. No pneumonia, no pulmonary edema, no pleural effusions. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Anorexia, SI Diagnosed with Anorexia nervosa, unspecified temperature: 98.5 heartrate: 52.0 resprate: 14.0 o2sat: 100.0 sbp: 91.0 dbp: 58.0 level of pain: 7 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ because you were still losing weight while at ___ Eating Disorder Unit and the physicians there found your low heart rate to be concerning. You were put on an eating disorder protocol responded well gaining weight appropriately. Your electrolytes and lab values remained stable throughout your stay. You are now healthy enough to restart treatment at ___ and have been accepted there. It was a pleasure taking care of you! Sincerely, Your ___ Healthcare Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: amoxicillin / Bactrim / Keflex Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: skin punch biopsy History of Present Illness: ___ female with history of benign neutropenia, psoriasis and recently diagnosed Crohn's disease (in ___ of this year) on humira and chronic prednisone who presents with high grade fevers and new petechial rash x2 days. Patient has been on a course of Bactrim for cellulitis of right antecubital fossa. She developed fevers and was seen again 2 days ago at which time it was thought that she needed a longer course of antibiotics for her cellulitis. They attempted an I&D but there was no e/o abscess on exam or ultrasound. Patent was then discharged with another 10 day course of Bactrim as well as doxycycline and Keflex. She returns today with persistent high grade fevers to 102-103 despite round the clock Tylenol. She also noted a new petechial rash involving her torso. She has been on prednisone 10mg daily since ___, prior to that she was on 40mg daily for several months followed by a slow taper. She did not receive her shot of Humira on Monnday because she was told she couldn't get it while being on antibiotics. Her recent baseline has been about 3 BM's a day without blood in stool but since missing her shot of Humira she has had on average about 6 bloody bowel movements a day. She denies any shortness of breath, cough, dysuria, joint pains or joint swelling. She had a mild headache 2 days ago but none since. She denies any dizziness, photophobia, blurry vision. She was recently at ___ at the ___ and reports sunburn and peeling / itchy skin in shoulder and back related to that. This was before she had started taking the doxycycline. She denies any mosquito bites or ticks / tick bites. She denies any known sick contacts. She reports history of Benign Neutropenia for which she is followed by a hematologist at ___. Her most recent labs are notable for normal white count and neutrophils. She denies previous history of drug reaction similar to current presentation. Of the 3 antibiotics started recently, she knows she has taken Keflex without issue before but doesn't think she's ever taken Bactrim before. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: Benign Neutropenia Crohn's disease Psoriasis Social History: ___ Family History: FAMILY HISTORY: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: DISCHARGE 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. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs. However R arm flexion at elbow limited to pain. With dressing taken down, on the antecubital fossa there is surrounding 2 cm patch of erythema around a 1 cm packed wound with scant persistent yellow drainage. Proximal suture intact. The erythema is significantly reduced from admission and retreated from the marked borders, as well as no edema/induration PSYCH: pleasant, appropriate affect NEUROLOGIC: MENTATION: alert and cooperative. Oriented to person and place and time. Pertinent Results: ___ Imaging US EXTREMITY LIMITED SO IMPRESSION: Subcutaneous edema and hyperemia without a drainable fluid collection. ================ ___ Pathology Tissue: SKIN, LEVELS X2 Report not finalized. Assigned Pathologist ___, MD ___ in only. PATHOLOGY # ___ SKIN, LEVELS X2 ================ COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 07:40 2.1* 4.05 7.8* 27.0* 67* 19.3* 28.9* 22.2* 48.1* 148* ___ 08:45 2.7* 3.94 7.4* 25.5* 65* 18.8* 29.0* 19.3* 43.6 54*2 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:50 741 7 0.4 142 4.2 ___ ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili ___ 04:00 18 25 54 <0.2 HIV SEROLOGY HIV Ab ___ 07:25 ___ 07:25 AnaplasmaPhagocytophilum DNA, Qualitative (see report): negative ___ 04:00 Parvovirus B19 Antibodies (see report) : IgM negative ___ 04:00 Anaplasma phagocytophilum (human granulocytic Ehrlichia agent) IgG/IgM PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 10 mg PO DAILY 2. Humira (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2 WEEKS Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild RX *acetaminophen 325 mg ___ tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills:*0 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 3. PredniSONE 10 mg PO DAILY 4. HELD- Humira (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2 WEEKS This medication was held. Do not restart Humira until instructed by Dr. ___ 5.Outpatient Lab Work Draw CBC with diff on ___. D70.9. Results forwarded to Dr. ___: ___ Discharge Disposition: Home Discharge Diagnosis: arm abscess and soft tissue skin infection, cellulitis pancytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT INDICATION: ___ year old woman with Crohn's disease with purulence expressed from punch biopsy by dermatology of erythematous tender plaque in right antecubital fossa. Reportedly, no abscess seen on bedside ultrasound in ED on ___. Evaluate for abscess collection in right antecubital fossa TECHNIQUE: Real-time grayscale an color Doppler imaging was performed of the area of concern over the right antecubital fossa. COMPARISON: None. FINDINGS: Physical examination was notable for packing material in the region of prior biopsy over the right antecubital fossa with surrounding erythema. Grayscale and color Doppler ultrasound evaluation of this region demonstrates diffuse subcutaneous edema and hyperemia. There is no drainable fluid collection. There is deep posterior acoustic shadowing in the region of the packing material. IMPRESSION: Subcutaneous edema and hyperemia without a drainable fluid collection. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with Fever, unspecified temperature: 100.1 heartrate: 115.0 resprate: 14.0 o2sat: 100.0 sbp: 122.0 dbp: 68.0 level of pain: 3 level of acuity: 3.0

Instructions: Dear Ms. ___, It was a pleasure to be a part of your care team at ___ ___. ==================================== Why did you come to the hospital? ==================================== -You had fever, new rash, and found to also have low blood counts. ==================================== What happened at the hospital? ==================================== -You were found to have an abscess in the right arm that was infected and likely causing your fevers. It was incised and drained which allowed your new antibiotics to work. -Your low blood counts were likely due to bone marrow suppression from the Bactrim antibiotic you were taking prior to this hospital stay. Your bone marrow should continue to recover on its own. You did require a unit of blood transfusion due to a very low blood count. ================================================== What needs to happen when you leave the hospital? ================================================== -WHEN TAKING DOXYCYCLINE: Administer with meals to decrease GI upset. Administer capsules and tablets with at least 8 ounces (240 mL) of water and have patient sit up for at least 30 minutes after taking to reduce the risk of esophageal irritation and ulceration. Use skin protection and avoid prolonged exposure to sunlight and ultraviolet light. Last day to take doxycycline is on ___. Avoid Bactrim antibiotic in the future. -For the right arm wound, cover with gauze and wrap in Kerlix. Change dressing once daily until your appointment with Dr. ___. Do not remove the iodoform packing. -Take your medications every day and have your CBC (blood count) laboratory levels checked as directed by your doctors. ___ should be drawn on ___, with results being forwarded to Dr. ___. -Please attend all of your doctor appointments and arrange for them as below. It was a pleasure taking care of you during your stay! Sincerely, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: latex / aspirin Attending: ___ Chief Complaint: Dysarthria, unsteady gait Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. ___ is a ___ yo man with hx multiple vascular risk factors including afib on Coumadin who presents from ___ with RLE weakness, found to have IPH. Mr. ___ was watching the football game, and thinks he was last normal between 1800 and ___. At one point during the game he stood to walk across the room but almost fell. He was able to hold onto nearby objects to keep himself from falling. He noted that he was unable to move his RLE. He states he had no movement of the limb. He waited between 1 and 2 hours, and then noted he had significantly more movement in the RLE and was able to walk. He then presented to ___. On arrival to ___, his BP was 205/86, which improved after labetalol 10 mg IV to 120s. He was also given NS at 100/hr. NCHCT showed IPH and he was transferred to ___ because there was no neurosurgery available at that hospital. Of note, on ___, metoprolol XL 25 mg daily was stopped by PCP due to pt reported hypotension with HD. Past Medical History: - ESRD on HD (___) - Basal Cell Cancer - Right Carotid Endarterectomy - Paroxysmal Atrial Fibrillation, off Coumadin - DMII - GERD - Hypertension - Hyperlipidemia - TIA Social History: ___ Family History: Mother with hypertension. Father with CAD and MI at age ___. Physical Exam: Physical Exam: VS: T 97.9, HR 75, BP 125/69, RR 16, SpO2 96% RA General: Sitting up in chair in NAD, appears stated age. Lungs: breathing comfortably in room air CV: well-perfused, irregularly irregular rhythm Resp: Breathing comfortably in room air Abd: non-distended Extremities: Brachiocephalic fistula in L forearm; extremities warm, well-perfused Neuro: MS: Awake, alert, oriented to person, place with prompting, date (looks at wall calendar) and year (unassisted). He has trouble stating why he is in the hospital. Able to name his 3 sons and his home address. Speech is fluent. CN: PERRL, 3>2 bl; no gaze restriction, no nystagmus, subtle R ptosis. Tongue protrudes midline. Smile symmetric. Motor: RUE: Delt 5, tric 5, bi 5, WE 5, FE ___ FF 5 RLE: IP 5, ham 5, quad 5, TA 5, gastroc 5 LUE: Delt 5, tric 5, bi 5, WE 5, FE ___ FF 5 LLE: IP 5, ham 5, quad 5, TA 5, gastroc 5 Sensory: Grossly intact to light to touch in all extremities. Reflexes: R Biceps 2, BR trace. L Biceps difficult to assess ___ fistula, L BR 2. B/L patellae and Achilles trace to none. R toe mute, L toe up. Pertinent Results: ___ 06:20AM ALT(SGPT)-20 AST(SGOT)-19 ALK PHOS-80 TOT BILI-0.9 ___ 06:20AM ALBUMIN-4.4 CALCIUM-10.1 PHOSPHATE-5.7* MAGNESIUM-2.3 ___ 06:20AM WBC-6.9 RBC-3.93* HGB-12.3* HCT-39.0* MCV-99* MCH-31.3 MCHC-31.5* RDW-17.8* RDWSD-65.1* ___ 06:20AM ___ PTT-31.7 ___ ___ 11:52PM cTropnT-0.01 ___ 11:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 11:52PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 11:52PM WBC-7.3 RBC-3.92*# HGB-12.1*# HCT-38.4*# MCV-98 MCH-30.9 MCHC-31.5* RDW-17.8* RDWSD-64.6* ___ 11:52PM NEUTS-72.4* LYMPHS-17.4* MONOS-7.9 EOS-1.0 BASOS-0.5 IM ___ AbsNeut-5.28 AbsLymp-1.27 AbsMono-0.58 AbsEos-0.07 AbsBaso-0.04 ___ 11:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5* LEUK-NEG ___ 05:52AM BLOOD ___ PTT-24.4* ___ ___ 12:55PM BLOOD Glucose-126* UreaN-42* Creat-7.1*# Na-141 K-4.5 Cl-94* HCO3-27 AnGap-20* ___ 05:52AM BLOOD Glucose-117* UreaN-50* Creat-7.8* Na-139 K-4.0 Cl-94* HCO3-26 AnGap-19* ___ 07:00AM BLOOD Glucose-127* UreaN-51* Creat-8.0* Na-140 K-4.0 Cl-96 HCO3-25 AnGap-19* ___ 07:00AM BLOOD Calcium-10.2 Phos-4.9* Mg-2.1 ___ 12:55PM BLOOD WBC-11.7* RBC-3.52* Hgb-11.2* Hct-35.1* MCV-100* MCH-31.8 MCHC-31.9* RDW-17.9* RDWSD-64.6* Plt Ct-91* ___ 12:55PM BLOOD Neuts-85.9* Lymphs-6.9* Monos-6.2 Eos-0.3* Baso-0.1 Im ___ AbsNeut-10.03*# AbsLymp-0.80* AbsMono-0.72 AbsEos-0.03* AbsBaso-0.01 ___ 07:00AM BLOOD Glucose-127* UreaN-51* Creat-8.0* Na-140 K-4.0 Cl-96 HCO3-25 AnGap-19* ___ 12:26AM URINE Blood-SM* Nitrite-POS* Protein-100* Glucose-150* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG* ___: Urine culture pending IMAGING: CT head (OSH) ___: significant for L putamen hemorrahge CXR ___: no official report available; appears negative for consolidation or pulmonary edema MRI Head w/o contrast ___: IMPRESSION: 1. Unchanged acute left putaminal hematoma, measuring up to 1.4 cm allowing for differences in imaging modalities. No definite underlying putaminal lesion allowing for lack of intravenous contrast. 2. Findings compatible with an old right parietal infarct with associated volume loss and gliosis. 3. Confluent white matter chronic small vessel ischemic disease given the patient's age ___. Parenchymal involutional changes, likely age-related. MRI Head w/ and w/o contrast ___: IMPRESSION: Hemorrhage centered on left basal ganglia, stable, mild edema. There is mild hyperemia, typical of early subacute hemorrhage, no evidence of underlying mass or vascular malformation. Consider follow-up imaging when hemorrhage resolves, if indicated. Chronic infarcts. Severe chronic small vessel ischemic changes. Advanced generalized brain parenchymal atrophy. Fistulogram ___: IMPRESSION: Successful balloon angioplasty of mild in stent stenosis due to intimal hyperplasia, with no residual stenosis seen post angioplasty. RECOMMENDATION(S): The fistula may be used for dialysis immediately. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Warfarin 5 mg PO DAILY 4. Amiodarone 200 mg PO DAILY 5. Calcitriol 0.5 mcg PO DAILY 6. Calcium Acetate 1334 mg PO TID W/MEALS 7. FoLIC Acid 1 mg PO DAILY 8. sevelamer CARBONATE 800 mg PO TID W/MEALS 9. Viagra (sildenafil) 100 mg oral PRN Discharge Medications: 1. amLODIPine 5 mg PO DAILY Take ___ hrs after dialysis on dialysis days. 2. Sulfameth/Trimethoprim DS 1 TAB PO Q24H Duration: 5 Days To end ___. Give after dialysis on dialysis days. 3. Warfarin 2.5 mg PO Q24H 4. Amiodarone 200 mg PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. Calcitriol 0.5 mcg PO DAILY 7. Calcium Acetate 1334 mg PO TID W/MEALS 8. FoLIC Acid 1 mg PO DAILY 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. Tamsulosin 0.4 mg PO DAILY 11. Viagra (sildenafil) 100 mg oral PRN Sexual activity Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left putamen hemorrhagic stroke Urinary tract infection ESRD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with L putamen IPH, ESRD on HD// Eval for underlying lesion, microbleeds TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CT head without contrast ___. FINDINGS: No significant change in size of the acute left putaminal hematoma, measuring up to 1.4 cm. There is associated diffusion abnormality and susceptibility on gradient echo imaging compatible with blood products. There is no definite underlying putaminal lesion allowing for lack of intravenous contrast. No new hemorrhage is identified. Right parietal volume loss and gliosis likely represents sequela of an old infarct. No evidence of mass effect or midline shift. Confluent subcortical, deep and periventricular white matter T2/FLAIR hyperintensity is compatible with chronic small vessel ischemic disease given the patient's age. The major intracranial vascular flow voids are maintained. Prominence of ventricles and cerebral sulci are compatible with age related involutional changes. The paranasal sinuses, mastoid air cells and orbits are normal. There is an incompletely evaluated ovoid subcutaneous 1.4 cm T1 hypointense focus at the posterior midline neck, which is favored to represent a sebaceous cyst. IMPRESSION: 1. Unchanged acute left putaminal hematoma, measuring up to 1.4 cm allowing for differences in imaging modalities. No definite underlying putaminal lesion allowing for lack of intravenous contrast. 2. Findings compatible with an old right parietal infarct with associated volume loss and gliosis. 3. Confluent white matter chronic small vessel ischemic disease given the patient's age ___. Parenchymal involutional changes, likely age-related. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with L putamen hemorrhage// please perform MPRAGE sequence to evaluate for ?enhancing mass vs. AVM TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: MRI brain ___ 1144 a.m., head CT ___. FINDINGS: Left putamen, adjacent corona radiata acute hemorrhage is again noted with marked blooming artifact on the gradient echo sequence measuring 10 x 13 mm in the axial plane. There is mild to moderate surrounding vasogenic edema. There is surrounding hyperemia, but no obvious underlying mass or vascular malformation. Chronic infarct with resultant cystic encephalomalacia involving the right temporal occipital area. Hemorrhage products limited usefulness of diffusion-weighted images in the area of acute hemorrhage. There are no other areas of restricted diffusion to suggest an acute ischemic infarct. There is large chronic infarct involving posterior right temporal and adjacent occipital lobe, stable small cortical infarct right middle frontal gyrus. Advanced generalized cerebral atrophy with ex vacuo dilatation of the ventricles. Periventricular T2 and FLAIR hyperintense changes are most likely secondary to severe small vessel disease. Nonenhancing sebaceous cyst in the neck subcutaneous soft tissue measuring 13 x 11 mm in the sagittal plane. The pituitary gland appears normal. The craniocervical junction appears normal. Absent right vertebral artery flow void, may be from slow flow or occlusion. There is little flow within right vertebral artery on MP rage images. The intracranial arteries demonstrate normal T2 flow voids. Mild opacification of the dependent mastoid air cells. Minimal mucosal thickening involving the paranasal sinuses. The orbits appear normal. IMPRESSION: Hemorrhage centered on left basal ganglia, stable, mild edema. There is mild hyperemia, typical of early subacute hemorrhage, no evidence of underlying mass or vascular malformation. Consider follow-up imaging when hemorrhage resolves, if indicated. Chronic infarcts. Severe chronic small vessel ischemic changes. Advanced generalized brain parenchymal atrophy. Radiology Report INDICATION: ___ year old man with ESRD on HD admitted for L putamen stroke.// L brachiocephalic fistulogram- assess for patency due to difficult cannulation COMPARISON: None. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 37.5mcg of fentanyl and 0 mg of midazolam throughout the total intra-service time of 55 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None. CONTRAST: 36 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 6.2 min, 11 mGy PROCEDURE: 1. Left upper extremity brachiocephalic fistulagram. 2. Axillary, subclavian and super vena cava venography. 3. Balloon angioplasty of the stent complex. PROCEDURE DETAILS: Written informed consent was obtained from the patient outlining the risks, benefits and alternatives to the procedure. The patient was then brought to the angiography suite and placed supine on the image table with the left upper extremity abducted and stabilized. Clinical examination demonstrated a left upper extremity fistula with a good thrill. Further evaluation by targeted ultrasound demonstrated patency of the fistula, with good flow. The left upper extremity was prepped and draped in the usual sterile fashion. A preprocedure timeout and huddle was performed as per ___ protocol. Using ultrasound and fluoroscopy, the arterial inflow and outflow stent levels were identified and the skin was marked with a skin marker. Antegrade (directed towards the venous outflow) access into the fistula was obtained using a 21G micropuncture needle. An 0.018 wire was then advanced easily into the outflow vein under fluoroscopic guidance. A 4.5F micropuncture sheath was advanced. The inner piece of the sheath and Nitinol wire were removed. Gentle injection of dilute contrast confirmed intravascular positioning. DSA was performed, with the fistula noted to be patent, however there was mild intimal hyperplasia resulting in mild stenosis within the stent complex. Venography was then performed centrally, demonstrating patency of the axillary vein, subclavian vein, and superior vena cava. A ___ wire was advanced through the micropuncture sheath. Exchange was made for a short 7 ___ sheath which was placed over the wire. A 9 mm x 4 cm Conquest balloon was advanced over the wire. Angioplasty was performed of the proximal aspect of the stent complex. The balloon was left inflated and DSA was performed, demonstrating patency of the arterial inflow, without stenosis. Subsequently, balloon angioplasty was performed progressively distally throughout the stent complex with the 9 mm balloon, in overlapping fashion to include the entire stent construct. Completion DSA in antegrade fashion through the 7 ___ sheath demonstrated near complete resolution of the initially noted intimal hyperplasia with no residual stenosis. The sheath was then removed and gentle manual pressure was held to assure hemostasis. The access site was bandaged in sterile fashion. Clinical examination revealed a satisfactory thrill along the length of the fistula. There were no immediate complications. FINDINGS: 1. Patent brachiocephalic fistula with stent complex near the arterial anastomosis which had mild in stent stenosis due to intimal hyperplasia. 2. Successful balloon angioplasty of the stent construct, with resolution of in stent stenosis. 3. Satisfactory appearance of the arterial anastomosis. No central venous stenosis. IMPRESSION: Successful balloon angioplasty of mild in stent stenosis due to intimal hyperplasia, with no residual stenosis seen post angioplasty. RECOMMENDATION(S): The fistula may be used for dialysis immediately. Case was discussed with Dr. ___ by telephone on ___ at 10:55 AM. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ICH, Transfer Diagnosed with Anesthesia of skin temperature: 98.4 heartrate: 89.0 resprate: 18.0 o2sat: 98.0 sbp: 120.0 dbp: 70.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, You were admitted to the ___ after you had right-sided weakness which was due to a bleed, or hemorrhage, in a small part of your brain. This was probably caused by your blood pressure being uncontrolled while you were on a blood thinning medication. Your symptoms had dramatically improved by the time you were discharged. We worked closely with our nephrology team to come up with a good plan to manage your blood pressure without it going too high or too low. After you leave the hospital, it is very important to continue to monitor your blood pressure closely and to work with your primary care doctor to manage your medications. Because you have hypertension, high cholesterol, and a-fib, you are risk to have more strokes in the future. We adjusted your medications as below to minimize the risk of this happening. You are being discharged on a new blood pressure medication, Amlodipine, which you should take every day. You should wait until after dialysis ___ hours) to take it on the days you have dialysis. We are also restarting your Coumadin, a blood thinning medication to help prevent future strokes. You should continue to take your anti-cholesterol medication, atorvastatin, every day. Finally, you were diagnosed with a urinary tract infection prior to discharge and were prescribed an antibiotic, Bactrim, which you should take for a total of 7 days (starting ___. You should take it after dialysis on the days when you have dialysis. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: allopurinol / Percocet / doxycycline / Zestril / amoxicillin Attending: ___ Chief Complaint: Fever, chills Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ PKD s/p LRRT ___ on tacro/MMF/prednisone, prostate cancer, htn/hl, presents from ___ with fever/chills, and shakes. Pt is from ___, and get his care at ___ normally. Pt is in town to visit this grandson. Of note, pt was admitted to ___ in ___ for e coli urosepsis. He completex ___ x 3 weeks - he did not remember the name of the ___. On morning of admission (___), pt reports onset of fever, chills and rigor. He also noted urinary frequency w/o dysuria or hematuria. He had clear emesis x 1. He otherwise denies cough, diarrhea, new skin rash, or abdominal pain. He presented initially to ___. He was noted to have T 100.8 HR 99, BP 132/84 RR 18 O2 97%RA. At ___, lactate was 2.2, WBC 3.8. UA was +leuks, neg nitrite. Tbili 1.36 Per record, UCx and blood cx was drawn. CTU reportedly showed non-obstructing stone, transplanted kidney did not show hydronephrosis. Pt received vanc 1g, zosyn 2.25mg prior to transfer to ___. In the ___ ED, vitals were: 100.7 ___ 12 94% RA Labs were notable for: Cr 2.5 (baseline unknown), WBC 2.4 1 10% bands, Hgb 12.3, lactate 1.3 Patient was given: ___ 00:29 IVF 1000 mL NS 1000 mL Transplanted kidney ultrasound: Normal on prelim. On the floor, pt reports feeling better. Though he reports that he had loose stool x 1 since being in the hospital - he himself attributed it to ___. On arrival to floor, nursing staff received report that BCx grew GNB ___. Past Medical History: -Recent hospitalization for e. coli sepsis ___ UTI (___) -PKD s/p LRRT ___: on immunosuppression. Baseline Cr 1.5-2.1 -HTN -HLD -GERD -Gout -Pre-diabetes Social History: ___ Family History: Daughters both with ADPKD Physical Exam: ADMISSION VS: 100.0 89 104/56 15 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, no suprapubic tenderess bowel sounds present, no organomegaly, no rebound or guarding Back: no CVA tenderness. 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: VS: 97.4, 122/66, 79, 18, 95% on RA I/O: ___, x2BM General: NAD HEENT: Sclera anicteric, EOMI, PERRL, MMM, OP clear Neck: Supple, no LAD CV: RRR, (+) S1 + S2, no murmurs/rubs/gallops Lungs: CTAB b/l, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, no suprapubic tenderess (+)BS, (+) tip of spleen detected below coastal margin, no rebound or guarding BACK: no CVA tenderness. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3 Pertinent Results: ADMISSION: ___ 11:55PM WBC-2.4* RBC-4.19* HGB-12.3* HCT-36.5* MCV-87 MCH-29.4 MCHC-33.7 RDW-14.0 RDWSD-44.1 ___ 11:55PM NEUTS-60 BANDS-10* LYMPHS-11* MONOS-3* EOS-1 BASOS-0 ATYPS-1* METAS-4* MYELOS-10* AbsNeut-1.68 AbsLymp-0.29* AbsMono-0.07* AbsEos-0.02* AbsBaso-0.00* ___ 11:55PM GLUCOSE-105* UREA N-32* CREAT-2.5* SODIUM-135 POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-14 ___ 12:14AM LACTATE-1.3 ___ 06:28AM WBC-1.7* RBC-3.81* HGB-11.2* HCT-33.7* MCV-89 MCH-29.4 MCHC-33.2 RDW-14.0 RDWSD-45.1 ___ 06:28AM tacroFK-8.7 ___ 06:28AM CALCIUM-8.0* PHOSPHATE-2.3* MAGNESIUM-1.1* ___ 06:28AM HAPTOGLOB-133 ___ 06:28AM GLUCOSE-130* UREA N-34* CREAT-2.5* SODIUM-135 POTASSIUM-4.6 CHLORIDE-111* TOTAL CO2-18* ANION GAP-11 ___ 06:28AM ALT(SGPT)-20 AST(SGOT)-23 LD(LDH)-207 ALK PHOS-64 TOT BILI-1.0 ___ 06:28AM LIPASE-18 ___ 08:30PM ___ INTERIM: ___ 06:10AM BLOOD Glucose-112* UreaN-25* Creat-2.0* Na-135 K-4.7 Cl-107 HCO3-19* AnGap-14 ___ 02:50AM BLOOD ALT-14 AST-18 AlkPhos-60 TotBili-0.8 DISCHARGE: ___ 05:40AM BLOOD WBC-5.6# RBC-3.48* Hgb-9.9* Hct-31.0* MCV-89 MCH-28.4 MCHC-31.9* RDW-14.4 RDWSD-46.5* Plt ___ ___ 05:40AM BLOOD ___ PTT-26.7 ___ ___ 05:40AM BLOOD Glucose-146* UreaN-21* Creat-1.5* Na-138 K-5.1 Cl-103 HCO3-27 AnGap-13 ___ 05:45AM BLOOD ALT-17 AST-19 AlkPhos-161* TotBili-0.8 ___ 05:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.6 ___ 05:40AM BLOOD tacroFK-6.7 IMAGING: -Renal transplant U/S (___): IMPRESSION: Normal renal transplant ultrasound. -Abd U/S (___): IMPRESSION: 1. The patient is status post cholecystectomy. 2. Splenomegaly. 3. No sonographic evidence of abscess or other intraabdominal infectious source. -CXR (___): IMPRESSION: There no prior chest radiographs available for review. Lungs clear. Heart size normal. No pleural abnormality. -MRI abdomen w/o contrast (___): IMPRESSION: 1. Innumerable cysts in the liver and left kidney, as well as several small cysts in the pancreas, in keeping with the history of polycystic kidney disease. Many of them have hemorrhagic or proteinaceous material, though none have overtly concerning features or evidence of an obvious infection on this limited noncontrast exam. 2. Status post right nephrectomy. No abnormality in the surgical bed. 3. Splenomegaly. -MRI Head w/o contrast (___): IMPRESSION: 1. No evidence for parenchymal abnormalities on noncontrast MRI. No extra-axial collection. No evidence for meningitis on FLAIR images; however, CSF studies would be more sensitive for meningitis. 2. Paranasal sinus abnormalities and trace fluid in bilateral mastoid air cells may be secondary to prolonged supine positioning in the inpatient setting. However, please correlate clinically whether there may be associated infectious symptoms. -CXR (___): IMPRESSION: There is a new left-sided PICC line with tip in the mid SVC. There is no pneumothorax. The lungs are clear. -TTE (___): IMPRESSION: Normal biventricular cavity size and systolic function. No 2D echocardiographic evidence of endocarditis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tacrolimus 4 mg PO QAM 2. Tacrolimus 3 mg PO QPM 3. Mycophenolate Mofetil 750 mg PO BID 4. PredniSONE 5 mg PO DAILY 5. NexIUM (esomeprazole magnesium) 40 mg oral BID 6. Losartan Potassium 50 mg PO QHS 7. Metoprolol Tartrate 12.5 mg PO BID 8. Colchicine 0.6 mg PO DAILY 9. Januvia (sitaGLIPtin) 25 mg oral DAILY 10. ezetimibe-simvastatin ___ mg oral DAILY 11. Tamsulosin 0.4 mg PO QHS 12. Cinacalcet 30 mg PO DAILY 13. Aspirin 81 mg PO DAILY 14. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 15. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___) 16. Zolpidem Tartrate 10 mg PO QHS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Colchicine 0.6 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO BID 4. PredniSONE 5 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Refills:*0 7. CeftriaXONE 2 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV q24h Disp #*23 Intravenous Bag Refills:*0 8. Zolpidem Tartrate 10 mg PO QHS 9. ezetimibe-simvastatin ___ mg oral DAILY 10. Januvia (sitaGLIPtin) 25 mg oral DAILY 11. Losartan Potassium 50 mg PO QHS 12. NexIUM (esomeprazole magnesium) 40 mg oral BID 13. Mycophenolate Mofetil 500 mg PO BID RX *mycophenolate mofetil 500 mg one tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 14. Tacrolimus 1.5 mg PO Q12H RX *tacrolimus 1 mg one capsule(s) by mouth daily Disp #*60 Capsule Refills:*0 RX *tacrolimus 0.5 mg one capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Sepsis Gram-negative rod bacteremia Acute kidney injury Neutropenia SECONDARY DIAGNOSES: Autosomal dominant polycystic kidney disease Status-post kidney transplant (___) Hypertension Hyperlipidemia Prostate cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with 49cm left arm DL power PICC. ___ ___ // 49cm left arm DL power PICC. ___ ___ Contact name: ___: ___ TECHNIQUE: Chest single view COMPARISON: ___. IMPRESSION: There is a new left-sided PICC line with tip in the mid SVC. There is no pneumothorax. The lungs are clear. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: History: ___ with report of kidney stone, ? normal flow and appearance of transplanted kidney // ? abnormality in transplanted kidney TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: CT from ___ FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.67 to 0.74, within the normal range. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 60 cm/second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Normal renal transplant ultrasound. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old man with hx. of renal transplant in ___ presenting with sepsis with ___ blood culture bottles positive for GNRs. // Please evaluate for intraabdominal process. Please evaluate for acute cholecystitis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT urogram dated ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. Innumerable anechoic cysts are seen throughout the liver parenchyma. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: The CBD measures 6 mm proximally and 8 mm more distally, most likely related to prior cholecystectomy. No definite mass or stone is identified. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: Imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: The spleen is enlarged measuring 16 cm. A small adjacent splenule is noted measuring 1.3 x 1.5 x 1.3 cm. KIDNEYS: The right kidney is surgically absent. The left kidney measures 22 cm. Innumerable cysts are seen within the left kidney, consistent with the patient's diagnosis of polycystic kidney disease. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. The patient is status post cholecystectomy. 2. Splenomegaly. 3. No sonographic evidence of abscess or other intraabdominal infectious source. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with septic shock, unclear source // Eval for cardiopulmonary process Eval for cardiopulmonary process IMPRESSION: There no prior chest radiographs available for review. Lungs clear. Heart size normal. No pleural abnormality. Radiology Report EXAMINATION: MRI of the Abdomen INDICATION: History of polycystic kidney disease, presenting with gram negative bacteremia of unclear source. Evaluate for liver or kidney infection. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: None, given the patient's acute kidney injury. COMPARISON: Abdominal ultrasound from ___. CT of the abdomen and pelvis from ___. FINDINGS: Lower Thorax: There are small bilateral pleural effusions. Within the limitations of MRI, the lung bases are otherwise clear. The base of the heart is normal in size. There is no pericardial effusion. Liver: The liver is normal in shape and contour without morphologic features of cirrhosis. There are innumerable cysts in the liver, some of which are intrinsically hyperintense on the precontrast T1 weighted images, suggesting proteinaceous or hemorrhagic contents. Within the limitations of this noncontrast exam, none have overtly concerning features. The largest cyst in the right lobe is 39 x 38 mm (15, 21), and has layering proteinaceous debris or hemorrhage. The largest cyst in the left lobe is 45 x 46 mm (15, 22), and is simple. There is no obvious evidence of infection, such as a thickened rim or surrounding parenchyma abnormalities, in any of the cysts. Biliary: There is no intrahepatic biliary duct dilation. The common bile duct measures 7 mm, which is mildly prominent for a patient of this age. It tapers smoothly to the ampulla without evidence of a mass or choledocholithiasis. The gallbladder is not visualized, and presumed to be surgically absent. Pancreas: The pancreatic parenchyma is normal in signal there is no duct dilation or solid mass. A few tiny subcentimeter cysts are noted. Spleen: The spleen is enlarged, measuring 16.6 cm. There are no focal lesions. Adrenal Glands: The bilateral adrenal glands are normal. Kidneys: The right kidney is surgically absent. There is no abnormality in the gallbladder fossa. The left kidney is enlarged, and completely replaced by cysts. No normal parenchyma is identified. The majority of the cysts have some intrinsic hyperintensity on the precontrast T1 weighted images, suggesting proteinaceous or hemorrhagic debris. The debris is layering within many of the cysts. There are no obviously concerning features, though the exam is limited by the lack of intravenous contrast. None are significantly thick rimmed or have the appearance of an infected cyst. Note, the transplanted kidney is not included in the field of view on this abdominal MRI. Gastrointestinal Tract: The stomach and small bowel are normal in course and caliber. There is no evidence of obstruction. The imaged portions of the large bowel are normal. There is no ascites. Lymph Nodes: There is no periportal, retroperitoneal, or mesenteric lymphadenopathy. Vasculature: The abdominal aorta is normal in caliber without evidence of an aneurysm. There is moderate atherosclerotic plaque. Osseous and Soft Tissue Structures: There are no concerning osseous lesions. Mild multilevel degenerative changes are noted throughout the spine. Postsurgical changes are noted in the anterior abdominal wall. There is no evidence of a hernia or fluid collection. The soft tissues are otherwise unremarkable. IMPRESSION: 1. Innumerable cysts in the liver and left kidney, as well as several small cysts in the pancreas, in keeping with the history of polycystic kidney disease. Many of them have hemorrhagic or proteinaceous material, though none have overtly concerning features or evidence of an obvious infection on this limited noncontrast exam. 2. Status post right nephrectomy. No abnormality in the surgical bed. 3. Splenomegaly. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST PORT INDICATION: ___ year old man with persistent gram-negative rod bacteremia and headache concerning for intracranial process. Evaluate for abscess or other intracranial process. TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained. Intravenous contrast was withheld due to poor renal function. COMPARISON: None. FINDINGS: Diffusion weighted and gradient echo images are mildly limited by motion artifact. T2 weighted and FLAIR images were successfully repeated with motion reducing technique. There is no evidence for edema, mass effect, abnormal diffusion, blood products, or other signal abnormalities in the brain parenchyma. FLAIR images demonstrate no signal abnormality in the sulci to suggest meningitis. There is no extra-axial collection. Ventricles, sulci, and basal cisterns are normal in size. Cerebellar tonsils are normally positioned. Major intravascular flow voids are grossly preserved. There is moderate mucosal thickening and trace aerosolized secretions in the left maxillary sinus. There is mucosal thickening in left greater than right ethmoid air cells with complete opacification of the left anterior ethmoid air cell. There is mild mucosal thickening in the right maxillary and left sphenoid sinuses. There is trace fluid in bilateral mastoid air cells. IMPRESSION: 1. No evidence for parenchymal abnormalities on noncontrast MRI. No extra-axial collection. No evidence for meningitis on FLAIR images; however, CSF studies would be more sensitive for meningitis. 2. Paranasal sinus abnormalities and trace fluid in bilateral mastoid air cells may be secondary to prolonged supine positioning in the inpatient setting. However, please correlate clinically whether there may be associated infectious symptoms. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever Diagnosed with Urinary tract infection, site not specified temperature: 100.7 heartrate: 106.0 resprate: 12.0 o2sat: 94.0 sbp: 91.0 dbp: 51.0 level of pain: 1 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ due to an infection in your bloodstream; you received intravenous antibiotics. Your blood was checked daily until it was clear of the infection. You underwent a number of laboratory and imaging studies to determine the source of infection, which were unrevealing. Due to the severity of the infection, a PICC line was placed; you will continue on intravenous ceftriaxone 2gm daily through ___ (a 4-week course); the Infectious Disease doctors at ___ then determine whether you need a longer course of antibiotics or if you can stop at that time. In addition, during your stay, your immunosuppression was monitored closely. You should continue taking tacrolimus 1.5mg twice daily, Cellcept 500mg twice daily, and prednisone 5mg daily. Because you had a decrease in your white blood cell count during your stay, your Bactrim was stopped; you should take Dapsone 1500mg daily for prevention of infection while on chronic steroids. Please follow up with your Transplant doctor to monitor these medications. Thank you for letting us be a part of your care! Your ___ Kidney Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / Sulfa (Sulfonamide Antibiotics) / Nsaids / lisinopril / egg / iodine Attending: ___. Chief Complaint: ___ w/ COPD, T2DM, prior cellulitis presents with 2 weeks of drainage from RLE lesions. Major Surgical or Invasive Procedure: None History of Present Illness: Two weeks prior to admission, Ms. ___ was in her usual state and had noticed wide-based blisters developing on her right lower extremity (RLE). While she was using a washcloth on her right leg, she noted the removal of skin from a blister with immediate drainage of clear fluid. Given her body habitus, she cannot directly visualize her lower extremities. However, she noted continued leakage based on the wetness on her clothes. She believes the leakage rate increased over time, and 4 days prior to admission noted the leakage of milky white fluid from the lesions. That day, she was seen by her PCP who believed the lesions to be venous stasis ulcers. She denies fevers and endorses feeling chilly. On ___ she presented to the ___ ED due to concern about possible cellulitis. She denies interaction with cats or dogs, any recent trauma, gardening, and exposure to freshwater. #Review of Systems: (+) per HPI and chronic intermittent headache, vision changes, dyspnea on exertion, periumbilical abdominal pain, constipation. (-) fever, night sweats, sore throat, cough, shortness of breath at rest, chest pain, nausea, vomiting, diarrhea, hematochezia, dysuria. Past Medical History: SLEEP APNEA, nonadherent to BIPAP at home due to nosebleeds Asthma with chronic obstructive pulmonary disease (COPD), on 3L NC at home DM (diabetes mellitus), type 2 with neurological complications ANEMIA Hypertension, essential DEPRESSIVE DISORDER ANXIETY STATES, UNSPEC VITAMIN D DEFIC, UNSPEC CROHN'S DISEASE Fibromyalgia Cellulitis ___ years ago, hospitalized at ___ for rx) MRSA ___ (documented at ___) Social History: ___ Family History: -Mother: ___, leukemia -Father: ___, cancer not specified -Brother: ___, lung cancer with metastases -Sister: ___ cancer -Niece: lung cancer Physical Exam: ================== EXAM ON ADMISSION ================== Vitals- T 98.3 HR 90 BP 166/51 RR 18 SaO2 95%(3L) General: Woman with large body habitus laying in bed. CV: RRR, mild systolic murmur Lungs: CTAB Abdomen: Bowel sounds present, protuberant, nontender GU: no foley Ext: Pitting edema throughout lower extremities up to the knee. RLE: 3 1x1 cm contiguous areas of apparent granulation tissue w/ serous drainage w/ a single 0.5x0.5 cm area of similar appearance just proximal. These areas are raised compared to surrounding skin and tender to palpation. Just medial to these is a raised, tense lesion that appears as though it could be a precursor lesion. Surrounding all of these is mild induration, erythema, and warmth. In addition, there is deeper pigmentation of the distal extremity along with an area of hypopigmentation on the medial heel. LLE: Dry and scaly, with a few isolated areas of deeper pigmentation. Neuro: AOx3, responsive to questions and commands, moves all 4 extremities at will. Diminished sensation to light touch on plantar aspects bilaterally. Skin: see above ================== EXAM ON DISCHARGE ================== Vitals- Tmax 98.7, Tcurr 98.5, HR 80, BP 158/62, RR 20, SaO2 96%(BiPAP) General: Woman with large body habitus sitting in her power chair. CV: RRR, mild systolic murmur Lungs: CTAB Abdomen: Bowel sounds present, protuberant, nontender GU: no foley Ext: Pitting edema throughout lower extremities up to the knee. RLE: Under dressing, there are 3 1x1 cm contiguous areas of apparent granulation tissue (was purulent yesterday) w/ a single 0.5x0.5 cm area of similar appearance just proximal. These areas are tender to palpation. Interval decrease in the surrounding induration, erythema, and warmth. In addition, there is deeper pigmentation of the distal extremity along with an area of hypopigmentation on the medial heel that is erythematous. LLE: Dry and scaly, with a few isolated areas of deeper pigmentation. Neuro: AOx3, responsive to questions and commands, moves all 4 extremities at will. Diminished sensation to light touch on plantar aspects bilaterally. Skin: see above Pertinent Results: LABS AT ADMISSION: ___ 01:50PM BLOOD WBC-9.4 RBC-4.02 Hgb-10.9* Hct-36.9 MCV-92 MCH-27.1 MCHC-29.5* RDW-14.2 RDWSD-47.8* Plt ___ ___ 01:50PM BLOOD Neuts-71.1* Lymphs-17.0* Monos-6.8 Eos-4.3 Baso-0.4 Im ___ AbsNeut-6.69* AbsLymp-1.60 AbsMono-0.64 AbsEos-0.40 AbsBaso-0.04 ___ 01:50PM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-142 K-4.7 Cl-103 HCO3-32 AnGap-12 ___ 01:50PM BLOOD Calcium-10.6* Phos-3.6 Mg-1.8 ___ 06:30AM BLOOD CRP-10.2* ___ 02:58PM BLOOD Lactate-1.4 IMAGING: X-ray right tib/fib ___: No radiographic evidence for osteomyelitis. Diffuse soft tissue swelling. Right lower extremity ultrasound ___: Extremely limited examination secondary to patient's known right lower extremity cellulitis. No evidence of deep venous thrombosis in the right lower extremity veins. LABS PRIOR TO DISCHARGE: ___ 07:00AM BLOOD WBC-9.7 RBC-3.98 Hgb-10.7* Hct-37.0 MCV-93 MCH-26.9 MCHC-28.9* RDW-14.2 RDWSD-48.2* Plt ___ ___ 07:00AM BLOOD Glucose-178* UreaN-11 Creat-0.6 Na-140 K-4.4 Cl-100 HCO3-32 AnGap-12 ___ 06:30AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.6 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral BID 2. Montelukast 10 mg PO DAILY 3. Morphine Sulfate ___ 30 mg PO Q8H:PRN pain 4. NPH 33 Units Breakfast NPH 36 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Potassium Chloride 20 mEq PO BID 6. TraMADOL (Ultram) 50 mg PO TID:PRN pain 7. Baclofen 20 mg PO TID 8. HydrOXYzine 10 mg PO DAILY:PRN very itchy 9. Fluticasone Propionate 110mcg 4 PUFF IH BID 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 13. Aspirin 81 mg PO DAILY 14. Ascorbic Acid ___ mg PO DAILY Discharge Medications: The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral BID 2. Montelukast 10 mg PO DAILY 3. Morphine Sulfate ___ 30 mg PO Q8H:PRN pain 4. NPH 33 Units Breakfast NPH 36 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Potassium Chloride 20 mEq PO BID 6. TraMADOL (Ultram) 50 mg PO TID:PRN pain 7. Baclofen 20 mg PO TID 8. HydrOXYzine 10 mg PO DAILY:PRN very itchy 9. Fluticasone Propionate 110mcg 4 PUFF IH BID 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 13. Aspirin 81 mg PO DAILY 14. Ascorbic Acid ___ mg PO DAILY 15. Clindamycin 450 mg PO Q6H Until ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Cellulitis Venous stasis dermatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with chronic right lower extremity wounds with purulent drainage. TECHNIQUE: Two views of the right tibia and fibula COMPARISON: None. FINDINGS: No acute fracture or focal lytic or sclerotic osseous abnormality is identified. No cortical destruction or periosteal new bone formation is visualized. Imaged aspect of the right knee and right ankle demonstrate no gross dislocation. There is diffuse soft tissue swelling without radiopaque foreign body or subcutaneous gas. IMPRESSION: No radiographic evidence for osteomyelitis. Diffuse soft tissue swelling. Radiology Report EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) RIGHT INDICATION: ___ year old woman with RLE cellulitis // Evaluate for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: Lower extremity DVT examination from ___. FINDINGS: Extremely limited examination secondary to patient's known right lower extremity cellulitis. There is normal compressibility, flow and augmentation of the rightcommon 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. IMPRESSION: Extremely limited examination secondary to patient's known right lower extremity cellulitis. No evidence of deep venous thrombosis in the rightlower extremity veins. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Wound eval Diagnosed with Cellulitis of right lower limb temperature: 97.6 heartrate: 95.0 resprate: 18.0 o2sat: 98.0 sbp: 151.0 dbp: 61.0 level of pain: 5 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at the ___. You were admitted for treatment of cellulitis. You were treated with antibiotics and with elevation of your right leg to help drain the infected fluids. We also had our wound care nurses place ___ dressing over the blisters. The cellulitis improved so we felt you were ready to continue treatment from home. However, the cellulitis infection is not yet cured, please continue to take the antibiotic called Clindamycin until ___. We also will have a visiting nurse assist with changing your leg dressing. We'd also like you to follow-up with your PCP. 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: referral for abnormal labs Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx of chronic anemia (Hct 30) who p/w fatigue and palpitations x 3 months. She has also been having nonradiating, exertional chest pain, ___ in intensity. She went to outpt provider and was found to have Hct 18 and referred here for further evaluation. She denies hemoptysis, hematemesis, hematochezia, melena. She was guiac negative in the ED. She does however endorse heavy periods, sometimes requiring ___ pads per day. She denies sob, f/c, night sweats, rash, abd pain. In the ED, her initial VS 98 80 122/52 15 100%. Labs remarkable for H/H 4.9/17.5, RDW 21.9, MCV 60, Plat 302, INR 0.8, Cre 3.4 (baseline 1.2), Fe 15 and ferritin 4.1. EKG demonstrates NSR with no st-t wave abnormality. CXR demonstrates cardiomegaly. UA was not obtained. She was typed and screened. PIVs were placed. She was transfuse 2U PRBCs. She was guiac negative. On arrival to the MICU, her VS were afebrile 74 150/83 200% RA. REVIEW OF SYSTEMS: Otherwise negative in detail Past Medical History: Chronic anemia Chronic kidney disease Social History: ___ Family History: No family hx of anemia or renal failure Physical Exam: Admission exam: Vitals: 74 150/83 100% RA. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, otherwise grossly nonfocal Discharge exam: AVSS anicteric rr, nl rate (occasional PVC) CTAB abdomen soft, nontender, nondistended Pertinent Results: ___ 08:27PM BLOOD WBC-5.1 RBC-2.87* Hgb-4.9* Hct-17.5* MCV-61* MCH-17.2* MCHC-28.2* RDW-21.9* Plt ___ ___ 02:18AM BLOOD WBC-6.8 RBC-3.36* Hgb-6.6*# Hct-23.1*# MCV-69*# MCH-19.7*# MCHC-28.7* RDW-24.5* Plt ___ ___ 06:25AM BLOOD WBC-4.6 RBC-3.48* Hgb-7.4* Hct-24.2* MCV-70* MCH-21.4* MCHC-30.8* RDW-24.9* Plt ___ ___ 08:27PM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+ Macrocy-1+ Microcy-3+ Polychr-OCCASIONAL Ovalocy-2+ Schisto-1+ Tear Dr-1+ Envelop-OCCASIONAL Ellipto-1+ ___ 02:18AM BLOOD ___ PTT-30.9 ___ ___ 02:18AM BLOOD Ret Man-.9 ___ 08:27PM BLOOD Glucose-128* UreaN-50* Creat-3.4*# Na-137 K-4.8 Cl-104 HCO3-23 AnGap-15 ___ 06:25AM BLOOD Glucose-80 UreaN-46* Creat-3.4* Na-139 K-4.1 Cl-108 HCO3-23 AnGap-12 ___ 08:27PM BLOOD ALT-25 AST-20 LD(LDH)-208 AlkPhos-56 TotBili-0.1 ___ 06:25AM BLOOD Calcium-8.4 Phos-4.6* Mg-1.9 ___ 11:00AM BLOOD Iron-15* ___ 02:18AM BLOOD VitB12-553 Folate-11.6 ___ 08:27PM BLOOD Hapto-72 ___ 11:00AM BLOOD calTIBC-386 Ferritn-4.1* TRF-297 ___ 02:18AM BLOOD %HbA1c-5.2 eAG-103 ___ 11:00AM BLOOD TSH-3.0 ___ 11:00AM BLOOD Free T4-1.0 ___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 12:00AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 12:03AM URINE Hours-RANDOM Creat-32 Na-62 K-23 Cl-57 TotProt-91 Prot/Cr-2.8* Renal ultrasound: 1. Echogenic kidneys, compatible with chronic renal disease. 2. 1.2 cm right upper pole renal cyst contains a single thin septation. No dedicated followp necessary. 3. No splenomegaly. Medications on Admission: ___ Herbs Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Ferrous Gluconate 325 mg PO TID RX *ferrous gluconate 325 mg (36 mg iron) 1 tablet(s) by mouth three times per day Disp #*90 Tablet Refills:*3 3. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice per day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Chronic kidney disease iron deficiency anemia symptomatic 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: Severe anemia and chest pain. Assess for acute intrathoracic process. FINDINGS: Portable AP upright chest radiograph was obtained. The heart is mildly enlarged and there is mild pulmonary edema. No large effusions are seen and there is no pneumothorax. Mediastinal contour is normal. There is mild hilar congestion. Bony structures are intact. IMPRESSION: Cardiomegaly with mild edema. Radiology Report HISTORY: Renal insufficiency. TECHNIQUE: Ultrasonography of the kidneys and bladder. COMPARISON: None available. FINDINGS: The right and left kidneys measure 8.6 and 8.5 cm, respectively, and are echogenic, denoting chronic kidney disease. Within the upper pole of the right kidney is a 1.1 x 1.2 x 0.9 cm cyst containing a single thin septation. A 9 x 8 x 9 mm simple cyst resides within the lower pole of the right kidney. There is no stone or hydronephrosis. The bladder appears normal. The spleen is not enlarged, measuring 9.9 cm. IMPRESSION: 1. Echogenic kidneys, compatible with chronic renal disease. 2. 1.2 cm right upper pole renal cyst contains a single thin septation. No dedicated followp necessary. 3. No splenomegaly. Gender: F Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: PALLOR/ANEMIA Diagnosed with ANEMIA NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 98.0 heartrate: 80.0 resprate: 15.0 o2sat: 100.0 sbp: 122.0 dbp: 52.0 level of pain: 13 level of acuity: 3.0

You were admitted with symptomatic anemia and chronic kidney disease. You were given 2 units of red blood cells with improvement in your kidneys. You were found to be severely iron deficient. You were started on ferrous gluconate (you did not tolerate ferrous sulfate in the past). Do not discontinue this medication unless you discuss with PCP. You were found to have decreased kidney function. You will need to see the kidney doctor as an outpatient for further assessment and management.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ man with h/o Down syndrome who presents with cough for one week and concern for PNA on CXR. Per patients group leader, patient is minimally communicative at baseline, but has had cough for approximately 1 week. He thinks it may have been productive at first, but now appears to be dry. His group leader denies associated symptoms including fever or noticable shortness of breath. No one else in his group home is sick, and patient is without recent hospitalization or abx therapy. After group activities today, he developed a large coughing fit and was incontinent of urine and refused to get up off the floor, prompting the trip to the ED. Initial VS in the ED: T 99.0, HR 100, BP 105/p, RR 20. Patient triggered for O2 sat of 86% on room air. Initial labs were notable for lactate 3.3, Cr 1.3, BUN 25, and leukocytosis to 12.2 with 95% N. Patient was given 750mg levofloxacin and 1L NS prior to being admitted to medicine for furhter management. VS prior to transfer: Temperature 99.4 °F (37.4 °C). Pulse 77. Respiratory Rate 22. Blood Pressure 105/. O2 Saturation 98. O2 Flow ___ np. Pain Level 0. On the floor, patient appears well. He intermittently nods yes or no to questions, but appears very shy. He denies pain at this time. Past Medical History: None Social History: ___ Family History: No significant family history of recurrent pulmonary infections. Physical Exam: Physical Exam on admission: Vitals: T: 98.2 BP: 96/70 P:72 R:18 18 O2:96%RA General: Alert, well appearing middle aged man with featurs of Down syndrome. Interacts with examiner, but only intermittenty nods yes or no. Unable to assess orientation. HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Nonlabored on RA. Crackles at bases bilaterally, R>L. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Moves all extremities, symetric face. Tongue midline. Pertinent Results: ___ 06:05PM BLOOD WBC-12.2*# RBC-4.34* Hgb-14.3 Hct-42.3 MCV-97 MCH-33.0* MCHC-33.9 RDW-13.4 Plt ___ ___ 06:00AM BLOOD WBC-24.2*# RBC-3.69* Hgb-12.0* Hct-35.4* MCV-96 MCH-32.4* MCHC-33.8 RDW-13.9 Plt ___ ___ 06:00AM BLOOD WBC-21.6* RBC-3.71* Hgb-12.2* Hct-36.6* MCV-99* MCH-32.8* MCHC-33.2 RDW-13.5 Plt ___ ___ 06:05PM BLOOD Neuts-94.7* Lymphs-4.0* Monos-0.8* Eos-0.1 Baso-0.5 ___ 06:00AM BLOOD Neuts-93.9* Lymphs-4.2* Monos-1.8* Eos-0 Baso-0.1 ___ 06:05PM BLOOD Glucose-114* UreaN-25* Creat-1.3* Na-139 K-4.1 Cl-101 HCO3-27 AnGap-15 ___ 06:00AM BLOOD Glucose-93 UreaN-24* Creat-1.2 Na-138 K-4.2 Cl-103 HCO3-27 AnGap-12 ___ 06:00AM BLOOD Glucose-106* UreaN-20 Creat-1.4* Na-137 K-4.2 Cl-104 HCO3-28 AnGap-9 ___ 06:05PM BLOOD Calcium-8.8 Phos-1.7* Mg-1.9 ___ 06:00AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0 ___ 06:07PM BLOOD Lactate-3.3* ___ 08:26AM BLOOD Lactate-1.4 HISTORY: ___ man with pneumonia. Question changes. COMPARISON: ___. FINDINGS: Lung volumes are low, somewhat accentuating pulmonary vascular markings. Bibasilar opacities present in the prior radiograph are still apparent, although substantially less so. The upper lungs appear clear. Cardiomediastinal silhouette and hilar contours appear normal. IMPRESSION: Resolving opacities in the lower lung. The study and the report were reviewed by the staff radiologist. Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Hypoxia, assess for pneumonia. FINDINGS: Single AP upright portable chest radiograph was obtained demonstrating lower lung airspace opacities which are concerning for pneumonia. Small effusions would be difficult to exclude. Heart size is difficult to assess but appears grossly unchanged. No pneumothorax is seen. Bony structure is intact. IMPRESSION: Opacities in the lower lungs concerning for pneumonia. Radiology Report HISTORY: ___ man with pneumonia. Question changes. COMPARISON: ___. FINDINGS: Lung volumes are low, somewhat accentuating pulmonary vascular markings. Bibasilar opacities present in the prior radiograph are still apparent, although substantially less so. The upper lungs appear clear. Cardiomediastinal silhouette and hilar contours appear normal. IMPRESSION: Resolving opacities in the lower lung. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: COUGH Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 99.0 heartrate: 100.0 resprate: 20.0 o2sat: 86.0 sbp: nan dbp: nan level of pain: 13 level of acuity: 1.0

Mr. ___, You were admitted to the hospital for pneumona. You were started on antibiotics for the infection which improved your symptoms. You were given IV fluids and oxygen to help you breathe. We were able to ween you off of oxygen. We are sending you home on antibiotics for an additional 5 days. -Levofloxacin 750 mg Daily for 5 more days.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Cc: arm pain, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ with history of psychiatric illness (?ADHD, anxiety, bipolar disorder) recently admitted and discharged from ___ who re-presents with disorientation. She reported to the emergency department that she lost her medications. She complains that her backpack was stolen and she is also concerned her charger was stolen when she was in the emergency department. In terms of her breathing, she reports a longstanding history of asthma and COPD. She does not report her breathing has gotten significantly worse recently. She does have both a Combivent and pro-air inhaler which she reports she uses. She reports she uses the albuterol inhaler every 4hours. She does not report shortness of breath currently. She continues to smoke ___ packs/day. She complains of ongoing right arm pain due to her fracture. In the emergency department, given concern for COPD the patient was given Solumedrol 125mg IV and Azithromcyin. In addition to albuterol nebs and admitted to the floor for ongoing management. She is initially was cooperative and spoke with me. She then walked off of the floor and light a cigarrete in the elevator. A code purple was called. The patient was placed in a wheelchair and went back to her room. She yelled at security and attempted to kick and punch the security guard. She was given 5mg IM Haldol and 2mg IM Ativan and continued to ask for her personal belongings. She also asked to speak with psychiatry because she is here for a psychiatric reason. She ultimately was redirectable and remained in her room. ROS: Could not be obtained due to patient cooperation. Past Medical History: ___ Fractured R arm prior to ___ Admission Asthma and ?COPD PAST PSYCHIATRIC HISTORY: Per psychiatry consult note. "- Sx: ADHD and "fucking anxiety"; adds "I have 101 diagnoses under the fucking sun;" Prior hospitalizations for Bipolar Disorder, but denies this diagnosis. - Hospitalizations: "Plenty" - Most recently in ___ (couple months ago); reports she was hospitalized for Bipolar Disorder (but denies this diagnosis) - Current treaters and treatment: Dr. ___ saw 1 month ago); in ___ - Medication and ECT trials: Responds yes to trials of all medications I list, including: Lithium, Risperidone, Zyprexa, "Antidepressants." - Self-injury/Suicide attempts: Denies - Harm to others: Current HI toward multiple people. - Access to weapons: Responds "I wish"" Social History: Per OMR: SUBSTANCE ABUSE HISTORY: - EtOH: "Once in great while" - Illicits: Denies - Tobacco: 1- 2 packs/day SOCIAL HISTORY: ___ Family History: refuses to answer Physical Exam: Vitals: T: 98.7 BP: 115/77 P:111 R:20 O2:96RA Disheveled female laying in bed, speaking in full sentences HEENT: MMM Lungs: Faint crackles in all lung fields, no wheezes or ronchi ___: RRR S1 S2 Present Abdomen: Soft, NT, ND, no rebound or guarding Ext: No edema, some skin excoriations Psych: Tangential, disorganized. Repeats belief that Kid ___ stole something from her. Neuro: Moving all extremities. Good Grip strength in right and left hands. Limited ROM of right shoulder due to pain. Pertinent Results: ___ 08:37PM URINE HOURS-RANDOM ___ 08:37PM URINE UCG-NEGATIVE ___ 08:37PM URINE UHOLD-HOLD ___ 08:37PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 08:37PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:37PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG ___ 08:37PM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE EPI-1 ___ 12:15AM BLOOD WBC-8.1 RBC-3.91 Hgb-11.1* Hct-34.7 MCV-89 MCH-28.4 MCHC-32.0 RDW-13.6 RDWSD-44.3 Plt ___ ___ 06:45AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-142 K-3.8 Cl-109* HCO3-25 AnGap-12 ___ 12:15AM BLOOD ALT-17 AST-21 AlkPhos-111* TotBili-0.2 CXR: ___ IMPRESSION: 1. Bilateral streaky and patchy opacities likely represent atelectasis, but in the appropriate clinical setting, patchy retrocardiac opacity could represent very early pneumonia. 2. Compression deformity of L1 is age-indeterminate. Right arm ___ FINDINGS: Comminuted fracture of the proximal right humerus is re- demonstrated with possible slight increase in displacement, and with evidence of early callus formation. The space between the humeral head and the right acromion appears somewhat widened which may be due to underlying joint effusion. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/wheezing 2. Amphetamine-Dextroamphetamine 30 mg PO DAILY 3. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID:PRN worsening shortness of breath/wheezing 4. TraZODone 50-100 mg PO QHS:PRN insomnia 5. ARIPiprazole 15 mg PO DAILY 6. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN Pain - Severe 7. ClonazePAM 1 mg PO TID:PRN worsening anxiety 8. ClonazePAM 0.5 mg PO TID:PRN worsening anxiety Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate RX *ibuprofen 800 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. ARIPiprazole 20 mg PO DAILY RX *aripiprazole [Abilify] 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/wheezing 6. ClonazePAM 1 mg PO TID:PRN worsening anxiety 7. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID:PRN worsening shortness of breath/wheezing 8. TraZODone 50-100 mg PO QHS:PRN insomnia 9. HELD- Amphetamine-Dextroamphetamine 30 mg PO DAILY This medication was held. Do not restart Amphetamine-Dextroamphetamine until advised by your psychiatrist 10. HELD- ClonazePAM 0.5 mg PO TID:PRN worsening anxiety This medication was held. Do not restart ClonazePAM until advised by your psychiatrist 11. HELD- ClonazePAM 0.5 mg PO TID:PRN worsening anxiety This medication was held. Do not restart ClonazePAM until advised by your psychiatrist Discharge Disposition: Home Discharge Diagnosis: Schizoaffective disorder COPD without acute exacerbation R humerus fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with hx R humeral fracture // Eval for interval healing TECHNIQUE: Three views of the right shoulder COMPARISON: ___ FINDINGS: Comminuted fracture of the proximal right humerus is re- demonstrated with possible slight increase in displacement, and with evidence of early callus formation. The space between the humeral head and the right acromion appears somewhat widened which may be due to underlying joint effusion. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with productive cough (would cancel the prior pa/ lateral one but not available as option) // r/o pneumonia COMPARISON: CTA chest and chest radiographs ___ FINDINGS: AP upright and lateral views of the chest provided. There are streaky bibasilar opacities and patchy retrocardiac opacity. There is mild pulmonary vascular congestion and a trace left pleural effusion. There is no pneumothorax. The cardiomediastinal silhouette is normal. Compression deformity of T11 appears similar to ___. Compression deformity of L1 is age-indeterminate. No free air below the right hemidiaphragm is seen. Surgical clips are again seen in the right upper quadrant. IMPRESSION: 1. Bilateral streaky and patchy opacities likely represent atelectasis, but in the appropriate clinical setting, patchy retrocardiac opacity could represent very early pneumonia. 2. Compression deformity of L1 is age-indeterminate. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, SI Diagnosed with Schizoaffective disorder, unspecified, Encounter for issue of repeat prescription temperature: 98.6 heartrate: 100.0 resprate: 18.0 o2sat: 100.0 sbp: 120.0 dbp: 80.0 level of pain: 10 level of acuity: 3.0

You were admitted to the medical service with concerns for a COPD exacerbation. Your oxygen levels were checked and remained normal. You had no evidence of pneumonia or COPD exacerbation. You should continue to use your inhalers and quit smoking. You had an X-ray of your right arm which is known to be broken. You should remain non-weight bearing and start OT and pendulum swings. You will need to follow up with ortho-trauma as an outpatient. You were also seen by psychiatry for psychosis. You were started on abilify and got an injection. However, you should continue taking the abilify pills for 2 weeks until the injection kicks in.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Naprosyn / Lithium / Cephalexin / Neurontin Attending: ___. Chief Complaint: Nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ F w/ hx BRCA mutation, endometrial ca s/p TAH/ chemo/radiation, large bowel obstruction, radiation enteritis p/w acute onset b/l lower abd pain and nausea/ emesis starting at 1700 last night. She has been in usual state of health when she developed crampy abdominal pain followed by nausea and 20+ episodes of bilious vomiting. Reports feeling constipated with ___ episodes of small BRBPR. (She reports inserting her finger into her rectum to try to relieve the constipation but there was only blood.) Had soft and firm stool today w/ bright red blood. Reports subjective fevers and chills, no CP/SOB/vaginal bleeding. Denies recent illness, no recent travel, strange ingestions, or sick contacts. In the ED, initial vital signs were: T100 ___ 22 100% RA Labs were notable for leukocytosis to 17.5. ALT 82, AST72, AP 145, Hct 49.1. Lactate of 3.0 down to 2.5 with hydration. UA without evidence of infection. Guaiaic was performed which was +, no melena, no impaction noted. Patient was given Ativan, tylenol, zofran 4 mg x 2, dilaudid 1mg and morphine 5 mg iv x 1. Studies performed include ct abd/pelvis which showed no evidence of bowel obstruction, chronic radiation fibrosis of the sigmoid and rectum. Hepatic steatosis. Also had KUB which showed no evidence of obstruction and no free air. Vitals on transfer: 99.1 95 149/94 18 99% RA Upon arrival to the floor, the patient reports ___ sharp left-sided chest pain since this AM. Brought on by respiration, reproducible, non-radiating. No associated SOB/palpitations/diaphoresis. Past Medical History: PAST MEDICAL HISTORY: # Breast cancer # BRCA-1 mutation carrier # Prophylactic bilateral salpingo-oophorectomy # Endometrial cancer -- Stage IIIc serous adenocarcinoma of the uterus -- s/p chemotherapy, radiation # Psychiatric history (per OMR) - pt denies bipolar diagnosis but has been on lithium in the past PAST SURGICAL HISTORY: # Total abdominal hysterectomy # Omentectomy # Pelvic and para-aortic lymphadenectomy # Prophylactic bilateral salpingo-oophorectomy Social History: ___ Family History: # Twin sister -- died of breast cancer at age ___ Multiple family members with breast cancer, BRCA-1 mutation. Physical Exam: Admission Physical Exam: Vitals- 98.8 102/65 74 18 97 RA General: NAD, resting comfortably in bed HEENT: PERRL, EOMI, nares clear, MMM Neck: No cervical/supraclavicular LAD CV: RRR, normal S1, S2, no m/g/r, no JVP Lungs: CTAB Abdomen: +BS, soft, tender to palpation and with rebound, lower>upper quadrants, some increased tympany, +guarding, no rigidity GU: foley in place Ext: Pulses 2+ DP bilaterally Neuro: CN ___ intact, moving all extrem Skin: WWP Discharge Physical Exam: Vitals- Tm 98.5 Tc 98 BP 123/78 74 18 97 RA General: NAD, resting comfortably in bed HEENT: PERRL, EOMI, nares clear, MMM CV: RRR, normal S1, S2, no m/g/r, no JVP Lungs: CTAB Abdomen: +BS, soft, distended, tender to palpation and with rebound, lower>upper quadrants, some increased tympany, +guarding, no rigidity. Slightly improved from yesterday and somewhat distractable. GU: foley in place Ext: Pulses 2+ DP bilaterally, no edema Neuro: CN ___ intact, moving all extrem Skin: WWP Pertinent Results: Admission Labs: ___ 01:32AM BLOOD WBC-17.5*# RBC-5.55*# Hgb-16.4*# Hct-49.1*# MCV-88 MCH-29.5 MCHC-33.4 RDW-14.0 Plt ___ ___ 01:32AM BLOOD Neuts-89.8* Lymphs-6.9* Monos-2.5 Eos-0.5 Baso-0.3 ___ 01:32AM BLOOD ___ PTT-26.5 ___ ___ 01:32AM BLOOD Glucose-167* UreaN-24* Creat-0.9 Na-138 K-4.1 Cl-98 HCO3-21* AnGap-23* ___ 01:32AM BLOOD ALT-82* AST-72* AlkPhos-145* TotBili-0.6 ___ 01:32AM BLOOD Lipase-39 ___ 01:32AM BLOOD Albumin-4.6 Calcium-10.4* Phos-4.0 Mg-1.9 ___ 01:36AM BLOOD ___ Temp-37.8 ___ 01:36AM BLOOD Lactate-3.0* Pertinent Labs: ___ 05:31AM BLOOD Lactate-2.5* ___ 09:16PM BLOOD WBC-8.7 RBC-3.82* Hgb-11.6* Hct-34.6* MCV-91 MCH-30.4 MCHC-33.6 RDW-14.0 Plt ___ ___ 06:50PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 01:32AM BLOOD cTropnT-<0.01 Discharge Labs: ___ 08:00AM BLOOD WBC-6.9 RBC-3.73* Hgb-11.3* Hct-33.3* MCV-89 MCH-30.2 MCHC-33.8 RDW-14.0 Plt ___ ___ 08:00AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-141 K-3.5 Cl-109* HCO3-24 AnGap-12 ___ 08:00AM BLOOD ALT-43* AST-30 LD(LDH)-190 AlkPhos-81 TotBili-0.3 ___ 08:00AM BLOOD Calcium-8.3* Phos-2.1*# Mg-1.8 Imaging: - CXR ___: No acute cardiopulmonary abnormalities - ECG ___: Sinus rhythm. Possible inferior myocardial infarction of indeterminate age. Non-specific repolarization abnormalities. Compared to the previous tracing of ___ there is no diagnostic change. - KUB ___: No evidence of obstruction. No free air. - CT ABD+Pelvis w/con ___: No evidence of bowel obstruction. Chronic radiation fibrosis of the sigmoid and rectum. Hepatic steatosis. Micro: - Blood cx x 2: Pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 1 mg PO BID 2. CloniDINE 0.3 mg PO TID 3. Methadone 20 mg PO QAM 4. Methadone 10 mg PO QPM 5. QUEtiapine Fumarate 50 mg PO QHS 6. BuPROPion (Sustained Release) 150 mg PO QAM 7. Docusate Sodium 100 mg PO BID 8. Milk of Magnesia 30 mL PO Q6H:PRN constipation Discharge Medications: 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. ClonazePAM 1 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Methadone 20 mg PO QAM 5. Methadone 10 mg PO QPM 6. QUEtiapine Fumarate 50 mg PO QHS 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation 8. Calcium Carbonate 500 mg PO QID:PRN indigestion RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills:*0 9. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*10 Tablet Refills:*0 10. CloniDINE 0.3 mg PO TID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: viral gastroenteritis SECONDARY DIAGNOSIS: radiation enteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with abd pain // eval for air fluid levels, free air TECHNIQUE: Supine and upright views of the abdomen. COMPARISON: CT abdomen pelvis on ___. FINDINGS: Multiple clips are seen in the abdomen. There is seen throughout the small and large bowel without evidence of dilation or air-fluid levels. No free air. IMPRESSION: No evidence of obstruction. No free air. Radiology Report INDICATION: +PO contrast; History: ___ with hx bowel obstruction p/w acute onset abd pain+PO contrast // r/o obstruction, radiation colitis TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and submitted to PACS for review. Oral contrast was administered. DOSE: DLP: 493mGy-cm. IV Contrast: 130 mL Omnipaque injected at a rate of 2 cc/sec COMPARISON: CT abdomen pelvis on ___. FINDINGS: LOWER CHEST: 2 mm right lower lobe pulmonary nodule is unchanged since ___. The visualized heart and pericardium are unremarkable. ABDOMEN: HEPATOBILIARY: The liver is decreased in attenuation consistent with fatty infiltration. No focal lesions are identified.. The gallbladder is within normal limits, without stones or gallbladder wall thickening. 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. A 9 mm hypodensity in the spleen is unchanged. ADRENALS: The adrenal glands are normal bilaterally. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of stones or hydronephrosis. A 1.2 cm right renal cyst and another subcentimeter hypodensity is unchanged..There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Multiple surgical clips are again seen in the mesentery, omentum and retroperitoneum. No free air. The ascending, transverse and descending colon are unremarkable with normal wall thickness and stool burden. The sigmoid the and rectum are diffusely narrowed in caliber as seen on prior exam compatible with chronic radiation changes. No adjacent fat stranding. Appendix contains air, has normal caliber without evidence of fat stranding. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: No evidence of bowel obstruction. Chronic radiation fibrosis of the sigmoid and rectum. Hepatic steatosis. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with left sided inspiratory chest pain, elevated WBC count // ? pneumonia TECHNIQUE: Chest PA and lateral FINDINGS: Cardiomediastinal contours are normal. The lungs are clear with some minimal areas of scarring/ atelectasis at the bases. There is no pneumothorax or pleural effusion. The osseous structures are unremarkable IMPRESSION: No acute cardiopulmonary abnormalities Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with RECTAL & ANAL HEMORRHAGE, ABDOMINAL PAIN GENERALIZED temperature: 100.0 heartrate: 107.0 resprate: 22.0 o2sat: 100.0 sbp: 156.0 dbp: 102.0 level of pain: 10 level of acuity: 2.0

Dear Ms. ___, You were admitted with abdominal pain and vomiting due to viral gastroenteritis. Your imaging tests were reassuring and you were able to take in oral intake. Please call your PCP tomorrow to schedule a follow up visit in the next ___ days, as this appointment could not be made prior to your discharge. Please discuss a referral to gastroenterology for your chronic radiation enteritis. It was a pleasure caring for you. Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fever, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ M recently admitted to ___ surgery service on for management of a cystic duct stump leak following lap CCY at an OSH presents with abd pain and low grade temperatures. Pt and wife report pain has been present for 3 days. Continuous, dull, associated with nausea but no emesis. Pt is tolerating PO but has had a decreased appetite. Some associated chills and fevers to 102 at home. During recent admission pt has an ___ guided drain placed in his biloma. He had already had one in place from the OSH. He also underwent ERCP and is s/p sphincterotomy and stent placement. He was discharged to home on a 6 day course of C/F which he finished. Past Medical History: PMH: Hyperchoelsterolemia, colon CA, asthma, depression, chronic UTI, Afib PSH: Lap CCY, pacemaker, colectomy, ?additional abdominal surgery ___: Seroquel XR 100mg PO QHS, Cymbalta 30mg PO QHS, Digoxin 125mcg', Methylphenidate 10mg BID, Simvastatin 40mg', Albuterol Inh 2puffs Q2h PRN, APAP 650 Q4h PRN, Maalox''''prn, vicodin ___ q4h, miralax 1tbsp daily, Coumadin Social History: ___ Family History: NC Physical Exam: On Admission: VS:98.1 87 127/100 18 95% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, TTP in all four quadrant with guarding, no rebound, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused On Discharge: VS: GEN: NAD CV: RRR, no m/r/g PULM: CTAB ABD: Soft, NT/ND, RUQ old pigtail site with occlusive dressing and c/d/i Extr: Warm, no c/c/e Pertinent Results: ___ 10:05AM BLOOD WBC-9.7 RBC-3.94* Hgb-11.7* Hct-36.3* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.1 Plt ___ ___ 10:05AM BLOOD Glucose-220* UreaN-11 Creat-0.7 Na-138 K-4.7 Cl-103 HCO3-24 AnGap-16 ___ BLOOD CULTURES: Pending ___ LIVER US: IMPRESSION: 1. Pain with scanning along the surgical drain over the mid abdomen/periumbilical region. No fluid collection is identified along this drain to suggest abscess formation, however. 2. Likely interval resolution of the previously seen biloma in the gallbladder resection bed with a pigtail catheter remaining in place. 3. Stable liver cyst. ___ ABD CT: IMPRESSION: 1. Interval decrease in size of the fluid collection within the gallbladder resection bed compared to CT from ___, although the collection has not completely drained. The pigtail catheter is seen along the edge of the collection and correlation with catheter output is recommended to ensure proper positioning. 2. Likely subcapsular 6.5 cm collection along the inferior aspect of the right hepatic lobe appears more organized on the current study, now with a thick surrounding rind. 3. Reactive changes, without evidence of abscess formation, along the distal portion of the surgical drain that ends near the hepatic flexure. Of note, this drain does not end within either of the intra-abdominal collections Medications on Admission: Seroquel XR 50 PO QHS, Cymbalta 30mg PO QHS, Digoxin 125mcg', Methylphenidate 10mg am and noon PRN pt request, Simvastatin 40mg', Albuterol Inh 2puffs Q2h PRN, APAP 650 Q4h PRN, Maalox''''prn, vicodin ___ q4h, miralax 1tbsp daily, Coumadin 5' ___ and 2.5 rest Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)). 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO AM AND NOON, PRN () as needed for patient request. 7. Seroquel XR 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime. 8. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 13 days. Disp:*26 Tablet(s)* Refills:*0* 9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO ___. 10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO TUE/WED/FRI/SAT/SUN: please continue to check your INR as scheduled. Discharge Disposition: Home Discharge Diagnosis: Cystic duct stump leak and biloma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Stump leak, status post cholecystectomy. Assess for biloma. COMPARISON: The liver/gallbladder ultrasound from ___. FINDINGS: A pigtail catheter ends within the region of the previously seen biloma within the gallbladder resection bed. There is no definite remaining fluid collection within this area. A cyst within the left lobe of the liver is stable in appearance. The liver echogenicity and echotexture are grossly normal. There is no intrahepatic biliary duct dilatation. The portal vein is patent. The spleen is normal in size, measuring 10.2 cm. Scanning along the surgical tube within the right mid abdomen/periumbilical region elicited significant discomfort. No fluid collection was seen along the tube, however. IMPRESSION: 1. Pain with scanning along the surgical drain over the mid abdomen/periumbilical region. No fluid collection is identified along this drain to suggest abscess formation, however. 2. Likely interval resolution of the previously seen biloma in the gallbladder resection bed with a pigtail catheter remaining in place. 3. Stable liver cyst. Radiology Report INDICATION: Prior biloma with ___ drains in place. Patient with abdominal tenderness. Please evaluate for inflammation around prior biloma. TECHNIQUE: MDCT axial images were acquired from the lung bases to the lesser trochanters following administration of both oral and intravenous contrast material. Multiplanar reformations were performed. COMPARISON: Reference CT abdomen from ___, reference CT abdomen from ___. ABDOMEN CT: The visualized portions of the lung bases are clear. Pacer leads are seen within the right atrium and right ventricle. As seen on prior CT from ___, there are scattered liver cysts, measuring up to 3.7 cm in the left hepatic lobe (2:12), not significantly changed in size. There is no intrahepatic biliary duct dilatation. The portal vein is patent. The patient is status post cholecystectomy. A pigtail catheter is seen within the gallbladder resection bed along the edge of a small gallbladder fossa fluid collection, markedly decreased in size compared to ___, now measuring 5.9 x 1.6 cm in its greatest axial dimension, compared to 10.2 x 3.4 cm previously. Small foci of air within this collection likely relate to the presence of the pigtail catheter. A second likely subcapsular collection is seen along the inferior right hepatic lobe (2:27). This collection was seen previously on CT from ___, although appears to be more organized on the present study with a new thick surrounding rind. The overall size of this collection does not appear appreciably changed. A biliary stent is noted extending down the common duct and into the second portion of the duodenum. The spleen, pancreas, and adrenal glands are unremarkable. Scattered bilateral renal hypodensities are not significantly changed in size or number, at least one of which is a simple cyst and others of which are too small to characterize. The kidneys are otherwise unremarkable. The stomach, small bowel, and colon are unremarkable. There is no significant quantity of free fluid in the abdomen. No free air is noted. There are no pathologically enlarged abdominal lymph nodes. A surgical drain enters the right mid abdomen, loops within the pelvis and then ends near the hepatic flexure. There is reactive change along the distal catheter with associated fat stranding (60___:22) although no associated fluid collection is seen. PELVIS CT: The bladder and prostate are grossly unremarkable. There is no free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes are seen. BONE WINDOW: No suspicious lytic or blastic lesions are identified. Mild multilevel degenerative changes of the thoracolumbar spine are noted. IMPRESSION: 1. Interval decrease in size of the fluid collection within the gallbladder resection bed compared to CT from ___, although the collection has not completely drained. The pigtail catheter is seen along the edge of the collection and correlation with catheter output is recommended to ensure proper positioning. 2. Likely subcapsular 6.5 cm collection along the inferior aspect of the right hepatic lobe appears more organized on the current study, now with a thick surrounding rind. 3. Reactive changes, without evidence of abscess formation, along the distal portion of the surgical drain that ends near the hepatic flexure. Of note, this drain does not end within either of the intra-abdominal collections. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN, FEVERS Diagnosed with OTHER SPEC COMPL S/P SURGERY, ACCIDENT NOS temperature: 98.1 heartrate: 87.0 resprate: 18.0 o2sat: 95.0 sbp: 127.0 dbp: 100.0 level of pain: 4 level of acuity: 3.0

Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. *Continue to follow with ___ clinic as scheduled to monitor your INR level. Call Dr. ___ with any question regarding Coumadin.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Ventricular Fibrillation arrest Major Surgical or Invasive Procedure: - ___ - Cardiac catheterization - ___ - 1. Simple extraction, teeth numbers 30 and 29. 2. Surgical extraction, tooth number 19. - ___ - CABG X 4 (LIMA-> LAD, SVG-> OM1, OM2, R PDA) History of Present Illness: Mr. ___ is a ___ year-old gentleman with a PMH of hyperlipidemia and obesity, now admitted s/p VF arrest. Per ED records, patient had a cardiac arrest at a gas station; an ambulence was at the same gas station and initiated CPR. When EMS arrived, they continued CPR and delivered two defibrillations, as well as epinephrine with return of spontaneous circulation. Amiodarone was also administered. At ___, he was started on norepineprine and given IVF x6L. Cooling protocol was initiated there. There, non-contrast head CT, CTA torso and CT neck were all unremarkable. There was no evidence of PE. BY report, EKG at OSH also showed STEMI, but the EKG did not come with patient's records to ___. He was transported to ___ by MedFlight, which was uneventful. On arrival to the ___ ED at 10:45 am, initial EKG showed NSR with NA/NI, and no ST depressions/elevations, but anterior/inferior Q waves. Groin CVL and a-lines were placed. Norepinephrine was started at 0.15 mcg/kg/min, and was weaned down to 0.05 mcg/kg/min. The ___ post-arrest team continued cooling (at 11:30 am), which was presumably started at OSH. Patient was taken to the lab, where he underwent left heart cardiac cath via RRA ___. He was found to have a left-dominant system with severe RCA and LAD disease (LAD 80% ___, LCx 50-60% ___, RCA 80% ___ with normal flow. No PCI was done. Hemodynamics showed LV 80/___, aorta 80/___. He was given heparin IV, diltiazem IV bolus and nitroglycerine IV bolus during the case. Patient was brought to the cath lab with plan for continued cooling, and reassessment for PCI vs. CABG after rewarming is complete. Of note, for the past ___ years, the patient has had multiple episodes of chest pain for which he has gone to the ED and has been evaluated. As per his wife, for the past 2 weeks he has noted intermittant increased chest pressure along with increased shortness of breath. Today, she notes that he likely had to do heavy lifting for his ___ job. On arrival to the CCU, the patient was on assist control ventilator support, HR 63 and BP 107/82. Cardiac surgery consulted for coronary bypass evaluation. Past Medical History: 1. CARDIAC RISK FACTORS: HLD since age ___, has a history of being on Lipitor and Crestor but stopped for the past year b/c he was concerned about myalgias 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: BPH- has a history of not tolerating flomax Restless leg syndrome GERD dyslipidemia Past surgical history: TURP w/vasectomy ___ years ago Social History: ___ Family History: Brother ___ years younger)- ACD, multiple episodes of Vfib, EF ___ Father- h/o stroke, passed away from MI Mother- ___, CHF, pacemaker Physical Exam: ADMISSION PHYSICAL EXAM Vitals: HR 63 BP 107/82 General: intubated HEENT: NCAT Neck: difficult to assess JVD CV: distant heart sounds, no murmurs appreciated Lungs: course breath sounds anteriorly Abdomen: nondistended GU: foley in place Ext: no edema in lower extremities bilaterally Neuro: intubated and sedated, unable to assess Pulses: dopplerable DPs DISCHARGE PHYSICAL EXAM (********** please update on ___ Pulse:96 Resp:14 O2 sat:99/4L B/P ___ Height:5'9" Weight:86.4 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] gradeI/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [] Edema [x] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ ___ Right:1+ Left:1+ Radial Right:1+ Left:1+ Carotid Bruit Right:- Left:- Pertinent Results: ADMISSION LABS ___ 11:22AM BLOOD WBC-13.8* RBC-4.39* Hgb-13.9* Hct-41.6 MCV-95 MCH-31.6 MCHC-33.4 RDW-13.1 Plt ___ ___ 02:48PM BLOOD Neuts-89.0* Lymphs-5.8* Monos-4.4 Eos-0.4 Baso-0.3 ___ 11:22AM BLOOD ___ PTT-49.5* ___ ___ 11:22AM BLOOD Plt ___ ___ 11:22AM BLOOD UreaN-17 Creat-1.1 ___ 11:22AM BLOOD ALT-99* AST-102* AlkPhos-43 TotBili-0.8 ___ 11:22AM BLOOD Lipase-26 ___ 11:22AM BLOOD cTropnT-0.40* ___ 11:22AM BLOOD Albumin-3.0* ___ 11:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:15AM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-60 pO2-55* pCO2-62* pH-7.03* calTCO2-18* Base XS--15 -ASSIST/CON Intubat-INTUBATED ___ 11:29AM BLOOD Glucose-278* Lactate-3.8* Na-142 K-4.7 Cl-115* calHCO3-14* ___ 01:15PM BLOOD Hgb-13.5* calcHCT-41 O2 Sat-89 COHgb-0 ___ 11:29AM BLOOD freeCa-0.93* ___ CXR (AP portable): ET tube is present, 3.5 cm above the carina. An enteric tube is present with tip coursing towards the stomach but not captured on the film. An esophageal temperature probe is also noted. Moderate cardiomegaly is present. The mediastinal and hilar contours are unremarkable. Bilateral pleural effusions are likely. There is no large pneumothorax. Diffuse hazy opacification of all lung fields is consistent with pulmonary edema. IMPRESSION: Satisfactory positioning of ET tube. No obvious pneumothorax. ___ CARDIAC CATH: Hemodynamic Measurements (mmHg): Baseline Site ___ ___ End Mean A Wave V Wave HR ___ Findings: ESTIMATED blood loss: 2 cc Hemodynamics (see above): Coronary angiography: left dominant LMCA: normal LAD: proximal 80% disease just after S1; normal flow LCX: large dominant vessel; proximal 50-60% disease RCA: small nondominant vessel with proximal/mid disease to 80%; normal flow Assessment & Recommendations 1. Severe RCA and LAD disease with normal flow 2. Elevated LVEDP 3. No PCI at this time; can consider stenting of LAD if regains consciousness. 4. Continue cooling 5. Cardiac echo TTE ___ Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. LV systolic function appears depressed. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size is normal with depressed free wall contractility. There is no aortic valve stenosis. An eccentric, posteriorly directed jet of at least moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricle with severely depressed global left ventricular systolic function. Depressed right ventricular systolic function. At least moderate mitral regurgitation in the setting of tethering of the inferolateral left ventricular segments is seen. Indeterminate pulmonary artery systolic pressure. Compared to the previous study of ___ (images reviewed), the left ventricle has minimally increased in size (previously 5.9 cm). Mild aortic root and ascending aortic dilation were previously seen, but not reassessed on today's study. TTE ___ The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = ___ with relatively better wall motion in the basal inferolateral wall. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is mildly dilated with mild free wall motion hypokinesis.. The aortic root and ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve is abnormal. Moderate to severe (3+) mitral regurgitation is seen with posteriorly directed jet likely from tethered posterios mitral leaflet. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion with no signs of tamponade. Compared with the prior study (images reviewed) of ___ findings are similar with better visualization of the left ventricular apex which shows no thrombus. The severity of mitral regurgitation may be increased. The severity of tricuspid regurgitation is increased. Pulmonary artery systolic hypertension is moderate in severity (not estimated on prior study). TTE ___ The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF = 20 %) with regional variation. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, the mitral regurgitation is reduced. Left ventricular contractile function is slightly Thallium Viability Study ___ IMPRESSION: 1. Probably normal resting myocardial perfusion. Inferior wall defect most likely due to soft tissue attenuation. These results indicate that there is extensive myocardial viability in all coronary artery territories. Teeth X-ray ___ FINDINGS: Multiple missing teeth, the remaining teeth show other fillings or severe defects. One fractured tooth is seen in region IV. There is no convincing evidence of a periarticular osteolysis or granuloma. Medications on Admission: NONE Discharge Medications: 1. Amiodarone 400 mg PO BID Take 200mg twice daily for 30 days then starting ___ take 200mg daily thereafter. RX *amiodarone 200 mg 1 tablet(s) by mouth Twice daily for 30 days then switch to once daily on ___ Disp #*60 Tablet Refills:*2 2. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth Daily Disp #*90 Tablet Refills:*4 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice daily Disp #*60 Capsule Refills:*0 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Every ___ hours Disp #*50 Tablet Refills:*0 5. Warfarin 2 mg PO DAILY16 RX *warfarin [Coumadin] 2 mg As instructed tablet(s) by mouth Daily Disp #*40 Tablet Refills:*2 6. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*2 7. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 8. Ranitidine 150 mg PO BID Duration: 30 Days RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*0 9. Tucks Hemorrhoidal Oint 1% ___ID RX *pramoxine-mineral oil-zinc [Tucks] 1 %-12.5 % 1 Ointment(s) rectally four times a day Disp #*1 Tube Refills:*2 10. Atorvastatin 10 mg PO HS RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*2 11. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth Daily in AM Disp #*7 Tablet Refills:*0 12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 Tablet by mouth Daily in AM Disp #*7 Tablet Refills:*0 Discharge Disposition: Extended Care Discharge Diagnosis: Ventricular fibrillation arrest in the setting of 3 vessel coronary disease Hyperlipidemia since age ___ (has a history of being on Lipitor and Crestor but stopped for the past year b/c he was concerned about myalgias) Benign Prostatic Hyperplasia Restless leg syndrome Gastroesophageal Reflux Disease Asthma (in his ___ Tinnitus Cardiomyopathy Postoperative, paroxysmal Atrial Fibrillation Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 2+ Followup Instructions: ___ Radiology Report INDICATION: V-fib arrest, evaluate ET tube placement and pneumothorax. COMPARISON: CT torso ___. FINDINGS: ET tube is present 3.5 cm above the carina. An enteric tube is present with tip coursing towards the stomach but not captured on the film. An esophageal temperature probe is also noted. The cardiomediastinal and hilar contours are unremarkable. Bilateral pleural effusions are not excluded. There is no pneumothorax. Diffuse hazy opacification of all lung fields is consistent with pulmonary edema. IMPRESSION: Satisfactory positioning of ET tube. Pulmonary edema. No pneumothorax. Radiology Report PORTABLE CHEST ___ COMPARISON: Radiograph of earlier the same date. FINDINGS: Support and monitoring devices are unchanged in position. Interval slight decrease in width of mediastinal vascular pedicle, accompanied by improvement in extent of pulmonary edema and reduction in size of right pleural effusion. Left effusion has apparently resolved. Prominent lucency adjacent to left heart border and diaphragm could potentially represent a basilar pneumothorax on this supine view. Lateral decubitus radiograph may be helpful to exclude a left pneumothorax. Radiology Report PORTABLE CHEST FILM ___ AT 820 INDICATION: ___ with VF arrest, now with cooling protocol line and intubation. Comparison is made to prior study of ___ at 1454. A portable supine chest film ___ at 820 is submitted. IMPRESSION: 1. Support and monitoring devices are in satisfactory position. There is improving mild pulmonary and interstitial edema. In addition, there is retrocardiac opacity with probable associated layering left effusion which likely reflects patchy atelectasis and is slightly worse when compared to the prior study. No large pneumothorax is seen, although the sensitivity to detect a pneumothorax is diminished given supine technique. Overall, cardiac and mediastinal contours are unchanged. Radiology Report CHEST RADIOGRAPH INDICATION: Intubation, evaluation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the position of the endotracheal tube, the esophageal device and the feeding tube are unchanged. Moderate cardiomegaly persists. Increasing atelectasis in the retrocardiac lung areas. Likely presence of a small left pleural effusion. Minimal fluid overload. No other parenchymal changes. Radiology Report HISTORY: Male with coronary artery disease, status post cardiac arrest. Assess for pneumonia and effusion. TECHNIQUE: Single portable frontal chest radiograph. COMPARISON: Chest radiographs, ___, and ___. FINDINGS: Interval removal of ET tube and NG tube with mild improvement in lung volumes. Mild increase in pulmonary edema with mildly enlarged heart size and new bilateral perihilar haze. Minimal left lower lobe atelectasis with interval decrease in left pleural effusion. No pneumothorax, new focal opacity or right pleural effusion. No bony abnormality. IMPRESSION: 1. Interval increase in mild pulmonary edema. 2. Minimal improvement in lung volumes. Radiology Report INDICATION: CABG. COMPARISON: No comparison available at the time of dictation. FINDINGS: Multiple missing teeth, the remaining teeth show other fillings or severe defects. One fractured tooth is seen in region IV. There is no convincing evidence of a periarticular osteolysis or granuloma. Radiology Report CHEST RADIOGRAPH INDICATION: Status post CABG, evaluation. COMPARISON: Preoperative chest x-ray from ___. FINDINGS: As compared to the previous radiograph, the patient has undergone CABG. All monitoring and support devices, including the Swan-Ganz catheter and the left-sided chest tube are in correct position. Normal postoperative appearance of the thorax, with normal-sized cardiac silhouette. No larger pleural effusions and no pneumothorax. No pulmonary edema. Radiology Report HISTORY: CABG, for pre-discharge evaluation. FINDINGS: In comparison with study of ___, all of the monitoring and support devices have been removed. There is no convincing evidence of a residual pneumothorax. Blunting of both costophrenic angles, more prominent on the left, is consistent with pleural fluid. Some volume loss is noted in the left lower lung. No evidence of vascular congestion or acute focal pneumonia. Gender: M Race: WHITE Arrive by HELICOPTER Chief complaint: S/P V FIB ARREST Diagnosed with VENTRICULAR FIBRILLATION, CARDIAC ARREST temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for 6 months per Dr. ___ and while taking narcotics. Driving will be discussed at follow up appointment with Dr. ___. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns ___ 7) Per Dr. ___ can not return to working in the warehouse for 3 months. **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: joint pains Major Surgical or Invasive Procedure: skin biopsy ___ History of Present Illness: Primary Care Physician: ___. MD . ___ with new dx of nodular vasculitis is here with upper and lower extremity pain not relieved by morphine or ibuprofen at home. He has been undergoing W/U as outpt for fevers x 5 weeks. He then developed pain and stiffness in his hands, wrists, elbows, ankles and feet then developed small tender erythematous subcutaneous nodules over his upper and lower extremities. ID saw pt and felt this was not infectious. He was seen by Rheum and had nodule biopsy which revealed nodular vasculitis. Plan was to start IV steroids next week but b/c of pain pt came to the ER. Extensive work up revealed elevated ESR, WBC count, and LFTs. Pt reports abdominal CT and MRI of lower extremities was WNL. At this point in time pt is in so much pain he lays on the couch all day long and needs to use a wheelchair to get to the bathroom. . ROS: some dry mouth "I think this is from the AC" denies cough, hemoptysis, dysuria, hematuria, headache, n/v/d, chest pain, palpitations, shortness of breath, no rashes, no nausea vomittign diarrhea, no dry eyes, no vision changes . In the ED, initial vital signs were 98.9, 133, 105/91, 18, 100%. WBC 13K, CRP 163, ALT 124, AST 58, Alk P ___. Exam was notable for multiple SQ nodules in extremities and diffuse joint tenderness. Triggered for HR of 130's. 2 L IVF, 2 mg IV morphine, 30 mg IV ketorolac. Improved to 120's. Patient was given 2 L NS, 3 mg dilaudid and ketorolac. . Past Medical History: none Social History: ___ Family History: Paternal great grandmother had RA. Family history is negative for systemic lupus erythematosus, inflammatory myopathy, systemic sclerosis, Sjogren's syndrome, psoriasis or inflammatory bowel disease. Prostate CA in the family, grandparents with CAD, DM and HTN. Physical Exam: ADMISSION EXAM: VS: 98.9 133 ___ 100 General: sitting in bed, appears to be in pain, difficulty using his iphone HEENT: EOMI, tongue with no thrush CV: tachycardia 120s, normal S1 S2, no murmers Lungs: clear to auscultation b/l Abdomen: soft non tender no organomegaly Neuro: could not assess stregnth bc of pain Skin: many dime sized pink papules on arms, hands, legs, feet Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. MSK: Warmth, redness of the MCP/PIP joints in hands and feet bilaterally. nodules are also on hands and feet. No digit swelling of fingers or toes bilaterally. Tender wrists, elbows and feet and ankles. Decrease ROM due to pain. Shoulders, elbows, wrists, hands: no deformity, erythema, they are warm, tender, very limited ROM from pain. Knee, ankles, feet, toes: no deformity, there is warmth, tenderness, very limited ROM . DISCHARGE EXAM: 99.6 18 100%RA HR range 91-112 . Exam unchanged though he had fewer subcutaneous nodules and was able to move his extremities without as much pain, but still with pain . Pertinent Results: ADMISSION LABS . ___ 03:50PM BLOOD WBC-13.4* RBC-4.49* Hgb-11.7* Hct-35.1* MCV-78* MCH-26.0* MCHC-33.3 RDW-16.1* Plt ___ ___ 03:50PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Tear Dr-1+ ___ 03:50PM BLOOD Plt Smr-VERY HIGH Plt ___ ___ 03:50PM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-135 K-4.7 Cl-97 HCO3-23 AnGap-20 ___ 03:50PM BLOOD ALT-124* AST-58* CK(CPK)-21* AlkPhos-289* TotBili-0.9 ___ 07:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 Iron-25* ___ 07:45AM BLOOD calTIBC-286 Hapto-316* Ferritn-312 TRF-220 ___ 07:45AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND IgM HBc-PND ___ 03:50PM BLOOD CRP-163.8* ___ 04:06PM BLOOD Lactate-1.9 . DISCHARGE LABS: ___ 09:11AM BLOOD Plt ___ ___ 07:45AM BLOOD Ret Aut-3.5* ___ 05:35AM BLOOD Glucose-94 UreaN-16 Creat-0.7 Na-135 K-4.3 Cl-98 HCO3-27 AnGap-14 ___ 09:11AM BLOOD ALT-87* AST-39 AlkPhos-209* TotBili-0.7 ___ 05:35AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.2 ___ 09:11AM BLOOD WBC-8.9 RBC-3.57* Hgb-9.1* Hct-27.9* MCV-78* MCH-25.3* MCHC-32.4 RDW-15.9* Plt ___ ___ 09:11AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-OCCASIONAL Ovalocy-OCCASIONAL . ___ cxr FINDINGS: AP portable upright chest radiograph provided. The lungs are well expanded and clear. No signs of pneumonia or effusion. No pneumothorax is seen. The cardiomediastinal silhouette is normal. Bony structures are intact. IMPRESSION: No acute abnormalities. . ___ echo EF 65% The left atrium is normal in size. 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%). There is no ventricular septal defect. Interventricular septal motion is 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. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. . ___ RUQ u/s FINDINGS: The liver echogenicity and echotexture are normal. No focal liver lesions are identified. There is no intra or extrahepatic biliary duct dilatation, with the common duct measuring 3 mm. The portal vein is patent, with normal hepatopetal flow. The gallbladder is normal. The kidneys are normal in size, with the right kidney measuring 11.7 cm and the left kidney measuring 10.6 cm. There is no hydronephrosis, focal renal mass, or calculus. The pancreas is unremarkable. The spleen is normal in size, measuring 11.8 cm. The abdominal aorta is normal in caliber. Limited assessment of the IVC is unremarkable. There is no free fluid in the abdomen. IMPRESSION: Normal abdominal ultrasound. . ___ Skin Biopsy (___) Skin, right upper arm, biopsy (A-C): Extensive deep dermal and subcutaneous hemorrhage with early organization and associated acute and chronic inflammation, see note. Note: Definitive vasculitis is not seen; elastic stain evaluated. Special stains for organisms (PAS, Gram, ___, AFB, GMS) are negative. The differential diagnosis includes a bleeding diathesis. Although evidence of nodular vasculitis is not identified, a deeper biopsy may be of benefit if clinical suspicion persists. Studies for evaluation of coagulopathy are recommended if clinically warranted. . . ___ Review of outpt skin biopsy (originally bx done ___ as outpt) Skin, "right incisional forearm, biopsy" (___, ___, ___, 7 slides): Septal and lobular panniculitis with vasculitis, see note. Note: Sections show acute, chronic, and granulomatous septal and lobular inflammation with septal thickening and fibrosis. Prominent vasculitis of the subcutaneous vessels with fibrinoid necrosis and focal thromboses is seen. Special stains for fungus and mycobacteria (GMS, PAS and ___ performed at the outside institution and reviewed at ___ are negative. The findings are suggestive of erythema induratum/nodular vasculitis in the appropriate clinical setting. A less likely consideration is polyarteritis nodosa, although the degree of panniculitic inflammation and the pattern would be unusual. Clinicopathologic correlation is recommended. . . Pertinent Labs: ___ 07:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE ___ 07:45AM BLOOD HCV Ab-NEGATIVE ___ 07:10AM BLOOD HIV Ab-NEGATIVE ___ BLOOD HISTOPLASMA Ag-NEGATIVE ___ 12:27PM BLOOD LYME DISEASE ANTIBODY, IMMUNOBLOT-NEGATIVE ___ 07:10AM BLOOD QUANTIFERON-TB GOLD-NEGATIVE ___ 05:35AM BLOOD HISTOPLASMA ANTIBODY (BY CF AND ID)-NEGATIVE ___ 05:35AM BLOOD COCCIDIOIDES ANTIBODY, COMPLEMENT FIXATION AND IMMUNODIFFUSION-NEGATIVE ___ 05:35AM BLOOD PARACOCCIDIOIDES ___ ANTIBODY-NEGATIVE ___ 05:35AM BLOOD BLASTOMYCOSIS ANTIBODY (BY CF AND ID)-NEGATIVE ___ 05:35AM BLOOD B-GLUCAN-NEGATIVE ___ 10:15AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-NEGATIVE ___ 10:15AM BLOOD PARVOVIRUS B19 DNA-NOT DETECTED ___ 10:15AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-NEGATIVE ___ BLOOD HCV VIRAL LOAD-NOT DETECTED ___ BLOOD ASO SCREEN-NEGATIVE ___ BLOOD LYME DISEASE-EIA EQUIVOCAL ___ BLOOD CMV VIRAL LOAD-NOT DETECTED ___ Blood Culture - no growth ___ Blood Culture #1 - no growth ___ Blood Culture #2 - no growth ___ Blood Culture #3 - no growth ___ Blood Culture #1 - no growth ___ Blood Culture #2 - Gram-positive cocci in clusters Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 400 mg PO Q6H 2. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain Discharge Medications: 1. Ibuprofen 800 mg PO Q8H RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 [___] 17 gram 1 packet by mouth daily Disp #*30 Packet Refills:*0 3. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 capsule by mouth daily Disp #*30 Capsule Refills:*0 4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain RX *oxycodone 15 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills:*0 RX *oxycodone [OxyContin] 20 mg 1 tablet extended release 12 hr(s) by mouth twice a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: 1. Painful subcutaneous nodules, arthralgias 2. Anemia Discharge Condition: Mental Status: Clear and coherent. Followup Instructions: ___ Radiology Report HISTORY: 6 week history of fevers and painful subcutaneous nodules. Also with elevated LFTs. Evaluate hepatic tree for evidence of aneurysms or signs of vasculitis. COMPARISON: None. FINDINGS: The liver echogenicity and echotexture are normal. No focal liver lesions are identified. There is no intra or extrahepatic biliary duct dilatation, with the common duct measuring 3 mm. The portal vein is patent, with normal hepatopetal flow. The gallbladder is normal. The kidneys are normal in size, with the right kidney measuring 11.7 cm and the left kidney measuring 10.6 cm. There is no hydronephrosis, focal renal mass, or calculus. The pancreas is unremarkable. The spleen is normal in size, measuring 11.8 cm. The abdominal aorta is normal in caliber. Limited assessment of the IVC is unremarkable. There is no free fluid in the abdomen. IMPRESSION: Normal abdominal ultrasound. Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: None. CLINICAL HISTORY: Tachycardia, question pneumonia. FINDINGS: AP portable upright chest radiograph provided. The lungs are well expanded and clear. No signs of pneumonia or effusion. No pneumothorax is seen. The cardiomediastinal silhouette is normal. Bony structures are intact. IMPRESSION: No acute abnormalities. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: EXTREMITY PAIN Diagnosed with JOINT PAIN-MULT JTS, ERYTHEMA NODOSUM temperature: 98.9 heartrate: 133.0 resprate: 18.0 o2sat: 100.0 sbp: 105.0 dbp: 91.0 level of pain: 5 level of acuity: 1.0

Dear Mr. ___, It was a pleasure caring for you here at ___. You came to the hospital because of arm and leg pains and nodules on your skin. We had the rheumatologists, infectious disease doctors as ___ as the dermatologists see you while you were here. For your pain we gave you ibuprofen, oxycontin and oxycodone. To avoid stomach irritation, please take zantac (ranitidine) or pepcid (famotidine) while you are on ibuprofen. Also while here you were found to be anemic. You had no blood in your stool, and it seems that the inflammation may be causing your blood counts to be low. With improvement of the inflammation, we expect the anemia to improve. Please follow up with your primary care doctor and rheumatologist. Your primary care doctor ___ coordinate the appointment with your rheumatologist. There are still several tests pending and your PCP ___ be informed of the results. The rheumatologists who saw you here will communicate with your rheumatologist to update her on your hospital course. After we confirm you do not have TB you will likely be started on prednisone. Expect a call from the rheumatologists tomorrow.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / Vicodin / Food Extracts / Bactrim / Iodinated Contrast Media - IV Dye / dapsone / diazepam / raltegravir / Truvada Attending: ___. Chief Complaint: Joint pain Major Surgical or Invasive Procedure: SURGICAL WASHOUT OF L ELBOW, L WRIST, R KNEE ___ History of Present Illness: ___ hx HIV (last CD4 ___, last VL undetectable in ___ and extensive joint history including b/l steroid wrist injection for chronic carpal tunnel on ___ and right knee arthritis w/ tap and steroid injection on ___ presents with ___ days fevers, chills, night sweats, and exquisite tenderness worst in left wrist but notable in numerous PIP, DIP, MCP (left ___ digit worst), ?L elbow, right knee (though the latter is improving since ___. The left wrist pain has gotten worse since injection (which have helped in the past). Her right knee feels "tense." At At___, labs drawn ___ as below: - PENDING: ___ prev negative ___ - uric acid 2.9 - RF<30 - CRP 141 - ESR 90 Right knee tap showed 33K cells, gram stain with 4 PMNs but no organisms. No new sexual partners and ___ w/i marriage (20+ years), though per records does have history of gonoccocal proctitis a few years ago. No ocular symptoms. Bilateral steroid injections of hands for carpal tunnel ___. Knee tap of 81cc fluid + steroid injection ___. In the ED, initial vitals were: 100.6 97 144/92 18 100% RA - Exam notable for: Left wrist with erythema, edema, warm to touch, more swollen than right wrist. Tender per pt. All MCP tender, majority of PIP/DIP as well, left ___ PIP most visibly swollen. Pt yells out when most of these are touched. Also endorsing tenderness of right elbow though this has full ROM. Right knee also tender w/o frank erythema, edema, no ballottment. No restriction on ROM. - Labs notable for: WBC 8.7 Joint fluid with ___ WBC's, 79% PMN's and no crystals (GST PND) - Imaging was notable for: none obtained - Orthopedics, Hand surgery were consulted: -Please process synovial fluids for analysis. -Please elevate LUE as much as possible with IV pole. -Suggest NSAIDS. -NPO at midnight, please. -will plan for serial examinations. -please obtain hand and wrist films -Advise rheumatologic workup as well - Patient was given: Vanc/CTX Tylenol ___ mg Oxycodone 5 Dilaudid 0.5 IV x 2 - Vitals prior to transfer: 100.2 86 140/86 18 99% RA Upon arrival to the floor, patient reports severe debilitation in her L arm and hand. The pain has been getting worse and worse. She can barely use her L arm now. Endorses some occasional night sweats over the past month. Otherwise, denies fevers at home, weight changes, diarrhea, dysuria, abdominal pain, cough. Past Medical History: Past Medical History: Includes HIV positive, latent TB, hepatitis, gastroesophageal reflux, obstructive sleep apnea, knee pain, plantar fasciitis, thalassemia, G6PD deficiency, ___ syndrome, laryngeal reflux, allergic rhinitis, herpes, thenar atrophy, hyperlipidemia. Past Surgical History: Status post tubal, status post carpal tunnel. Sleeve gastrectomy ___ at ___ Social History: ___ Family History: Dad with DM, HTN Mom with DM, HTN, CAD Physical Exam: ADMISSION: Vital Signs: 98.2 124/81 88 18 100 Ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: slightly edematous and fluctuant R knee, L hand wrist elbow; all exquisitely TTP with limited ROM Neuro: CNII-XII intact DISCHARGE: General: Alert, oriented, no acute distress CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Right knee incision clean without discharge, LUE wrapped c/d/I, intact movement and circulation distally Neuro: Grossly intact Pertinent Results: ADMISSION: ___ 10:07PM BLOOD WBC-8.7 RBC-3.78* Hgb-11.5 Hct-35.1 MCV-93 MCH-30.4 MCHC-32.8 RDW-11.6 RDWSD-39.7 Plt ___ ___ 10:07PM BLOOD Neuts-60.3 ___ Monos-10.7 Eos-0.5* Baso-0.7 Im ___ AbsNeut-5.26 AbsLymp-2.38 AbsMono-0.93* AbsEos-0.04 AbsBaso-0.06 ___ 07:10AM BLOOD ___ PTT-29.3 ___ ___ 07:10AM BLOOD WBC-8.6 Lymph-21 Abs ___ CD3%-71 Abs CD3-1290 CD4%-44 Abs CD4-787 CD8%-27 Abs CD8-491 CD4/CD8-1.6 ___ 10:07PM BLOOD Glucose-132* UreaN-13 Creat-0.5 Na-137 K-5.2* Cl-104 HCO3-22 AnGap-16 ___ 07:10AM BLOOD Calcium-9.9 Phos-2.7 Mg-2.1 UricAcd-2.0* NOTABLE LABS: ___ 07:10AM BLOOD WBC-8.6 Lymph-21 Abs ___ CD3%-71 Abs CD3-1290 CD4%-44 Abs CD4-787 CD8%-27 Abs CD8-491 CD4/CD8-1.6 ___ 07:30AM BLOOD Ret Aut-1.6 Abs Ret-0.04 ___ 07:30AM BLOOD calTIBC-179* Hapto-290* Ferritn-356* TRF-138* ___ 07:35AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Negative HAV Ab-Positive ___ 07:35AM BLOOD ANCA-NEGATIVE B ___ 07:35AM BLOOD ___ CRP-172.5* ___ 07:35AM BLOOD PEP-NO SPECIFI ___ 07:35AM BLOOD C3-158 C4-20 ___ 07:35AM BLOOD HCV Ab-Negative ___ 07:10AM BLOOD HIV1 VL-NOT DETECT DISCHARGE: ___ 07:25AM BLOOD WBC-5.7 RBC-3.02* Hgb-9.4* Hct-28.2* MCV-93 MCH-31.1 MCHC-33.3 RDW-14.0 RDWSD-47.6* Plt ___ ___ 07:25AM BLOOD Glucose-81 UreaN-21* Creat-2.0* Na-141 K-4.7 Cl-106 HCO3-22 AnGap-18 ___ 07:25AM BLOOD ALT-61* AST-35 LD(LDH)-217 AlkPhos-160* TotBili-0.5 ___ 07:25AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.0 ___ 07:25AM BLOOD ___ STUDIES: ___ TTE: The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No vegetations or clinically-significant regurgitant valvular disease seen (excellent-quality study). Normal global and regional biventricular systolic function. Compared with the prior study (images reviewed) of ___, the findings are similar. Renal US ___: Limited evaluation of the left kidney. However, no hydronephrosis bilaterally. MICRO: NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: NEISSERIA GONORRHOEAE. Positive by PANTHER System, APTIMA COMBO 2 Assay. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY 2. Etravirine 400 mg PO DAILY 3. Cyanocobalamin 500 mcg PO DAILY 4. Cetirizine 10 mg PO DAILY 5. Vitamin D ___ UNIT PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Ranitidine 300 mg PO QHS Discharge Medications: 1. Abacavir Sulfate 600 mg PO DAILY RX *abacavir 300 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day Disp #*100 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. Doxycycline Hyclate 100 mg PO Q12H END ___ RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 5. LaMIVudine 150 mg PO DAILY RX *lamivudine [Epivir] 150 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 10 Days RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY Please stop taking when regular bowel movements. RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth once a day Disp #*14 Packet Refills:*0 8. Senna 8.6 mg PO BID constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 9. Ranitidine 150 mg PO QHS RX *ranitidine HCl 150 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 10. Cetirizine 10 mg PO DAILY 11. Cyanocobalamin 500 mcg PO DAILY 12. Etravirine 400 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Vitamin D ___ UNIT PO DAILY 15. HELD- Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY This medication was held. Do not restart Epzicom until YOUR DOCTOR TELLS YOU TO 16.CRUTCHES ICD-10 CODE: ___.80 EXPECTED LENGTH: 13 MONTHS PROGNOSIS: GOOD Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Septic Arthritis due to gonorrhea Acute Kidney Injury Vaginal Bleeding Secondary: HIV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DX HAND AND WRIST INDICATION: ___ year old woman with severe L wrist pain, joint tap shows WBC of 145k// acute process acute process acute process TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left hand. COMPARISON: None FINDINGS: Fine osseous detail is obscured by the overlying cast. There is pronounced soft tissue swelling extending from the base of the proximal phalanx to the wrist and distal forearm. Within the limitations of the study, there is no evidence of acute fracture or dislocation, significant degenerative changes, bony erosions or periostitis, nor suspicious lytic or sclerotic lesions. No soft tissue calcification or radio-opaque foreign bodies are detected. IMPRESSION: 1. Pronounced soft tissue swelling extending from the base of the proximal phalanx to the distal forearm without acute bony abnormality or osseous erosions makes osteomyelitis less likely. However, fine osseous detail is obscured by the overlying cast. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with acute ___ s/p joint washout// hydronephrosis? TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 12.8 cm. The left kidney measures 11.4 cm. Evaluation of the left kidney is limited due to poor acoustic window. There is no hydronephrosis bilaterally. There is no mass or stones in the right kidney. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder was completely collapsed. IMPRESSION: Limited evaluation of the left kidney. However, no hydronephrosis bilaterally. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by WALK IN Chief complaint: Body pain Diagnosed with Fever, unspecified temperature: 100.6 heartrate: 97.0 resprate: 18.0 o2sat: 100.0 sbp: 144.0 dbp: 92.0 level of pain: 10 level of acuity: 3.0

Ms. ___, You were admitted to ___ because you were having severe joint pain. WHILE YOU WERE HERE: - We found out that you had an infection in your joints called gonorrhea - We washed out your joints with surgery and gave you antibiotics - You had some kidney injury while you were here that is recovering now WHEN YOU GO HOME: - Please continue all medications as directed - Please follow-up with the doctors listed below - ___ monitor for the "alarm symptoms" listed below; if you experience any of these symptoms please call your doctor or return to the emergency room immediately We wish you 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 Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with hx remote paroxysmal afib presenting as transfer from OSH with c/o cough, n/diarrhea, and chest pain. Patient reports onset of cough/congestion 4d ago. Cough productive of green sputum. Had progressive fatigue, and yesterday had 6 episodes watery diarrhea with nonbloody emesis x1. Denies fevers/chills although did not take temp at home, no recent travel or sick contacts Yesterday evening then developed sharp left sided chest pain, left sided, ___, also involving left shoulder. Pain lasted about 10mins and went away on its own, denies associated aggravating or releiving factors. He presented to ___ where initial EKG showed STE in I, avL. Patient received nitro/morphine x1 with improvement in chest pain, however became bradycardic to the ___ with SBP 73/44, received 0.5mg atropine. Also received ASA 325, ceftriaxone, lovenox ___, toradol and 1L IVF. Plan was for PCI but this was aborted after reviewing subsequent EKGs. Also ceftriaxone x1 and 2L IVF. Trop/MB neg x2, WBC @ 15.3 with 52% bands. He was transferred to our ED for further eval. In the ED, initial vitals: 99 87 126/68 18 96% 3L, Tm 104.9. Iniital labs notable for chem-7 with bicarb 21, Bun/Cr ___ (baseline 1.0). CBC with plt 134, INR 1.3, lactate 2.5. trop neg, LFTs WNL. Patient was given tylenol, vanc/levofloxacin, oseltamivir and toradol x1, and 2L IVF. CXR was done with evidence of bibasilar opacities concerning for rapidly developing pneumonia vs. alveolar hemorrhage. On arrival to the MICU, patient has no complaints. Says he is feeling a little better. Denies dyspnea, chest pain, abdominal pain, no further episodes emesis or diarrhea since yesterday. Denies hemoptysis. Past Medical History: Low back pain Disc disorder of lumbar region PROSTATITIS, UNSPEC H/O SCC left forehead ___ Atopic Dermatitis paroxysmal atrial fibrillation - noticed on ETT in ___, asymptomatic Social History: ___ Family History: Unknown/adopted Physical Exam: Admission Physical Exam: ======================== Vitals- T: 98.4 BP: 106/64 hr 87 94% 4L General- awake, alert, NAD HEENT- EOMI, PERRLA, OMM no lesions Neck- supple JVP mildly elevated at 30deg to under mandible CV- RRR, split s2 more prominent during inhalation, no murmurs Lungs- rhonchi bilaterally with fair air movement, + egophany LLB Abdomen- mildly distended/hypertympanic, no r/g/r, +BS GU- no foley Ext- WWP no c/c/e Neuro- CN II-XII intact, strength ___ in UE and ___ b/l Dishcarge Physical Exam: ========================= Vitals - 97.9, 126/88, HR 72, 18, 97% on RA General- awake, alert, NAD HEENT- EOMI, PERRLA, OMM no lesions Neck- supple JVP mildly elevated at 30deg to under mandible CV- RRR, split s2 more prominent during inhalation, no murmurs Lungs- CTAB, improved egophany LLB Abdomen- mildly distended/hypertympanic, no r/g/r, +BS GU- no foley Ext- WWP no c/c/e Neuro- CN II-XII intact, strength ___ in UE and ___ b/l Pertinent Results: ADMISSION LABS =============== ___ 05:05AM BLOOD WBC-6.8 RBC-4.95 Hgb-15.3 Hct-46.1 MCV-93 MCH-30.9 MCHC-33.2 RDW-12.5 Plt ___ ___ 05:05AM BLOOD ___ PTT-36.9* ___ ___ 05:05AM BLOOD Glucose-127* UreaN-26* Creat-1.4* Na-137 K-4.0 Cl-101 HCO3-21* AnGap-19 ___ 05:05AM BLOOD Albumin-3.9 ___ 05:25AM BLOOD Lactate-2.5* DISCHARGE LABS =============== ___ 05:40AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.0* Hct-32.9* MCV-93 MCH-30.9 MCHC-33.4 RDW-12.9 Plt ___ ___ 05:40AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-145 K-3.4 Cl-106 HCO3-27 AnGap-15 ___ 05:40AM BLOOD Calcium-7.4* Phos-3.3# Mg-1.9 IMAGING ======= TTE: Normal global and regional biventricular systolic function. No diastolic dysfunction, pulmonary hypertension or pathologic valvular abnormality seen. No pericardial effusion. CXR: Short interval development of bibasilar opacities, which are concerning for a rapidly developing pneumonia versus alveolar hemorrhage. CT CHEST W/CONTRAST (___): 1. Bilateral pleural effusions, moderate on the left side without evidence of empyema. 2. Multifocal airspace disease which is predominant at the lung bases and is likely in keeping with multifocal pneumonia. Multiple mediastinal and hilar reactive lymph nodes are noted. 3. Incidental finding of a 6 mm non-obstructing stone in the upper pole of the left kidney. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Docusate Sodium 200 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. Guaifenesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL 5 mL by mouth every 6 hours Disp #*1 Bottle Refills:*0 4. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Pneumonia Secondary: Ileus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Cough and tachypnea. COMPARISON: Comparison is made with chest radiographs from ___. FINDINGS: PA and lateral images of the chest. There has been interval development of bibasilar opacities, which are concerning for a rapidly developing pneumonia versus alveolar hemorrhage. There appears to be a small left pleural effusion. There is no right pleural effusion or pneumothorax. The cardiomediastinal silhouette is unremarkable. IMPRESSION: Short interval development of bibasilar opacities, which are concerning for a rapidly developing pneumonia versus alveolar hemorrhage. Radiology Report AP CHEST, 7:27 A.M., ___. HISTORY: ___ man with rapidly developing basilar opacities. IMPRESSION: AP chest compared to ___: Large scale consolidation in both lower lungs developed between ___, most likely severe pneumonia or pulmonary hemorrhage. Aspiration is most likely scenario. Mild-to-moderate cardiomegaly unchanged. Pulmonary vascular congestion is probably a function of volume resuscitation. Small left pleural effusion is larger, small right pleural effusion, presumed. No pneumothorax. Radiology Report INDICATION: ___ year old man with pneumonia and distended abdomen, evaluate for intra-abdominal process TECHNIQUE: Single portable supine radiograph of the abdomen and pelvis was obtained. COMPARISON: None available. FINDINGS: There is mild gaseous distension of loops of small and large bowel with air seen within the rectum. No definite intraperitoneal free air is identified. Right basilar opacities partially imaged and better characterized on chest radiograph from the same day. IMPRESSION: Mild gaseous distention of loops of small and large bowel with air seen within the rectum. No evidence of obstruction. Radiology Report PORTABLE CHEST FILM ___ AT 7:34. CLINICAL INDICATION: ___ with pneumonia, here for followup. Comparison to ___ at 7:27. A portable AP upright chest film ___ at 7:34 is submitted. IMPRESSION: There is persistent opacification within the left lower lobe and to a somewhat lesser extent at the right lung base. These findings would be consistent with aspiration or pneumonia. The heart remains enlarged. No pulmonary edema. Probable small layering left effusion. No evidence of pneumothorax. Marked thoracolumbar curvature. Radiology Report INDICATION: ___ man with history of pneumonia and bacteremia. Evaluate for empyema. COMPARISON: No prior CT scan is available for comparison. Prior chest x-rays of ___ and ___ available for review. TECHNIQUE: Axial helical MDCT images were obtained of the chest after the administration of IV contrast. Multiplanar reformats were generated in the coronal and sagittal planes. DLP: 323 mGy-cm FINDINGS: There are bilateral pleural effusions, moderate on the left and small on the right. Loculated fluid is seen along the left major fissure. There is no enhancement of the pleural cavity to suggest an empyema. There is no pericardial effusion. The vessels of the mediastinum are patent. The main pulmonary artery is borderline in size, measuring 32 mm. There are multiple enlarged and prominent hilar and mediastinal lymph nodes. There is a 1 cm right paratracheal lymph node (series 3, image 19) and bilateral hilar lymph nodes measuring 9 mm on the right (series 3, image 26) and 9 mm on the left (series 3, image 28). These are likely reactive in nature. The trachea and proximal segmental bronchi are patent. There are bilateral patchy airspace and ground-glass opacities which are more predominant at the bases and most likely represent multifocal pneumonia and associated atelectasis. There is no pneumothorax. There is a non-obstructing 6 mm stone in the upper pole of the left kidney. The remainder of the visualized portion of the abdomen is unremarkable. No suspicious bony lesions. Dextroconvex thoracolumbar scoliosis. 14 mm rounded hyperdensity in the soft tissues of the back in the midline which may represent a sebaceous cyst (6b;115). IMPRESSION: 1. Bilateral pleural effusions, moderate on the left side without evidence of empyema. 2. Multifocal airspace disease which is predominant at the lung bases and is likely in keeping with multifocal pneumonia. Multiple mediastinal and hilar reactive lymph nodes are noted. 3. Incidental finding of a 6 mm non-obstructing stone in the upper pole of the left kidney. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 99.0 heartrate: 87.0 resprate: 18.0 o2sat: 96.0 sbp: 126.0 dbp: 68.0 level of pain: 0 level of acuity: 3.0

Dear Mr ___, It was a pleasure taking care of you during your stay at ___. You were admitted after you were diagnosed with pneumonia. We started you on antibiotics and you improved. You also had issues with moving your bowels which resolved with conervative measures. Please continue a full liquid diet at home (soups, jello, shakes) and advance to regular diet slowly as tolerated. ___ MDs

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Novocain / Lidocaine / Penicillins / Fentanyl / Morphine / Codeine / Motrin Attending: ___. Chief Complaint: nausea, polyuria, polydipsia Major Surgical or Invasive Procedure: PATIENT LEFT AMA. She did not wait for her paperwork, but was given a prescription for Metformin and instructed to follow up with her PCP. History of Present Illness: ___ with a PMH of HepC, arthritis on a narcotics contract, and multiple admission for ___ who presents with four days of malaise, fatigue, polyuria, and polydipsia. She called EMS and was found to have a FSBG >500 by EMS and brought into the ED. The patient is a poor historian, but notes subjective fevers, chills, cough, dysuria, and genital rash. She denied a history of diabetes or insulin use. She states that she eats significant amounts of sugar in the form of Koolaid, ice cream, and cookies. In the ED, initial vitals were: 98.7 78 155/97 16 94% RA Her glucose was >1000 and and AG of 26. She was given 10U of insulin and 3L of IV fluids. Her AG fell to 16 and her fingerstick fell to 513. On the floor, the patient arrived stating she felt much improved compared to when she had come in the ED. She expressed a desire to use diet and oral medications to control her diabetes rather than insulin, even acutely here while recovering. Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. Denies arthralgias or myalgias. Past Medical History: - seen by neurology for HA, sleep walking, possible long fiber neuropathy - chronic lower back pain - arthritis, on narcotics, has history of requesting early refills - HTN - HL - HepC - GERD - Depression - H/o viral labryinthitis with persistent vertigo - H/o MRSA PNA - H/o - S/p bilateral carpal tunnel release ___ Social History: ___ Family History: Sister with CAD in her ___. Physical Exam: ADMISSION: Vitals: 97.7 149/91 66 70 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM best at LUSB Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: no foley, white film surrounding labia Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE EXAM: Patient left AMA. Pertinent Results: ADMISSION LABS: ___ 09:56PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 09:56PM URINE RBC-4* WBC-3 BACTERIA-FEW YEAST-RARE EPI-1 ___ 09:56PM URINE MUCOUS-RARE ___ 03:15PM GLUCOSE-388* UREA N-10 CREAT-0.9 SODIUM-139 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 ___ 03:15PM CALCIUM-10.3 PHOSPHATE-2.3* MAGNESIUM-2.2 ___ 03:15PM OSMOLAL-302 ___ 09:52AM ___ PO2-46* PCO2-49* PH-7.34* TOTAL CO2-28 BASE XS-0 COMMENTS-PERIPHERAL ___ 09:52AM GLUCOSE-GREATER TH LACTATE-2.0 NA+-137 K+-4.0 CL--98 TCO2-25 ___ 09:52AM O2 SAT-73 ___ 09:45AM GLUCOSE-693* UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16 ___ 09:45AM CALCIUM-9.8 PHOSPHATE-3.4 MAGNESIUM-2.1 ___ 08:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 07:13AM GLUCOSE->500 LACTATE-3.0* NA+-130* K+-4.3 CL--88* TCO2-24 ___ 07:00AM GLUCOSE-1021* UREA N-15 CREAT-1.1 SODIUM-127* POTASSIUM-4.6 CHLORIDE-83* TOTAL CO2-23 ANION GAP-26* ___ 07:00AM cTropnT-<0.01 ___ 07:00AM WBC-9.6# RBC-5.03 HGB-16.2* HCT-52.0* MCV-104* MCH-32.3* MCHC-31.2 RDW-12.7 ___ 07:00AM NEUTS-75.7* ___ MONOS-3.2 EOS-0.8 BASOS-0.9 ___ 07:00AM PLT COUNT-247 STUDIES: ___ CXR - no acute process DISCHARGE LABS: ___ 07:15AM BLOOD WBC-6.3 RBC-4.45 Hgb-14.6 Hct-44.5 MCV-100* MCH-32.8* MCHC-32.8 RDW-13.0 Plt ___ ___ 07:15AM BLOOD Glucose-384* UreaN-9 Creat-0.7 Na-135 K-4.1 Cl-102 HCO3-24 AnGap-13 ___ 07:15AM BLOOD Calcium-9.8 Phos-1.7* Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain 2. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 3. Atenolol 25 mg PO DAILY 4. Amlodipine 10 mg PO DAILY 5. Simvastatin 10 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Acetaminophen 500 mg PO Q6H:PRN pain 9. Gabapentin 600 mg PO TID 10. Meclizine 25 mg PO Q8H:PRN vertigo Discharge Medications: 1. MetFORMIN (Glucophage) 500 mg PO BID RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 2. Acetaminophen 500 mg PO Q6H:PRN pain 3. Amlodipine 10 mg PO DAILY 4. Atenolol 25 mg PO DAILY 5. Gabapentin 600 mg PO TID 6. Meclizine 25 mg PO Q8H:PRN vertigo 7. Omeprazole 20 mg PO DAILY 8. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain 9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 10. Vitamin D 1000 UNIT PO DAILY 11. Simvastatin 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: hyperglycemia secondary diagnosis: chronic pain, opiate use vaginal yeast infection Discharge Condition: PATIENT LEFT AMA. She did not wait for her paperwork, but was given a prescription for Metformin and instructed to follow up with her PCP. Followup Instructions: ___ Radiology Report HISTORY: Cough and fever. Assess for pneumonia. COMPARISON: ___. FINDINGS: 2 views were obtained of the chest. The lungs are clear. There is no pneumothorax or pleural effusion aside from trace fluid on the minor fissure. Heart and mediastinal contours are unremarkable. IMPRESSION: No acute intrathoracic process. Trace fluid on the minor fissure. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: HYPERGLYCEMIA Diagnosed with NIDDM UNCONTROLLED temperature: 98.7 heartrate: 78.0 resprate: 16.0 o2sat: 94.0 sbp: 155.0 dbp: 97.0 level of pain: 13 level of acuity: 3.0

Dear Ms. ___, You were admitted to the hospital because your sugars were very elevated. We think that you likely have diabetes. We wanted to treat you with insulin while we were awaiting some more lab work, but you decided to leave the hospital against medical advice. You understand the risks of leaving the hospital without further treating your elevated blood sugars. It will be VERY important for you to follow up with your primary care doctor this week. We are giving you a prescription for metformin, a medication that can help lower your sugars. Please start taking this medication to help control your sugars and follow up with your primary care doctor. PATIENT LEFT AMA. She did not wait for her paperwork, but was given a prescription for Metformin and instructed to follow up with her PCP.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / aspirin Attending: ___ Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ female past medical history significant for smoking, COPD presented to the emergency department with a 3-day history of worsening of shortness of breath with exertion as well as intermittent lower extremity edema. Patient states that she has for the past few months had dyspnea walking up stairs, but no associated chest pain. Patient denies any fevers, chills but endorses significant coughing with some green/brown sputum the past few days. Patient states that this feels consistent with her prior COPD episodes but feels worse. If she attempts to ambulate for father than a few steps, she has a coughing fit and feels like she cannot breath. No lightheadedness or falls. Last TTE ___ with normal EF Spirometry ___ FEV1/FVC 65%, ___ 92% In the ED: - Initial vital signs were notable for: T98 HR96 BP130/66 RR16 O2-95 - Exam notable for: GA: Comfortable HEENT: No scleral icterus Cardiovascular: Normal S1, S2, regular rate and rhythm, no murmurs/rubs/gallops, 2+ peripheral pulses bilaterally Pulmonary: Rhonchi Abdominal: Soft, nontender, nondistended, no masses Extremities: No lower leg edema Integumentary: No rashes noted - Labs were notable for: FluAPCR: Negative FluBPCR: Negative BNP 292 - Studies performed include: CXR w volume overload - Patient was given: ___ 18:44 PO PredniSONE 50 mg ___ 18:44 IH Ipratropium-Albuterol Neb 1 NEB ___ 18:48 IH Ipratropium-Albuterol Neb 1 NEB ___ 22:41 IV Azithromycin ___ 00:27 NEB Ipratropium-Albuterol Neb 1 NEB ___ 05:06 NEB Ipratropium-Albuterol Neb 1 NEB ___ 08:28 PO/NG PredniSONE 50 mg - Consults: none Vitals on transfer: T98 HR76 BP131/80 RR16 ___ Upon arrival to the floor, patient confirms the above history. Respiratory decline has been going on for several months but she cannot identify clear trigger. Initially had trouble going up steps in her house, now also gets out of breath going down steps or walking on flat ground. She is unable to sleep flat because she "chokes" and needs to sit up. Denies chest pain or pressure at any time. No hemoptysis. Lives alone with her cat, no one around her are recent illnesses. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: - Nephrolithiasis with 4mm left UPJ stone in ___ - COPD - Asthma - Tubal pregnancy - Seizure disorder - Allergic rhinitis - GERD - Overweight - Sciatica - Stress incontinence - Active smoking - Depression with psychotic features, multiple prior suicide attempts - Bipolar disorder - History of pneumothorax - Pulmonary nodule - Chronic back pain Social History: ___ Family History: Heart disease, diabetes in multiple family members (MGM, ___. MI in PGM. Father with lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 1129) Temp: 97.2 (Tm 98.1), BP: 94/50 (94-118/50-73), HR: 69 (69-74), RR: 16, O2 sat: 97%, O2 delivery: 2L, Wt: 249.12 lb/113.0 kg GEN: Overnweight, sitting up in NAD, coughing frequently, speaking in full sentences HEENT: Sclera anicteric and without injection. MMM. NECK: Large, unable to visualize JVD but limited ___ habitus. CARDIAC: rrr, no mrg but difficult exam given coughing LUNGS: difficult exam as patient coughing w deep breaths. diffuse wheezing, rhonchi in upper lobes, crackles in bilateral lower fields. normal WOB on 2L NC ABDOMEN: obese, non-tender, non-distended, no rebound/guarding EXTREMITIES: warm, 1+ pitting edema bilateral, no cyanosis NEUROLOGIC: AOx3, CN2-12 intact. ___ strength throughout. DISCHARGE PHYSICAL EXAM: 24 HR Data (last updated ___ @ 753) Temp: 97.7 (Tm 98.5), BP: 124/78 (120-134/57-84), HR: 66 (66-80), RR: 20 (___), O2 sat: 96% (94-98), O2 delivery: 2L, Wt: 236.1 lb/107.09 kg GEN: Overweight, NAD, coughing intermittently, speaking in full sentences HEENT: Sclera anicteric and without injection. MMM. NECK: supple, no LVD CARDIAC: rrr, no mrg but difficult exam given coughing LUNGS: diffuse wheezing, rhonchi in upper lobes, crackles in bilateral lower fields. normal WOB on 2L NC ABDOMEN: obese, non-tender, non-distended, no rebound/guarding EXTREMITIES: warm, no cyanosis, trace edema NEUROLOGIC: AOx3, CN2-12 intact grossly, moving all extremities with purpose Pertinent Results: ADMISSION LABS: =============== ___ 06:54PM BLOOD WBC-8.2 RBC-4.65 Hgb-13.9 Hct-42.2 MCV-91 MCH-29.9 MCHC-32.9 RDW-13.4 RDWSD-44.7 Plt ___ ___ 06:54PM BLOOD ___ PTT-25.7 ___ ___ 06:54PM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-141 K-4.3 Cl-107 HCO3-24 AnGap-10 ___ 06:54PM BLOOD proBNP-292* ___ 06:54PM BLOOD cTropnT-<0.01 ___ 11:35PM BLOOD cTropnT-<0.01 ___ 05:40AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 ___ fluAPCR, fluBPCR - negative DISCHARGE LABS: =============== ___ 08:15AM BLOOD Glucose-97 UreaN-19 Creat-0.8 Na-141 K-4.2 Cl-105 HCO3-26 AnGap-10 ___ 08:15AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0 MICRO: ====== none IMAGING: ======== ___ CTA CHEST: There is no thoracic aortic dissection or aneurysm. There is mild scattered noncalcified atherosclerotic plaque throughout the thoracic aorta. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect to indicate the presence of pulmonary embolism. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. Heart size is normal. There is no pericardial effusion. The visualized inferior aspect of the thyroid gland appears unremarkable. There is no supraclavicular or axillary lymphadenopathy. Borderline right paratracheal lymph nodes measuring up to 10 mm in short axis are stable. There is no hilar lymphadenopathy. There is no pleural effusion. There is mild paraseptal emphysema, most pronounced in the bilateral upper lobes. A 4 mm left fissural nodule likely represents a lymph node (series 301, image 94). A 6 mm paramediastinal nodular density in the left upper lobe (series 2, image 37) is also stable. There is mild diffuse peripheral reticulation. There is no consolidation. There is mild linear subsegmental atelectasis and/or scarring in the bilateral lung bases. The airways are patent to the subsegmental level. This study is not tailored for subdiaphragmatic evaluation. Visualized upper abdominal structures are unremarkable. There is a small hiatal hernia. There is no suspicious osseous lesion. There are mild multilevel endplate degenerative changes of the thoracic spine. IMPRESSION: 1. No evidence of pulmonary embolism or acute pulmonary parenchymal process. ___ TTE: The left atrial volume index is normal. The right atrium is mildly enlarged. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 71 %. 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 mildly dilated descending aorta. 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 no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. No valvular pathology or pathologic flow identified. Normal pulmonary artery systolic pressure. ___ CXR: Persistent mild pulmonary edema. ___ CXR: Top-normal heart size with increased interstitial opacity suggestive of interstitial pulmonary edema. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 2. ClonazePAM 0.5 mg PO DAILY:PRN panic attack 3. Aspirin 81 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Cetirizine 10 mg PO DAILY 6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN GERD 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. TraZODone 50-100 mg PO Frequency is Unknown unknown 9. HydrOXYzine 50 mg PO Q6H:PRN anxiety 10. Omeprazole 20 mg PO DAILY 11. diclofenac sodium 1 % topical QID:PRN Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*1 Tablet Refills:*0 2. Nicotine Patch 14 mg/day TD DAILY RX *nicotine [Nicoderm CQ] 14 mg/24 hour apply one 14mg/24hr daily transdermal patch once a day Disp #*30 Patch Refills:*0 3. PredniSONE 40 mg PO DAILY Duration: 3 Doses RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2 Tablet Refills:*0 4. TraZODone 50-100 mg PO QHS:PRN unknown 5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN GERD 6. Aspirin 81 mg PO DAILY 7. Cetirizine 10 mg PO DAILY 8. ClonazePAM 0.5 mg PO DAILY:PRN panic attack 9. diclofenac sodium 1 % topical QID:PRN pain 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 12. HydrOXYzine 50 mg PO Q6H:PRN anxiety 13. Omeprazole 20 mg PO DAILY 14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 15.Outpatient Physical Therapy ICD10 H81.10 benign paroxysmal vertigo, unspecified ear Please perform vestibular physical therapy Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Acute hypoxemic respiratory failure COPD exacerbation Pulmonary edema Secondary diagnosis: Benign paroxysmal positional vertigo Panic attacks GERD Tobacco abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with COPD admitted with worsening SOB/DOE and being treated for COPD exacerbation. Pulm edema of unclear etiology was noted on prior imaging.// Interval change of pulmonary edema? TECHNIQUE: Chest PA and lateral COMPARISON: Radiograph of the chest performed on ___. FINDINGS: Mild cardiomegaly is unchanged compared to the prior exam. Mild pulmonary edema is unchanged. No large pleural effusion or pneumothorax. Visualized osseous structures are grossly unremarkable. IMPRESSION: Persistent mild pulmonary edema. Radiology Report EXAMINATION: CTA CHEST INDICATION: ___ woman w hx COPD (last PFTs "normal" per ___ note ___, ongoing smoker, presented w acute on chronic SOB and DOE, symptoms and findings concerning for both COPD exacerbation as well as potential congestive heart failure. However, PE is in differential given new O2 requirement and worsening SOB, in setting of recent ankle injury. // evidence of 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 2.5 s, 32.7 cm; CTDIvol = 23.2 mGy (Body) DLP = 758.4 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3 mGy-cm. 3) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 16.1 mGy (Body) DLP = 8.1 mGy-cm. Total DLP (Body) = 768 mGy-cm. COMPARISON: CT from ___. FINDINGS: There is no thoracic aortic dissection or aneurysm. There is mild scattered noncalcified atherosclerotic plaque throughout the thoracic aorta. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect to indicate the presence of pulmonary embolism. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. Heart size is normal. There is no pericardial effusion. The visualized inferior aspect of the thyroid gland appears unremarkable. There is no supraclavicular or axillary lymphadenopathy. Borderline right paratracheal lymph nodes measuring up to 10 mm in short axis are stable. There is no hilar lymphadenopathy. There is no pleural effusion. There is mild paraseptal emphysema, most pronounced in the bilateral upper lobes. A 4 mm left fissural nodule likely represents a lymph node (series 301, image 94). A 6 mm paramediastinal nodular density in the left upper lobe (series 2, image 37) is also stable. There is mild diffuse peripheral reticulation. There is no consolidation. There is mild linear subsegmental atelectasis and/or scarring in the bilateral lung bases. The airways are patent to the subsegmental level. This study is not tailored for subdiaphragmatic evaluation. Visualized upper abdominal structures are unremarkable. There is a small hiatal hernia. There is no suspicious osseous lesion. There are mild multilevel endplate degenerative changes of the thoracic spine. IMPRESSION: 1. No evidence of pulmonary embolism or acute pulmonary parenchymal process. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation temperature: 98.0 heartrate: 96.0 resprate: 16.0 o2sat: 95.0 sbp: 130.0 dbp: 66.0 level of pain: 6 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. Why did you come to the hospital? - You were having worse shortness of breath than usual, as well as leg swelling. What did you receive in the hospital? - You were treated for a COPD exacerbation with steroids and antibiotics. - You received a water pill to help remove fluid from your lungs. - We performed an ultrasound of your heart which did not show obvious signs of heart failure. - We performed a CAT scan of your chest which did not show blood clots. - You were evaluated by our physical therapy team, who diagnosed you with BPPV, which can be easily treated as an outpatient. - Your oxygen level improved and you were ready to leave the hospital. What should you do once you leave the hospital? - Try as hard as you can to stop smoking, as this will help improve your shortness of breath. - Take your medications as prescribed. - Attend your follow up appointments as scheduled. We wish you all the best! - Your ___ Care 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: Right facial droop, headache, and chest pain Major Surgical or Invasive Procedure: none History of Present Illness: At work, around 9:45 am, the patient reported the acute onset of a headache, along with chest pain and a right facial droop. The headache came on suddenly and remained in the front of his head. He experienced nausea, but no vomiting, photophobia, or vision changes. The chest pain was located substernally and was sharp. The patient reported that it felt "like food was stuck in my throat". The pain did not radiate and was constant. He felt that the right side of his face had drooped, but was not sure if it involved his forehead. He was able to comprehend speech but was non-fluent. He knew what he wanted to say and thought he was speaking clearly, but others noted that his speech was slurred but could be understood. A friend drove him home where his wife was returning from work, at which time she noted his right face was drooping. She activated EMS for transport to ___ ED for further evaluation. On arrival, his symptoms per the wife and clinical evaluation by the ED were gone (around 1200hrs). Per the patient and his wife's report, the patient has had a number of episodes similar to this in the past years with the most recent in ___ specifically, the facial weakness on the right side. He did not seek medical attention for these episodes, except for the first one that occured in ___. On neuro ROS, the pt denied loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denied difficulties producing or comprehending speech. Denied focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denied difficulty with gait. On general review of systems, the pt denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough. Denied palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: - Multiple reported TIA's in the past few years (reported by patient, evaluation was at ___) - Hepatitis C - Peripheral Artery Disease - COPD/Asthma - Hyperlipidemia - Hypertension - Elevated blood sugars ___ A1c% was >7%) - Active Tobacco Abuse - Obesity Social History: ___ Family History: - Per patient no history of cardiovascular disease, or stroke - Several relatives with lupus, including death of ___ year old son. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: Pain=7, T=98.3F, HR=56, BP=150/68, RR=16, SaO2=96% RA , Glucose 99 General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. 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. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive, had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch, pinprick in all distributions, and ___ strength noted bilateral in masseter VII: Right facial droop with good activation, 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, and is equal ___ strength bilaterally as evidenced by tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 5 R ___ ___ ___ 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 - Plantar response was flexor bilaterally. - Pectoralis Jerk was absent, and Crossed Adductors are absent. -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Did not assess ========================================== DISCHARGE PHYSICAL EXAM T=98.1F, HR=49-55, BP=135-157/67-88, RR=20, SaO2=94-96% RA , Glucose: 76-113 General: Awake, alert, oriented x3. Slightly frustrated by exam and having to repeat answers to questions. HEENT: NC/AT, MMM Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL, no rhonchi, rales, or wheezes Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, WWP Skin: no rashes or lesions noted 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. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive, had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch, pinprick in all distributions, and ___ strength noted bilateral in masseter VII: Slight face asymmetry but with good activation, 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: 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 R ___ ___ ___ 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 - Plantar response was flexor bilaterally. -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: normal gait but some difficulty with tandem gait Pertinent Results: ___ 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 12:18PM GLUCOSE-103 LACTATE-1.2 NA+-140 K+-4.2 CL--101 TCO2-25 ___ 12:11PM GLUCOSE-105* UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 ___ 12:11PM ALT(SGPT)-66* AST(SGOT)-63* ALK PHOS-86 TOT BILI-0.5 ___ 12:11PM cTropnT-<0.01 ___ 12:11PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.2 ___ 12:11PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:11PM WBC-11.4*# RBC-6.94* HGB-17.0 HCT-51.8 MCV-75* MCH-24.5* MCHC-32.8 RDW-15.7* ___ 12:11PM PLT COUNT-247 ___ 12:11PM ___ PTT-35.2 ___ CT: No acute intracranial process. Please note, MRI is more sensitive for detecting acute ischemia. No thrombosis, aneurysm or dissection within the principal arteries of the head and neck. MRI: No acute infarct. Extensive supratentorial white matter signal abnormalities, nonspecific but likely sequela of chronic small vessel ischemic disease in a patient of this age. Echo: Biatrial enlargement. Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Mildly dilated ascending aorta. No ASD/PFO demonstrasted on saline contrast injection CXR: Bibasilar opacities are likely atelectasis with low lung volumes, however, pneumonia could be considered in the correct clinical setting. Mild pulmonary edema. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Ipratropium Bromide MDI 2 PUFF IH QID 3. Amlodipine 10 mg PO DAILY 4. Viagra (sildenafil) 100 mg oral 1 tablet(s) 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough 6. Atenolol 100 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Nicotine Patch 21 mg TD DAILY 9. Pravastatin 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Ipratropium Bromide MDI 2 PUFF IH QID 4. Nicotine Patch 21 mg TD DAILY 5. Viagra (sildenafil) 100 mg oral 1 tablet(s) 6. Hydrochlorothiazide 25 mg PO DAILY 7. Amlodipine 10 mg PO DAILY 8. Azithromycin 250 mg PO Q24H Duration: 4 Days RX *clarithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough 10. Pravastatin 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: 1. Right facial droop and difficulty with language concerning for stroke. 2. Stroke work up 3. Alcohol dependency 4. Tobacco dependency 5. Hypertension 6. Hyperlipidemia 7. Headache 8. Diabetes 9. Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK INDICATION: Right facial droop and slurred speech. Evaluate for intra cerebral hemorrhage or CVA. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, rapid axial imaging was performed from the aortic arch through the brain during infusion of Omnipaque intravenous contrast material. Three-dimensional angiographic Images were generated. DOSE: DLP: 2360.74 mGy-cm COMPARISON: None. FINDINGS: NONENHANCED HEAD CT: There is no acute hemorrhage, edema or shift of the normally midline structures. The ventricles and sulci are of normal size and configuration for age. Confluent, periventricular white matter hypodensities, while nonspecific, are presumably sequela of chronic small vessel ischemic disease. Otherwise, the gray-white matter differentiation is preserved and there is no evidence for an acute, vascular territorial infarction. The basal cisterns are patent. There is no fracture. The included paranasal sinuses and mastoid air cells are well-aerated. The lenses and globes are unremarkable. HEAD AND NECK CTA: The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses. The distal cervical internal carotid arteries measure 5.5 mm in diameter on the left and 5.4 mm in diameter on the right. There is no evidence of aneurysm formation or other vascular abnormality. The lung apices are clear. The known hilar lymphadenopathy was not fully imaged. The thyroid is unchanged from the thyroid ultrasound of ___. The bones are unremarkable. IMPRESSION: 1. No acute intracranial process. Please note, MRI is more sensitive for detecting acute ischemia. 2. No thrombosis, aneurysm or dissection within the principal arteries of the head and neck. 3. This report is provided without 3D and curved reformats. When these images are available, and if additional information is obtained, then an addendum may be given to this report. Radiology Report INDICATION: Chest pain. Evaluate for pneumonia. TECHNIQUE: Bedside frontal chest radiograph. COMPARISON: Chest radiograph ___ and chest CT ___. FINDINGS: The lung volumes are low, resulting in crowding of bronchovascular structures. Bibasilar opacities are likely atelectasis, however, pneumonia could be considered in the correct clinical setting. There is no pleural effusion or pneumothorax. Bilateral hilar lymphadenopathy is unchanged. Heart is mildly enlarged but unchanged. There is mild pulmonary edema. IMPRESSION: 1. Bibasilar opacities are likely atelectasis with low lung volumes, however, pneumonia could be considered in the correct clinical setting. 2. Mild pulmonary edema. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ year old man with transient right facial droop. Evaluate for ischemia. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique. COMPARISON: CTA head and neck ___. FINDINGS: There is no evidence of acute infarction, edema, mass effect, or blood products. There are numerous foci of patchy and confluent T2/FLAIR hyperintensity in the subcortical, deep, and periventricular white matter. These are nonspecific but commonly seen due to severe chronic small vessel ischemic disease. The ventricles and sulci are normal in size for age. There is mild mucosal thickening of the frontal and ethmoid sinuses. There is scattered fluid in the right mastoid air cells. IMPRESSION: 1. No acute infarct. 2. Extensive supratentorial white matter signal abnormalities, nonspecific but likely sequela of chronic small vessel ischemic disease in a patient of this age. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain, R FACIAL DROOP Diagnosed with TRANS CEREB ISCHEMIA NOS temperature: 98.3 heartrate: 56.0 resprate: 16.0 o2sat: 96.0 sbp: 150.0 dbp: 68.0 level of pain: 7 level of acuity: 1.0

Dear Mr. ___, You were hospitalized due to the sudden onset of a right facial droop, headache, and chest pain. You had a CT and MRI of your brain which showed that you did not have a stroke. The symptoms you experienced were most likely due to a complex migraine, which is a type of headache. You have an appointment with Neurology to follow up. We are not making any changes to your regular medications. Please continue to take your regular medications as prescribed. Please followup with Neurology and your primary care physician as listed below. It was a pleasure providing you with care during this hospitalization. -The ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Oxycodone Attending: ___. Chief Complaint: Patient without Chief Complaint, per ED consult has history of behavioral changes and sleep disturbances Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year-old man with history of history ?afib/WPW on A/C, HTN, CHF, cirrhosis/EtOH, and 2wks ago wide exision of sarcoma resection bed (RLE). He was in his USOH until he underwent skin grafting on his RLE last ___. Following this, he has been complaining frequently of pain in that leg/ankle, and while taking several sedating medications, he developed drowsiness and mild behavioral changes. . His behavior was normal until ___ morning. At that time, his wife noticed that he was falling asleep at the breakfast table. He said he wanted to walk downstairs to put up his leg and watch TV. She argued against this (due to concern for falling on the stairs given his drowsy state and gait instability since the surgeries), but he went anyway. He had to catch himself on the wall near the bottom few stairs and sat on the staircase while she helped him up (no fall/trauma). He watched TV and dozed in his chair. His daughter says that he looked "fine" in the afternoon when she visited. His wife said that he would close his eyes and keep talking or mumbling sometimes, and that all his extremities would twitch or jerk briefly when he closed his eyes sometimes (I witnessed this in the ED room, see below). That night (___), he went to bed early, around 7:30pm, which is very out of character for him. His daughter checked on him, and he told her, "I'm fine, I just need rest." His wife says he arose at least 6x during the night to use his bedside urine container. This morning, he told his wife that he was speaking with his sister (in ___ on the phone, but there was no one there and no phone. She called the orthopedics office to discuss -- nurse there recommended 911, ED. . His wife and ___ say that he has no history of stroke or seizure. Never, at any time, was his speech slurred or garbled. Never was his comprehension abnormal. He never complained of weakness or numbness. A couple days ago, he mentioned blurry vision to his wife, in passing, but this resolved. No sustained or rhythmic jerking movements at any time. . His wife says he was prescribed a bottle of 40 tabs of oxycodone 5mg (q4h PRN). This was adequate for pain control for the first week, but this past ___, he said 5mg q4hrs was not cutting it for his pain. She says it is unusual for him to want to take medications of any kind. ___, she spoke with a nurse from the orthopedist's office, who suggested increasing to two tabs (10mg q4hrs). She gave him 10mg ___ night around 11pm. He got another 5mg and 5mg ___ morning and afternoon (none ___ evening), and the last dose of oxycodone was 5mg yesterday morning with breakfast (___). A visiting nurse suggested stopping the oxycodone at that point (started Tylenol) due to behavioral changes, as described above. In addition to the oxycodone, he was prescribed Ambien, which he took for a week after the skin grafting, then stopped this past ___ due to concern for sedating side-effects. Since that time (the past four nights), he has been taking 50mg of Benadryl every night. Also, his wife and daughter say that he stopped drinking on ___ (since the surgery). Prior to that, he drank ___ beers and a "nip" of ___ whiskey every night. The wife says he usually hides his EtOH intake from her, but they do not think he had anything to drink this past week. The daughter said his food intake is good (eggs, fruit, and milk every morning), but his fluid intake is poor. He was BIBA to our ED. NAD. VS and routine lab studies unremarkable (other than irreg HR in the ___, c/w h/o afib). He was given Tylenol ___ for leg pain and surgery consult saw him, said he was OK for follow-up and dressing changes as previously planned (See OMR note). We were consulted with the question "is this Neurologic?" Review of Systems: <negative except as above> On neuro ROS, the pt denies headache, loss of vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness (just related to RLE ankle/leg pain), numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait other than recent post-op basline. 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. + poor sleep (wife says he snores and should have sleep study) Past Medical History: 1. sarcoma RLE s/p excision and 2wks ago (late ___ an elective wide excision of the tumor bed (wound healing well per surgery note here in ED today. 2. atrial fibrillation on chronic A/C (warfarin ....) 3. status post ablation for ___ syndrome in ___ 4. congestive heart failure 5. cirrhosis 6. hemochromatosis diagnosed two to ___ years ago 7. hypertension 8. GERD 9. "asthma" 10. depression 11. hypothyroidism 12. int hemorrhoids Social History: ___ Family History: Significant for alcoholism. He has a brother who has hepatocellular carcinoma and there is a history of breast cancer in both his mother and a sister. Physical Exam: Vital signs @ED triage: T 99.2F HR 99-->77,irreg BP 144/77 RR 14 ___ 95% RA General: Awake, cooperative, NAD. Sleeping on arrival, awakens to verbal request. HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous membranes are moist. No lesions noted in oropharynx. Neck: Obese neck. Supple. No bruits. No lymphadenopathy. Mallampati IV airway. Pulmonary: Lungs CTA. Non-labored breathing. Cardiac: RRR, no loud M/R/G appreciated in ED core. Abdomen: Soft, non-tender, and non-distended. Extremities: Stasis changes above dressing/wrap RLE near and including ankle. Mildly tender. LLE minimal stasis changes; no ___. WWP feet/toes. ***************** Neurologic examination: Mental Status: Oriented to ___. Said date was the ___ and it was ___. Knew he was in ___ ED. Mildly confused, interrupts with questions and jokes. *Moderately inattentive -- can do DOWfw and bw. Can do MOYfw, but repeats fw when repeatedly asked to do bw. Speech was not dysarthric. Language is fluent with intact repetition and comprehension, normal prosody, and normal affect. There were no paraphasic errors. Able to read (raise your right hand -- yet does not follow the command) and write (how is the weather today?) without difficulty. Naming is intact. Able to follow both midline and appendicular commands. Memory - registers 3 objects and recalls ___ (out of order, with difficulty) at 4 minutes. Good knowledge of recent and current events, discussed upcoming election. Calculation was intact (answers seven quarters in $1.75, with difficulty). There was no evidence of apraxia, although ?utilization (used finger to brush teeth, hand to brush hair). Mild left-right confusion, but worked his way through instruction to tough left ear with right hand. Luria sequencing was good. Cube 3D copying impaired (draws three square/rectanglular shapes, no 3D features). Frontal release signs are: Not present (no glabellar, no grasp, no palmar-mental reflex). * Line-bisection task -- bisected lines appropriately, at center, but he left uncrossed all the lines to the left of center, and did not seem to notice when I asked repeatedly if anything was missing or if any lines were left uncrossed. -Cranial Nerves: I: Olfaction not tested. II: PERRL, 3.5 to 2mm and brisk. No anisocoria. Visual fields are grossly full, [although initially it seemed that he might be neglecting or missing part of the Left superior quadrant]. III, IV, VI: EOMs full and conjugate; no nystagmus. V: Facial sensation intact and subjectively symmetric to light touch and pin V1-V2-V3. VII: No ptosis, no flattening of either nasolabial fold. Normal, symmetric facial elevation with smile. Brow elevation is symmetric. Eye closure is strong and symmetric. VIII: Hearing intact bilaterally. IX, X: Palate elevates symmetrically with phonation. XI: ___ equal strength in trapezii bilaterally. XII: Tongue protrusion is midline. -Motor: No drift. No asterixis. Mild, low-amplitude high-frequency postural tremor. Normal muscle bulk and tone; no flaccidity, hypertonicity, or spasticity noted. Delt Bic Tri WE FE dIO/ADM | IP ___ ___ ___ L ___ ___ 5 5 5 5 5 5 R ___ ___ 5 5 5 5 4+ 5 -Sensory: * patient reports patchy "40%" deficit of pinprick in left arm and hand, sparing most but not all finger tips. Otherwise, there are no gross deficits to light touch, pinprick, cold sensation, or vibratory sensation in any extremity. Joint position sense is grossly normal in both lower extremities (great toes). Eyes-closed Finger-to-nose testing revealed no proprioceptive deficit (did not miss nose). No extinction. -Reflexes (left; right): Biceps (++;++) Triceps (++;++) Brachioradialis (+;+) Quadriceps / patellar -- cannot assess, as pt does not relax leg when about to strike. ___ / achilles (0;0) Plantar response appears flexor bilaterally, but contaminated by strong tickle response. -Coordination: Finger-nose-finger testing and heel-knee-shin testing with no dysmetria or intention tremor. No dysdiadochokinesia noted on rapid-alternating movements. -Gait: Stands without difficulty. Gait is slightly antalgic (c/o left foot/ankle pain). Good initiation. Narrow-base. Turns quickly. Able to walk on toes (pain, stopped quickly). Romberg absent, slight wobble. Pertinent Results: LABS ON ADMISSION: ___ 08:58AM BLOOD WBC-7.3# RBC-3.85* Hgb-11.7* Hct-36.7* MCV-95 MCH-30.5 MCHC-31.9 RDW-13.2 Plt ___ ___ 08:58AM BLOOD Neuts-77.3* Lymphs-14.8* Monos-6.4 Eos-1.1 Baso-0.4 ___ 11:26AM BLOOD ___ PTT-31.9 ___ ___ 08:58AM BLOOD Glucose-111* UreaN-26* Creat-1.1 Na-139 K-4.9 Cl-101 HCO3-30 AnGap-13 ___ 08:58AM BLOOD ALT-16 AST-22 AlkPhos-96 TotBili-0.4 ___ 08:58AM BLOOD Lipase-28 ___ 08:58AM BLOOD Albumin-3.7 ___ 08:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . CARDIAC ENZYMES: ___ 06:35AM BLOOD CK-MB-1 cTropnT-<0.01STROKE RISK FACTORS: . STROKE RISK FACTOR ASSESSMENT: ___ 06:35AM BLOOD Triglyc-68 HDL-33 CHOL/HD-4.9 LDLcalc-114 ___ 06:35AM BLOOD TSH-1.0 ___ CT Head: No evidence of acute intracranial process. No fracture identified. . ___ CXR: No acute cardiopulmonary process. Mild cardiomegaly. . ___ MRI/MRA: FINDINGS: MRI OF THE BRAIN: There is no evidence of intracranial hemorrhage, mass, mass effect or shifting of the normally midline structures. The ventricles and sulci are prominent, likely age related and involutional in nature. On FLAIR and T2, few scattered foci of high signal intensity are identified in the subcortical white matter and periventricular regions, which are nonspecific and may reflect chronic microvascular ischemic disease. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. There is no evidence of abnormal enhancement. The orbits are grossly unremarkable, the paranasal sinuses and mastoid air cells are clear. IMPRESSION: Slightly prominent ventricles and sulci, likely age related and involutional in nature. Few scattered areas of high signal intensity are demonstrated on T2 and FLAIR sequences, distributed in the subcortical white matter and periventricular regions, which are nonspecific and may reflect chronic microvascular ischemic disease. No diffusion abnormalities or areas with abnormal enhancement are identified. MRA OF THE HEAD: There is evidence of vascular flow in both internal carotid arteries as well as the vertebrobasilar system, no flow stenotic lesions or aneurysms larger than 2 mm in size are seen. The anterior, middle and posterior cerebral arteries are grossly unremarkable. Both vertebral arteries and the basilar artery are patent. IMPRESSION: Essentially normal MRA of the head with no evidence of flow stenotic lesions or aneurysms. MRA OF THE NECK: The origin of the supra-aortic vessels appears normal, the common carotid arteries are patent and the bifurcations are widely patent with no stenotic lesions. Both vertebral arteries are patent and appear unremarkable as well as the visualized intracranial structures. IMPRESSION: Normal MRA of the neck with no evidence of flow stenotic lesions or major vascular abnormalities. . ECG: Atrial fibrillation. No significant change compared with previous tracing of ___. Read by: ___. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 0 92 362/430 0 27 18 . LABS AT DISCHARGE: ___ 06:35AM BLOOD WBC-7.5 RBC-3.75* Hgb-11.7* Hct-37.0* MCV-99* MCH-31.3 MCHC-31.8 RDW-13.8 Plt ___ ___ 06:35AM BLOOD Glucose-97 UreaN-18 Creat-0.9 Na-140 K-4.2 Cl-101 HCO3-30 AnGap-13 ___ 06:35AM BLOOD ALT-16 AST-24 AlkPhos-95 TotBili-0.5 Radiology Report INDICATION: Altered mental status, evaluate for hemorrhage. COMPARISON: CT head on ___. TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. Coronal and sagittal reformations were performed. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or acute territorial infarction. Ventricles and sulci are normal in size and configuration for the patient's age. The gray-white differentiation is preserved. The visualized paranasal sinuses and mastoid air cells are well aerated. There is no fracture identified. IMPRESSION: No evidence of acute intracranial process. No fracture identified. Radiology Report INDICATION: Altered mental status, evaluate for pneumonia. COMPARISON: CT chest on ___. FINDINGS: PA and lateral views of the chest. There is mild cardiomegaly. The cardiomediastinal and hilar contours are normal. The lungs are clear. There is no evidence of pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Mild cardiomegaly. Radiology Report STUDY: MRI and MRA of the brain and MRA of the neck. CLINICAL INDICATION: ___ man with history of recent induced delirium, subtle right parietal signs on clinical exam of uncertain chronicity (left visual neglect). Evaluate for small right parietal lesion. COMPARISON: Prior head CT dated ___ and ___. TECHNIQUE: MRI of the brain. Pre-contrast axial and sagittal T1-weighted images were obtained, axial FLAIR, axial T2, axial magnetic susceptibility and axial diffusion-weighted sequences. The T1-weighted images were repeated after the administration of gadolinium contrast in axial T1, sagittal MP-RAGE and multiplanar reconstructions were provided. MRA OF THE HEAD: 3D time-of-flight arteriography of the head was obtained, multiple axial source images and maximum intensity projection images were reviewed. MRA OF THE NECK: Bolus tracking technique sequences were obtained after the intravenous administration of gadolinium contrast, coronal reformations and multiple maximum intensity projection images of the neck vessels were reviewed. FINDINGS: MRI OF THE BRAIN: There is no evidence of intracranial hemorrhage, mass, mass effect or shifting of the normally midline structures. The ventricles and sulci are prominent, likely age related and involutional in nature. On FLAIR and T2, few scattered foci of high signal intensity are identified in the subcortical white matter and periventricular regions, which are nonspecific and may reflect chronic microvascular ischemic disease. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. There is no evidence of abnormal enhancement. The orbits are grossly unremarkable, the paranasal sinuses and mastoid air cells are clear. IMPRESSION: Slightly prominent ventricles and sulci, likely age related and involutional in nature. Few scattered areas of high signal intensity are demonstrated on T2 and FLAIR sequences, distributed in the subcortical white matter and periventricular regions, which are nonspecific and may reflect chronic microvascular ischemic disease. No diffusion abnormalities or areas with abnormal enhancement are identified. MRA OF THE HEAD: There is evidence of vascular flow in both internal carotid arteries as well as the vertebrobasilar system, no flow stenotic lesions or aneurysms larger than 2 mm in size are seen. The anterior, middle and posterior cerebral arteries are grossly unremarkable. Both vertebral arteries and the basilar artery are patent. IMPRESSION: Essentially normal MRA of the head with no evidence of flow stenotic lesions or aneurysms. MRA OF THE NECK: The origin of the supra-aortic vessels appears normal, the common carotid arteries are patent and the bifurcations are widely patent with no stenotic lesions. Both vertebral arteries are patent and appear unremarkable as well as the visualized intracranial structures. IMPRESSION: Normal MRA of the neck with no evidence of flow stenotic lesions or major vascular abnormalities. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: HALLUCINATIONS Diagnosed with ALTERED MENTAL STATUS temperature: 99.2 heartrate: 77.0 resprate: 14.0 o2sat: 95.0 sbp: 144.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, . It was a pleasure taking care of you at ___. You were admitted due to having sleep disturbances and a concern for a change in your behavior. After initial evaluation in the ED there was concern that you might have had a stroke, and therfore you were admitted to the Neurology Service. An initial scan of your head was performed (CT Scan) and was reassuring. Afterwards you had another more detailed scan (MRI) to evaluate for stroke and it demonstrated no evidence of stroke, bleeding, masses or other clearly contributory changes. There were no obvious vessel abnormalities. In addition, several investigatory studies were done to evaluate for other causes of cognitive change; there were no signs of significant infectious or toxic-metabolic disturbances. It is thought that your thinking and behavior changed in the setting of increased use of pain medication and sleep aids. We stopped these agents (oxycodone, ambien, benadryl) at the time of admission, with excellent improvement in your thinking. (The abnormalities noted at the admission exam completely resolved as well.) We recommend you refrain from taking these medications in the future; please use tylenol (eg 650 mg every four hours as needed for pain). . We made the following changes to your medications: - discontinue ambien - discontinue benadryl - discontinue oxycodone . Please start thiamine, folate, and a multivitamin. . As you were discharged on the weekend, we were unable to schedule follow up appointments for you. Please coordinate an appointment with Dr. ___ (___).

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 leg pain Major Surgical or Invasive Procedure: IM nail insertion left tibia. History of Present Illness: This is a ___ year-old woman in her USOH until this afternoon when she sutained a mechanical fall from a chair. She was transferred from an OSH with a splint in place.She denies headstrike and LOC. She also denies, neck or chest pain. She presented to ___ ED with films demonstrating a tibia shaft fracture. Past Medical History: Hysterectomy, Depression, Anxiety Social History: ___ Family History: Non-contributory Physical Exam: Vitals: 99, 98.5, 71, 93/51, 18, 99%RA Gen: NAD, A and O X3 CV: RRR, no m/r/g Pulm: CTAB LLE: Aircast boot in place. Exposed toes +flex/extend, SITL, WWP, cap refill ,2sec. Pertinent Results: ___ 07:40AM BLOOD ___-44 ___ 07:40AM BLOOD 25VitD-PND Medications on Admission: Escitalipram 20 mg QD Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days 4. Escitalopram Oxalate 20 mg PO DAILY 5. Methocarbamol 750 mg PO QID:PRN muscls spasm Please take 1 tablet up to 4 times daily only as needed for muscle spasm. 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain 7. Senna 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: Left tibial shaft 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 CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: None. CLINICAL HISTORY: Tibia and fibula fractures, preop assessment. FINDINGS: AP upright and lateral views of the chest are provided. The lungs are hyperinflated, though clear. Patient is rotated to her left. No effusion or pneumothorax. No focal consolidation or signs of pulmonary edema. Cardiomediastinal silhouette is normal. Bony structures are intact. IMPRESSION: Hyperinflated lungs without superimposed acute pathology. Radiology Report HISTORY: Postreduction films. COMPARISON: Comparison is made to radiographs from the left tibia and fibula from outside hospital (___) from 5 hours prior. FINDINGS: 4 views of the left tibia and fibula demonstrate unchanged alignment of the obliquely oriented and displaced fracture through the proximal tibial shaft with angulation and posterior displacement of the proximal fracture fragment. Additionally, there is a minimally displaced segmental fracture through the proximal fibula (neck and ___ shaft). An overlying splint is in place. There is no evidence of joint effusion at the knee. IMPRESSION: Unchanged alignment of displaced proximal tibial shaft fracture. Minimally displcated segmental fracture of the proximal fibula. Radiology Report HISTORY: Left Tib/fib ORIF in OR COMPARISON: Radiograph ___. A total of 201 intraoperative images demonstrate a fracture in the proximal shaft of the tibia and segmental fibular fractures. Images obtained during placement of an IM nail with interlocking screws through the tibial fracture. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: TIB FIB FX Diagnosed with FX SHAFT TIBIA-CLOSED, FALL FROM CHAIR OR BED temperature: 98.7 heartrate: 74.0 resprate: 16.0 o2sat: 100.0 sbp: 127.0 dbp: 70.0 level of pain: 4 level of acuity: 3.0

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 4 weeks WOUND CARE: - You can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - Partial weight bearing in the LLE. - Remain in air cast boot until post op visit.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ======================================================= HMED ADMISSION NOTE Date of admission: ___ ======================================================= PCP: ___. ___ CC: ___ Major ___ or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ is a ___ yo ___ speaking man with h/o BPH with urinary retention c/b recurrent UTIs and dementia who presents with fevers, and confusion x 1 day. This is his third admission for identical symptoms within the last 2 months. ___ is unable to provide history given mental status so history obtained from his daughter who is his primary care taker. Per daughter, patient has been fine, at his baseline mental and functional status all week until yesterday. In fact, yesterday morning he walked with a walker, ate breakast as he typically does and was doing well. She returned from her afternoon walk and found him laying in his bed, confused, not answer questions and shivering. He also had abdominal distension and pain with palpation of his abdomen. She took his temperature and it was 101, she gave him 500mg PO Tylenol and watched him, he was no better and mounted another fever 4 hours later for which she gave him another 650mg tylenol. He had an "extra large" bowel movement and his abdomen pain resolved but by morning he was still shivering and confused so she brought him to the ED. In the ED, initial vitals were 98.5 91 73/47 19 99% RA. Labs were notable for marked leukocytosis, acute renal failure and elevated lactate. UA was grossly positive and CXR showing atelectasis. CT showing dilated sigmoid colon concerning for Ogilve. He was started on IV Vanc and Cefepime for possible UTI and/or pneumonia and admitted to medicine. Of note, this presentation is identical to his last two admissions. During prior admissions he was found to have a UTI, the first time treated with zosyn and he was transitioned to macrobid to complete a ___fter Cx returned E.Coli with significant resistance pattern. Last admissions his Cx returned positive for resistant Klebsiella and he was discharged to continue IV Meropenem. Regarding his BPH history, patient has had multiple admissions (4x in ___, 4x in ___ at ___ for UTI, urosepsis, or pyelonephritis. He has been evaluated by urology as inpatient for complicated foley placement and their complications as well as outpatient for voiding trial. He was started initially on macrobid for UTI ppx but now is on Fosfomycin QWeekly. On the floor, patient is confused, unable to communicate and appears to br shivering. Daughter is at the bedside and provides history. She reports his abdomen is much softer than before and he is no longer having abdominal pain and this is his baseline abdominal exam. Review of systems: Unable due to mental status Past Medical History: 1. BPH. 2. Hyperlipidemia. 3. Dementia, A+Ox1 at baseline 4. Acute cholecystitis ___ 5. UTI, recurrent, prior pyelonephritis Social History: ___ Family History: Unspecified coagulopathy in one of his daughters, otherwise none. Physical Exam: Admission PHYSICAL EXAM: Vitals: 100.1 PO 96 / 59 87 24 97 RA Pain Scale: Unable General: Patient appears acutely ill, he is confused, unable to communicate but makes eye contact, he is noticeably shivering and makes incoherent noises, mumbling. HEENT: Dry MM Neck: supple, JVP low, no LAD appreciated Lungs: Reduced air movement bilaterally though patient cannot follow commands. Bibasilar faint rales. CV: Regular rate and rhythm, S1 and S2 clear and of good quality, ___ systolic murmur at ___ most prominently Abdomen: Distended but soft, non-tender to palpation, no rebound or guarding, hypoactive bowel sounds, tympanic to percussion Ext: Warm, well perfused, full distal pulses, no clubbing, cyanosis or edema Neuro: Unable to communicate, non-verbal, mumbling Discharge physical exam: 97.9 PO 103 / 50 L Lying 68 16 98 RA Gen: Sitting in chair, NAD, interactive HEENT: MMM Cardiovascular: RRR ___ systolic murmur at apex. Pulmonary: Lung fields clear to auscultation throughout Gastroinestinal: Soft, distended, +BS, no TTP, no guarding or rebound. MSK: No edema, warm well perfused. Neurological: Alert, interactive, face symmetric, moving all extremities Pertinent Results: Admission Labs ___ 01:18PM BLOOD WBC-38.1*# RBC-3.44* Hgb-9.9* Hct-31.8* MCV-92 MCH-28.8 MCHC-31.1* RDW-16.7* RDWSD-57.0* Plt ___ ___ 01:18PM BLOOD ___ PTT-25.8 ___ ___ 01:18PM BLOOD Glucose-110* UreaN-20 Creat-1.3* Na-137 K-4.6 Cl-95* HCO3-22 AnGap-25* ___ 01:18PM BLOOD ALT-16 AST-33 AlkPhos-109 TotBili-0.4 ___ 01:18PM BLOOD Lipase-25 ___ 07:15PM BLOOD cTropnT-0.07* ___ 01:18PM BLOOD cTropnT-0.02* ___ 01:18PM BLOOD Albumin-4.3 ___ 01:39PM BLOOD Lactate-2.8* ___ 01:37PM BLOOD Lactate-3.1* Imaging: CT Head: No acute intracranial process. CT A/P: 1. Multiple dilated fluid and air-filled loops of small and large bowel. The sigmoid is markedly dilated compared to ___, but there is no transition point to suggest an obstruction. No bowel wall thickening. Again this may reflect ___ syndrome. 2. Other incidental findings include cholelithiasis and prostatomegaly CXR PA/LAT: 1. Patchy opacification at the medial lung bases bilaterally may reflect atelectasis, however an underlying pneumonia cannot be excluded. 2. Lucency under the right hemidiaphragm may be related to distended bowel loops. This can be resolved on the pending abdominal CT Prior Results: MICROBIOLOGY URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING ============== CT HEAD ___: No acute intracranial process. CT TORSO ___: 1. No evidence of acute intra-abdominal or pelvic abnormality. Persistent dilation of the sigmoid colon without bowel obstruction. 2. Cholelithiasis and common bowel duct dilation, unchanged since the prior study. 3. Thickened bladder wall may be secondary to chronic bladder outlet obstruction in the setting of a severely enlarged prostate. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl ___AILY constipation 2. Docusate Sodium 100 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY 4. Senna 17.2 mg PO BID 5. Simethicone 40-80 mg PO TID:PRN gas pain 6. Simvastatin 20 mg PO QPM 7. Tamsulosin 0.8 mg PO QHS 8. TraZODone 25 mg PO QHS 9. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY:PRN itch 10. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO) 11. Finasteride 5 mg PO DAILY Discharge Medications: 1. ertapenem 1 gram injection DAILY Duration: 3 Days Continue through ___ RX *ertapenem [Invanz] 1 gram 1 g IV daily Disp #*3 Vial Refills:*0 2. Fosfomycin Tromethamine 4 g PO EVERY 10 DAYS 3. Bisacodyl ___AILY constipation 4. Docusate Sodium 100 mg PO BID 5. Finasteride 5 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 17.2 mg PO BID 8. Simethicone 40-80 mg PO TID:PRN gas pain 9. Simvastatin 20 mg PO QPM 10. Tamsulosin 0.8 mg PO QHS 11. TraZODone 25 mg PO QHS 12. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY:PRN itch Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urosepsis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with cough, eval for pnacough, eval for pnaabd swelling, eval for intrabdominal infectionconfusion, eval for bleed in head// cough, eval for pnaabd swelling, eval for intrabdominal infectionconfusion, eval for bleed in head TECHNIQUE: Single AP radiograph of the chest. COMPARISON: Chest radiograph dated ___. FINDINGS: Low lung volumes. Left infrahilar consolidation is probably atelectasis rather than pneumonia because of leftward mediastinal shift and depression of the left hilus indicating volume loss. No pulmonary edema or consolidation elsewhere. Moderate cardiomegaly. No pleural abnormality. Lucency under the right hemidiaphragm is probably due to distended bowel loops rather than pneumo peritoneum. IMPRESSION: 1. Bilateral medial lung base atelectasis or pneumonia. 2. Lucency under the right hemidiaphragm may be related to distended bowel loops. The possibility of pneumoperitoneum will be resolved on the pending abdominal CT. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with cough, eval for pnacough, eval for pnaabd swelling, eval for intrabdominal infectionconfusion, eval for bleed in head// cough, eval for pnaabd swelling, eval for intrabdominal infectionconfusion, eval for bleed in head 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) = 714 mGy-cm. COMPARISON: Head CT dated ___. FINDINGS: There is no evidence of acute territory infarction,hemorrhage,edema,or mass effect. Subcortical, deep, and periventricular white matter hypodensities are nonspecific, but likely represent chronic microvascular ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of acute fracture. Mild mucosal thickening within the right sphenoid sinus. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT abdomen and pelvis with IV contrast. INDICATION: ___ with cough, eval for pnacough, eval for pnaabd swelling, eval for intrabdominal infection. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 624 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: LOWER CHEST: Dependent atelectasis at the lung bases bilaterally. No focal consolidations. No pleural or pericardial effusion. Cardiomegaly. Dense aortic valvular calcifications are visualized. ABDOMEN: HEPATOBILIARY: Subcentimeter hypodensity within the right lobe is too small to characterize, but likely represents a simple cyst or biliary hamartoma (series 2, image 22). Otherwise, the liver demonstrates homogenous attenuation throughout. There is no evidence of solid lesions. There is no evidence of intrahepatic dilatation. The common bile duct is prominent, but tapers distally, unchanged compared to prior. Multiple stones are seen within the decompressed gallbladder (series 2, image 32). 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: Multiple hypodensities are seen within the kidneys bilaterally, some of which are too small to characterize, others are consistent with simple cysts, and with intermediate density (series 2, image 33), likely represent proteinaceous cysts, unchanged compared to prior. Otherwise, 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: Small hiatal hernia. The stomach is unremarkable. Again seen are multiple dilated fluid and air-filled loops of small and large bowel. The sigmoid is markedly dilated in comparison to ___ measuring up to 13.6 cm (series 2, image 52). There is no transition point to suggest an obstruction, and there is air and fluid within the rectum. There is no bowel wall thickening. The bowel wall enhances normally throughout. 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 prostate is enlarged measuring 5.5 x 5.3 cm. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: Multiple chronic appearing left posterior rib fractures are visualized. Moderate levoscoliosis of the lumbar spine. Bilateral pars defects with grade 1 anterolisthesis of L5 on S1 is unchanged. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Multiple dilated fluid and air-filled loops of small and large bowel. The sigmoid is markedly dilated compared to ___, but there is no transition point to suggest an obstruction. No bowel wall thickening. Again this may reflect ___ syndrome. 2. Other incidental findings include cholelithiasis and prostatomegaly. Gender: M Race: BLACK/CARIBBEAN ISLAND Arrive by WALK IN Chief complaint: Altered mental status, Hypotension Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic temperature: 98.5 heartrate: 91.0 resprate: 19.0 o2sat: 99.0 sbp: 73.0 dbp: 47.0 level of pain: 0 level of acuity: 1.0

Mr. ___ it was a pleasure taking care of you during your stay at ___. You were admitted for an infection of your urinary tract. You were by the infectious disease specialist and treated with antibiotics. You will need to complete your antibiotic course at home.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: azithromycin / Dilaudid / morphine / Zofran (as hydrochloride) Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: EGD/colonoscopy with biopsy ___ History of Present Illness: Ms. ___ is a ___ woman who presents after leaving ___ ___ AMA this morning for further evaluation and treatment of lower abdominal pain and diarrhea. Patient reports having ongoing diarrhea and abdominal pain now for the past 8 weeks. Her diarrhea was as frequent as ___ a day in the beginning, mostly during the day. At times she would have incontinence of stool. On ___, she presented to the ED for these symptoms and was prescribed a week of Flagyl, which she says made the diarrhea and pain worse. During this time she had blood stools as well. She then presented to the ED again and was admitted. She had a colonoscopy by Dr. ___ at ___ and pathology returned for colitis with skip lesions, concerning for Crohn's disease vs c.diff. Repeat c.diff studies were negative. She was discharged. She represented to ___ on ___ with persistent diarrhea and abdominal pain and fevers to 102. She was started on solumedrol 40mg q8h per GI recommendations yesterday. She was planned to have an upper GI series but it was rescheduled and she became unsatisfied with her care there and thus left AMA. She continues to have ___ lower abdominal pain, mouth ulcers and diarrhea. Denies fever/chills at this time and denies blood in stool. Denies stools being dark or tarry. Reports odynophagia. Denies reflux, chest pain, shortness of breath. Reports hemorrhoids and rectal pain. She has had several similar episodes of abdominal pain and diarrhea over the last ___ years. She has had episodes of abdominal pain and diarrhea lasting as long as a week. They occur monthly or so. She was originally diagnosed with Celiac's disease although never had any blood work or biopsy. She has lost 17 pounds since end of ___. She also has had increases in her mouth ulcers. Initially started with ___ ulcers 8 weeks ago but then increased significantly. She endorses knee and angle swelling and pain as well. She denies any hip pain. She also has a rash on her thighs that she describes as appearing like pimples but then scabs over. In the ED, initial vital signs were: 98.3 88 134/83 16 100%RA - Exam was notable for: ulcers noted on uvula, gums and roof of mouth, all hemostatic, mildly tender to palpation in LLQ and RLQ, LLQ>RLQ - Labs were notable for: wbc 15.1, plts 428 - The patient was given: IV morphine - Consults: none Vitals prior to transfer were: 97.6 66 120/90 18 100% RA Upon arrival to the floor, patient feeling well. Continues to have some abdominal pain and diarrhea. Sores in her mouth are very painful as well. Past Medical History: asthma ? Celiac disease Social History: ___ Family History: - UC: mother - paternal grandmother: celiac's disease - maternal grandmother: colon cancer - significant diverticulitis in family. Physical Exam: ON ADMISSION VITALS: 98.5 124/82 66 18 100% RA GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, multiple small ulcers of the hard palate and posterior oropharynx, and uvula, multiple ulcers also of the gums of her lower teeth NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. There is very minimal edema of the ankles but they are tender to palpation. They is no palpable effusion of the knees. SKIN: There are scattered acne-like small lesions on an erythematous base of the left thigh, right thigh, and upper back NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. ON DISCHARGE VITALS: 97.9 123/90 45 18 98% RA GENERAL: Pleasant female in no acute distress, AAOx3 HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, small ulcers on posterior oropharynx NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally over anterior chest. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. Ankles TTP. They is no palpable effusion of the knees. SKIN: There are almost healed, scattered acne-like small lesions on an erythematous base of the inner thighs NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. Pertinent Results: ON ADMISSION ====================================== ___ 03:22PM URINE MUCOUS-RARE ___ 03:22PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-3 ___ 03:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:22PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03:22PM URINE UCG-NEGATIVE ___ 06:15PM PLT COUNT-428* ___ 06:15PM NEUTS-81.8* LYMPHS-10.8* MONOS-6.6 EOS-0.0* BASOS-0.3 IM ___ AbsNeut-12.33* AbsLymp-1.63 AbsMono-0.99* AbsEos-0.00* AbsBaso-0.05 ___ 06:15PM WBC-15.1* RBC-4.65 HGB-13.8 HCT-43.3 MCV-93 MCH-29.7 MCHC-31.9* RDW-12.9 RDWSD-43.5 ___ 06:15PM ALBUMIN-3.8 ___ 06:15PM ALT(SGPT)-14 AST(SGOT)-24 ALK PHOS-67 TOT BILI-0.2 ___ 06:15PM GLUCOSE-122* UREA N-10 CREAT-0.6 SODIUM-139 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17 CRP ___ 06:08AM BLOOD CRP-148.2* ___ 05:59AM BLOOD CRP-67.9* MICRO ==================== __________________________________________________________ ___ 12:19 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): __________________________________________________________ ___ 9:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. __________________________________________________________ ___ 3:05 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:11 am BLOOD CULTURE 1 OF 2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 8:08 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA 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. __________________________________________________________ ___ 7:55 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 1:42 pm THROAT CULTURE VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Pending): __________________________________________________________ ___ 9:44 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:22 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Log-In Date/Time: ___ 1:42 pm THROAT CULTURE VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Herpes simplex (HSV) virus isolated. ___ 8:08 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA 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. ___ 6:11 am BLOOD CULTURE 2 sets. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 9:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ___ 12:19 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. ___ 6:05 am Immunology (CMV) **FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. SACCHAROMYCES CEREVISIAE ANTIBODY PANEL Test Result Reference Range/Units S CEREVISIAE AB (IGA) 10.2 <=20.0 U Reference range(s): Negative : <=20.0 Equivocal: 20.1 - 24.9 Positive: >=25.0 Test Result Reference Range/Units S CEREVISIAE AB (IGG) 7.7 <=20.0 U QUANTIFERON-TB GOLD Test Result Reference Range/Units QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE Negative test result. M. tuberculosis complex infection unlikely. Test Result Reference Range/Units NIL 0.04 IU/mL MITOGEN-NIL 0.91 IU/mL TB-NIL <0.00 IU/mL Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL IMAGING: MR ENTEROGRAPHY ___: Along the cecum and ascending colon there is apparent wall thickening and hyperemia, however this may be secondary to nondistended bowel. The remainder the visualized loops of large and small bowel are within normal limits with no definite areas of wall thickening, or hyperemia identified. No extra intestinal manifestations of inflammatory bowel disease such as fibro fatty proliferation, mesenteric lymphadenopathy or engorgement of the vasa recta. No fluid collections. MRI OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST: Visualized liver, biliary tree, gallbladder, spleen, adrenal glands, and kidneys are within normal limits. Visualized bladder is unremarkable. Uterus and adnexa are within normal limits. No lymphadenopathy is seen within the abdomen or pelvis. No aneurysmal dilatation of the abdominal aorta. No acute or worrisome osseous lesions. IMPRESSION: No definite MR features of inflammatory bowel disease. Apparent wall thickening and hyperemia of the cecum and ascending colon may be secondary to nondistended bowel. No extra intestinal manifestations of inflammatory bowel disease. No fluid collections. PATHOLOGY: SURGICAL PATHOLOGY REPORT - Revised REVISED A: Immunohistochemical stain results: - H. pylori immunohistochemical stain (performed on part 1) is negative, with satisfactory control. - CMV immunohistochemical stains (performed on parts ___ are negative, with satisfactory control. PATHOLOGIC DIAGNOSIS: Gastrointestinal mucosal biopsies, five: 1. Stomach: - Antral mucosa with mild edema and minimal chronic inflammation, non-specific. - Immunohistochemical stain results for H. pylori will be issued in a revised report. 2. Duodenum: - Duodenal mucosa with intact villous architecture and rare foci of mildly increased intraepithelial lymphocytes. Note: The findings are mild and non-specific, but raise the possibility of a drug effect, infection, or celiac disease. Further correlation with clinical and serologic findings is recommended. 3. Ascending colon/cecum: ___ Department of Pathology Patient: ___ 2 of 3 - Focal severely active colitis with ulceration. See note. - Immunohistochemical stain results for CMV will be issued in a revised report. 4. Transverse colon: - Focal mildly active colitis. See note. - Immunohistochemical stain results for CMV will be issued in a revised report. 5. Rectum: - Mildly active colitis. See note. - Immunohistochemical stain results for H. pylori will be issued in a revised report Radiology Report EXAMINATION: MR ___ INDICATION: ___ year old woman with crohns, needs MRE to eval // eval crohns Colonoscopy performed ___ for rectal bleeding and diarrhea demonstrated inflammatory changes of the rectum and entire colon covering a non contiguous fashion, with biopsy results revealing increased inflammatory cells within the rectum, sigmoid and descending colon. No evidence of C diff colitis. TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis were acquired within a 1.5 T magnet, including 3D dynamic sequences performed prior to, during, and following the administration of 0.1 mmol/kg of Gadavist intravenous contrast (6 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0 mg of Glucagon was administered IM to reduce bowel peristalsis. COMPARISON: None. FINDINGS: MR ENTEROGRAPHY: Along the cecum and ascending colon there is apparent wall thickening and hyperemia, however this may be secondary to nondistended bowel. The remainder the visualized loops of large and small bowel are within normal limits with no definite areas of wall thickening, or hyperemia identified. No extra intestinal manifestations of inflammatory bowel disease such as fibro fatty proliferation, mesenteric lymphadenopathy or engorgement of the vasa recta. No fluid collections. MRI OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST: Visualized liver, biliary tree, gallbladder, spleen, adrenal glands, and kidneys are within normal limits. Visualized bladder is unremarkable. Uterus and adnexa are within normal limits. No lymphadenopathy is seen within the abdomen or pelvis. No aneurysmal dilatation of the abdominal aorta. No acute or worrisome osseous lesions. IMPRESSION: No definite MR features of inflammatory bowel disease. Apparent wall thickening and hyperemia of the cecum and ascending colon may be secondary to nondistended bowel. No extra intestinal manifestations of inflammatory bowel disease. No fluid collections. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Unspecified abdominal pain, Diarrhea, unspecified temperature: 98.3 heartrate: 88.0 resprate: 16.0 o2sat: 100.0 sbp: 134.0 dbp: 83.0 level of pain: 8 level of acuity: 3.0

Dear Ms. ___, You came to our hospital because of diarrhea and concern that you might have Crohn's disease. At our hospital we determined that this was an inflammatory bowel disease, possibly Crohn's disease. You had an MRI of your small intestine, an EGD and a colonoscopy, and were treated with steroids. Your pain and diarrhea improved with steroids. Please continue taking oral steroids and follow up with GI. We wish you all the best! -Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Naprosyn / Lisinopril / mirtazapine Attending: ___. Chief Complaint: abdominal discomofort and malaise Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ year-old woman with a history of HTN, spinal stenosis, vertigo, and anxiety who presents with a week of general malaise and low-grade fevers found to have new L upper lung opacity concerning for infection. Per the patient, she began feeling unwell last ___ with nausea, abdominal discomfort, decreased PO intake, dizziness and measured temperatures to ___ F. She describes the dizziness as occuring when walking and worse with sudden movement but not present if she is sitting/lying still. On ___, she saw an NP at her PCP's office where she was afebrile with T 93 but hypertensive BP 180/70. The nurse was concerned for "labyrinthitis and possibly due to otitis externa," for which she was prescribed topical Cortisporin drops and low-dose meclizine. She did not pick up the ear drops, but started taking meclizine, which she thought worsened her dizziness and subsequently discontinued. This morning, she woke up and attempted to drink a cup of coffee, which gave her significant nausea and abdominal discomfort and prompted her to come to ___ ED. ROS is positive for a dry cough that started around the time of her abdominal discomfort. She has also had a change in bowel habits - she typically has hard stools and takes daily metamucil and two stool softeners, but this past week she has had fewer bowel movements in the setting of PO intake followed by looser stools today. Notably negative for change in diet, sick contacts, F/C/CP/SOB, night sweats, weight loss/gain, headache, sinus tenderness, rhinorrhea,arthralgias or myalgias. In ___ ED, vital signs were 97.9 90 156/59 16 98% RA. Chem7 and CBC were unremarkable, and EKG was consistent with prior. CT Abd/Pelvis did not find any acute pathology to explain the patient's symptoms, but CXR showed new L upper lobe opacity concerning for infection. She was administered ceftriaxone azithromycin for possible pneumonia and admittion to Medicine. On arrival to the floor, patient's vitals were 98.8 143/51 85 18 97%RA. She was able to tolerate a small meal, and had a small loose bowel movement without any abdominal pain or nausea. Past Medical History: hypertension sarcoidosis iron deficiency anemia spinal stenosis stress incontinence depression chronic rhinitis diverticulosis SBO ___ Hpylori positive treated in ___ Social History: ___ Family History: Hypertension in many family members Sister and niece with DM Type 2 Sister with ___ Both children have thyroid disease Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.9 BP: 143/51 P: 81 R: 18 O2: 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII, motor, and sensory grossly intact. DISCHARGE PHYSICAL EXAM: Vitals: T: 98.5 BP: 132/66 P: 77 R: 20 O2: 95%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII, motor, and sensory grossly intact. Pertinent Results: ADMISSION LABS: ___ 07:40AM BLOOD Neuts-59.5 ___ Monos-7.3 Eos-1.4 Baso-0.9 ___ 07:40AM BLOOD Glucose-96 UreaN-20 Creat-0.6 Na-140 K-4.1 Cl-105 HCO3-28 AnGap-11 ___ 08:54AM BLOOD Lactate-0.9 DISCHARGE LABS: ___ 04:25AM BLOOD WBC-2.6* RBC-3.53* Hgb-10.9* Hct-34.5* MCV-98 MCH-30.9 MCHC-31.6 RDW-13.1 Plt ___ ___ 04:25AM BLOOD Glucose-88 UreaN-13 Creat-0.5 Na-140 K-4.7 Cl-104 HCO3-33* AnGap-8 STUDIES: ___ CT abdomen and pelvis: No acute pathology to explain pts symtoms. Degenerative changes of the thoracolumbar spine with deformity of T11 vertebral body of indeterminate chronicity. desc colon and sigmoid diverticulosis without evidence of diverticulitis. Mildly prominent panc duct, similar to decreased since ___. ___ CXR: 1. No acute focal consolidation. 2. 7-mm rounded opacity in the left upper lung new since 2 days prior and may be focus of infection; attention to this region on follow up imaging. MICROBIOLOGY: ___ Legionella Urinary Antigen -FINAL ___ Blood Culture x2-PENDING ___ C. difficile DNA amplification assay - Positive ___ FECAL CULTURE, CAMPYLOBACTER CULTURE, OVA + PARASITES - pending Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Fluticasone Propionate NASAL 2 SPRY NU BID 2. Gabapentin 300 mg PO QHS 3. Losartan Potassium 100 mg PO DAILY 4. Acetaminophen 1000 mg PO Q8H:PRN pain 5. Citracal + D Maximum *NF* (calcium citrate-vitamin D3) 315-250 mg-unit Oral BID 6. Docusate Sodium Dose is Unknown PO BID 7. Multivitamins 1 TAB PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Psyllium 1 PKT PO DAILY Discharge Medications: 1. Fluticasone Propionate NASAL 2 SPRY NU BID 2. Gabapentin 300 mg PO QHS 3. Losartan Potassium 100 mg PO DAILY 4. Levofloxacin 750 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H:PRN pain 6. Docusate Sodium 100 mg PO DAILY:PRN constipation 7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 8. Citracal + D Maximum *NF* (calcium citrate-vitamin D3) 315-250 mg-unit ORAL BID 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY 11. Psyllium 1 PKT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Pneumonia, C. difficile infection Secondary diagnoses: Hypertension, spinal stenosis, vertigo, anxiety, sarcoid 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: ___ female with abdominal pain, nausea, vomiting. Evaluate for chest pathology. COMPARISON: ___. PA AND LATERAL CHEST RADIOGRAPHS: Bilateral lungs are well expanded. Bilateral reticular nodular opacity similar to the prior examination. Calcification in the hila may reflect sarcoidosis, unchanged from the prior examination. The cardiac, mediastinal and hilar contours are unchanged from the prior examination. There is no evidence of pleural effusion or pneumothorax. There is a small 7-mm rounded opacity in the left upper lung, new since ___, 2 days prior. IMPRESSION: 1. No acute focal consolidation. 2. 7-mm rounded opacity in the left upper lung new since 2 days prior and may be focus of infection; attention to this region on follow up imaging. Radiology Report INDICATION: ___ female with abdominal pain, nausea, vomiting, green stool with urge to defecate, evaluate for enterocolitis, diverticulitis. COMPARISON: ___, CT of the chest with contrast, ___. TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis with the administration of IV contrast. Multiplanar reformats were generated and reviewed. FINDINGS: Visualized lung bases show mild opacification at the left lung base (2:80). Visualized heart and pericardium are unremarkable. The liver, gallbladder, spleen and bilateral adrenal glands appear unremarkable. The pancreatic duct appears mildly prominent, but improved compared to the CT of the chest with contrast of ___. Bilateral kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or renal calculi. Intra-abdominal loops of large and small bowel are within normal limits. There is no free air or free fluid within the abdomen. Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for pathology. Intra-abdominal vasculature appears normal in contour, with mild atherosclerotic calcification involving the abdominal aorta. CT OF THE PELVIS: There is evidence of sigmoid diverticulosis. There is also evidence of diverticulosis involving the descending colon. There is no evidence of colitis. The bladder, distal ureters, rectum and sigmoid colon appear unremarkable. The uterus appears within normal limits. There is no free fluid within the pelvis. Pelvic lymph nodes do not meet CT size criteria for pathology. Visualized osseous structures show multilevel degenerative changes including anterolisthesis of L4 on L5. Degenerative vacuum disc phenomenon is noted at the L3-L4, L4-L5 and L5-S1 disc spaces. Mild irregularity along the T11 vertebral body is unchanged from ___. IMPRESSION: 1. No definite acute abdominal pathology to explain patient's symptoms. 2. Descending colon and sigmoid diverticulosis without evidence of acute diverticulitis. 3. Mildly prominent pancreatic duct, but improved from ___. No definite acute intra-abdominal pathology. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: ABD PAIN Diagnosed with NAUSEA, OTHER MALAISE AND FATIGUE, FEVER, UNSPECIFIED temperature: 97.9 heartrate: 90.0 resprate: 16.0 o2sat: 98.0 sbp: 156.0 dbp: 59.0 level of pain: 13 level of acuity: 3.0

Dear Ms. ___, It was a pleasure to take care of you during this hospitalization. You were admitted to ___ ___ for abdominal discomfort and a dry cough. A chest X-ray was done that revealed a possible pneumonia, and you were given one dose of intravenous antibiotics followed by antibiotics by mouth. A stool sample was sent and revealed growth of a bacteria called C. difficile for which you were started on an antibiotic by mouth. You did not have any fevers, abdominal pain, or shortness of breath while you were in the hospital. You are now safe to go home to complete your oral antibiotics. The following medications were ADDED: - Please take Levofloxacin 750mg by mouth daily for 6 days - Metronidazole 500mg by mouth three times daily for 14 days Please hold your stool softeners until your diarrhea and infection resolve. Please take your medications as directed and attending your follow-up appointments as scheduled below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfamethoprim / Tegaderm / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: Nausea/Vomiting/Rash Major Surgical or Invasive Procedure: None History of Present Illness: REASON FOR MICU ADMISSION: hypoxemia, tachycardia HISTORY OF PRESENT ILLNESS: ___ is a ___ female with PMH significant for relapsed Hodgkin's lymphoma currently receiving Brentuximab/Bendamustine (C2D1 = ___ who presents with one day of fevers, rigors and N/V. Patient was in her usual state of health until last evening when she was noted by her mother to be ___ with N/V. Earlier in the day, patient had received cycle 2 day 1 of Brentuximab/Bendamustine without issue. She reported to the nearest emergency room (___) where she was noted to be febrile to ___, ___ and still with N/V. She then reportedly developed a erythematous rash beginning on her face and spreading to her trunk/arms. Mother reports that the rash developed prior to administration of any antibiotics or medications. She was given vanc/cefepime at ___. She was then transferred to ___ for further care. In the ED, initial vitals: ___, 120, 103/67, 20, 100% RA - Exam notable for erythematous rash of the face, arms and trunk. HR went as high as 150s. - Labs were notable for plts 118, lactate 2.2, Mg 1.2, HCO3 18. - CXR showed increased perihilar vascular markings. Left sided port access. No effusions or opacifications. - Patient was given: 2L IVF, IV Tylenol ___ x1, IV metoclopramide 10mg x1 and IV Zofran 4mg x1 with mild to moderate improvement in her symptoms - Consults: Heme/Onc On arrival to the MICU, patient reports feeling much better. Review of systems: (+) Per HPI Past Medical History: PAST ONCOLOGIC HISTORY: ___: CT Torso reveals extensive supraclavicular and anterior mediastinal lymphadenopathy, with two non-specific pulmonary nodules measuring up to 3 mm. - ___: Right cervical lymph node biopsy reveals classical Hodgkin Lymphoma, nodular sclerosis subtype. - ___: Bone Marrow Biopsy reveals normocellular bone marrow with maturing trilineage hematopoiesis, with no morphologic evidence of Hodgkin Lymphoma. Cytogenetics: 46,XX[20]. - ___: TTE shows normal LVEF (>55%). - ___: PET shows marked FDG uptake in a left supraclavicular lymph node conglomerate and anterior mediastinal lymph node conglomerate, gocal FDG uptake in the left posterior portion of the T9 vertebral body, diffuse increased FDG uptake throughout the bone marrow, and unusual distribution of higher density in the right breast may be normal breast tissue. - ___: PFTs demonstrate FEV1 87% of predicted, FEV1/FVC 0.82, and DLCO corrected for hemoglobin: 90% of predicted. - ___: C1D1 ABVD. - ___: MRI of the thoracic spine shows a focal lesion in the left side of the T9 vertebral body, approximately 2.3 x 1.6 cm with irregular peripheral edema and enhancement and a non-enhancing central area. - ___: EACOPP C1D1 ___ -___ disease (questionable history; likely not truly VW) -CAP treated as outpt at age ___ Social History: ___ Family History: Mother diagnosed with childhood leukemia. Otherwise no family h/o malignancy. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= Vitals: 99 100s 129/74 95%RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops 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: diffuse erythematous rash NEURO: moving all extremities DISCHARGE PHYSICAL EXAM: ========================= Pertinent Results: ADMISSION LABS: =============== ___ 10:40AM BLOOD WBC-3.2* RBC-4.17 Hgb-13.0 Hct-38.7 MCV-93 MCH-31.2 MCHC-33.6 RDW-13.2 RDWSD-44.4 Plt ___ ___ 10:40AM BLOOD Neuts-46 Bands-0 ___ Monos-24* Eos-0 Baso-0 Atyps-4* ___ Myelos-0 AbsNeut-1.47* AbsLymp-0.96* AbsMono-0.77 AbsEos-0.00* AbsBaso-0.00* ___ 10:40AM BLOOD Plt Smr-NORMAL Plt ___ ___ 10:40AM BLOOD UreaN-10 Creat-0.6 Na-137 K-4.1 Cl-103 HCO3-26 AnGap-12 ___ 10:40AM BLOOD ALT-46* AST-37 AlkPhos-67 TotBili-0.2 ___ 10:40AM BLOOD TotProt-6.9 Albumin-4.3 Globuln-2.6 Calcium-9.6 Phos-3.4 Mg-1.8 ___ 06:03AM BLOOD ___ pO2-73* pCO2-26* pH-7.45 calTCO2-19* Base XS--3 ___ 04:59AM BLOOD Lactate-2.2* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Lactulose 15 mL PO Q8H:PRN constipation 3. Dronabinol 5 mg PO BID 4. Atovaquone Suspension 750 mg PO DAILY 5. LORazepam 0.5 mg PO BID:PRN nausea 6. mometasone 50 mcg/actuation nasal DAILY 7. Acyclovir 400 mg PO Q8H 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 9. esomeprazole magnesium 40 mg oral DAILY:PRN heartburn Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Atovaquone Suspension 750 mg PO DAILY 3. Dronabinol 5 mg PO BID 4. esomeprazole magnesium 40 mg oral DAILY:PRN heartburn 5. Lactulose 15 mL PO Q8H:PRN constipation 6. LORazepam 0.5 mg PO BID:PRN nausea 7. mometasone 50 mcg/actuation nasal DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Drug reaction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with hodgkins lymphoma p/w tachycardia and new oxygen requirement // acute cardiopulmonary process TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Postradiation changes are noted. Cardiomegaly is mild. The lung fields are clear. A left Port-A-Cath terminates in the low SVC. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report INDICATION: History: ___ with hodgkins lymphoma s/p chemo (poss side effect pneumonitis), here w/ hypotension, tachycardia, fever // PE? Pneumonitis? 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 2) Stationary Acquisition 2.7 s, 0.2 cm; CTDIvol = 46.1 mGy (Body) DLP = 9.2 mGy-cm. 3) Spiral Acquisition 3.9 s, 25.1 cm; CTDIvol = 5.7 mGy (Body) DLP = 139.9 mGy-cm. Total DLP (Body) = 151 mGy-cm. COMPARISON: ___ FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. Prevascular mediastinal lymphadenopathy is slightly improved compared to the prior examination, with individual nodes measuring up to 8 mm in short axis diameter, previously 1 cm. Prominence of soft tissue in the anterior mediastinum may relate in part to prominence of thymic tissue/thymic rebound. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is no pleural effusion. Minimal ground-glass opacities in the left lower lobe and lingula likely reflect subsegmental atelectasis; a trace component up superimposed inflammatory change or atypical infection cannot be excluded. In the left upper lobe medially, a linearly configured area of ground-glass opacity and volume loss might reflect subsegmental atelectasis, or postradiation change if this has been performed. Motion artifact on the prior CT limits comparison between studies. The airways are patent to the subsegmental level. Limited images of the upper abdomen show diffuse hypodensity of the hepatic parenchyma consistent with hepatic steatosis. The imaged portion of the upper pole of the spleen appears unremarkable. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Prominence of soft tissue in the anterior mediastinum most likely reflect thymic hyperplasia/rebound and can be reassessed at followup imaging. 3. Slight interval improvement in mediastinal lymphadenopathy. 4. Minimal subsegmental atelectasis and/or superimposed inflammatory/atypical infectious changes at the left base and left apex. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Transfer Diagnosed with Fever, unspecified temperature: 102.0 heartrate: 120.0 resprate: 20.0 o2sat: 100.0 sbp: 103.0 dbp: 67.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, You were admitted with fevers, nausea, vomiting. You came to the ICU for a fast heart rate. You quickly improved with treatment for nausea and IV fluids. We found no evidence of an infection. We believe your symptoms are related to your chemotherapy regimen. After speaking to your oncologists we are holding this for now. You should follow up with your oncology team next week to discuss the next steps.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: CC: ___ Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The patient is a ___ y/o M with several months of BLE pain and muscle fasciculations of unclear etiology. He was recently admitted here with extensive work-up largely unrevealing (please refer to that discharge summary for further details). He presented to clinic today for ___ and experienced and acute pain episode in the waiting room with associated diaphoresis. While he stated that he would not have gone to the ED for this, clinic staff were concerned and referred him to the ED for evaluation. Neuro saw the patient in the ED and felt that exam was at baseline, recommended outpatient ___. In the ED, he also endorsed lightheadedness with standing as well as an episode of syncope several weeks ago. Orthostatics were checked and were positive. He was admitted to medicine for evaluation. ED Course: Initial VS: 98.3 ___ 18 98% RA Pain ___ Labs significant for lipase 67. UA with 30 RBC, 14 WBC, few bacteria. Imaging: CXR showing no acute cardiopulmonary process. Meds given: VS prior to transfer: 98.6 91 154/100 16 100% RA Pain ___ On my exam on the arrival to the floor, the patient described several months of BLE "electric shock" leg pains that started in the feet and progressed up to his back. This is associated with muscle fasciculations / spasms. These symptoms have actually improved since his recent admission. Since recent discharge, however, he reports new epigastric pain (x 2 weeks), which he attributed possibly to NSAIDs he was taking for pain. He also endorses ___ days of new spasms in his shoulders / upper back. Regarding his syncope, the episode occurred several weeks ago in the setting of walking from his bedroom to his dtr's room. Had prodromal darkening of vision. Episode was unwitnessed, but he does not believe he had a head strike. No further episodes, but he does note lightheadedness with standing. He does endorse poor PO intake and 40 lb weight loss since his symptoms began. Aside from the above symptoms, the patient also endorses intermittent episodes of diaphoresis, as well as difficulty concentrating and difficulty focusing his vision, all of which have been going on for the past few weeks. He also endorses several weeks of urinary urgency. ROS: As above. Denies chest pain, heart palpitations, shortness of breath, cough, vomiting, diarrhea, constipation. The remainder of the ROS was negative. Past Medical History: Neuropathy of unclear etiology (as described above) Venous ulcers S/p appy Obesity Pre-Diabetes History of TB Exposure s/p INH X 9 months Social History: ___ Family History: FAMILY HISTORY: Endorses a family history of ___. No other family history of neurologic disorders. Physical Exam: ADMISSION VS - 98.5 ___ 99%RA Pain ___ GEN - Alert, NAD HEENT - NC/AT NECK - Supple CV - RRR, no m/r/g RESP - CTA B ABD - Obese, soft, BS present, diffusely TTP without r/g EXT - No ___ edema or calf tenderness SKIN - Scab present on left calf (pt reports that has been there for a long time), hyperpigmentation of the skin of the BLE's NEURO - -- EOMI, PERRL -- ___ grip strength bilaterally; 4+/5 elbow flexion/extension; 4+/5 shoulder abduction -- ___ hip flexion, knee extension/flexion, ___ dorsiflexion/plantarflexion -- 2+ patellar and biceps reflexes bilaterally -- intermittent muscle fasciculations noted in the BLE's throughout interview PSYCH - calm, appropriate DISCHARGE VS: 97.6 ___ 99%RA Gen: sleeping, awaking to voice, then sitting up in bed, comfortable appearing Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft nontender, normoactive bowel sounds Ext - no edema Skin - venous stasis changes of legs bilaterally Vasc - 2+ DP/radial pulses Neuro - AOx3, ___ strength in lower extremities, hypersensitive to light touch of feet; Psych - mildly anxious Pertinent Results: ADMISSION ___ 03:25PM BLOOD WBC-8.8 RBC-4.90 Hgb-14.3 Hct-41.9 MCV-86 MCH-29.2 MCHC-34.1 RDW-13.4 RDWSD-41.6 Plt ___ ___ 03:25PM BLOOD Glucose-111* UreaN-15 Creat-0.7 Na-140 K-3.6 Cl-103 HCO3-25 AnGap-16 ___ 03:25PM BLOOD Albumin-4.2 Calcium-9.5 Phos-4.7* Mg-2.1 ___ 03:25PM BLOOD ALT-28 AST-20 AlkPhos-79 TotBili-0.3 DISCHARGE ___ 06:55AM BLOOD WBC-8.6 RBC-4.89 Hgb-14.2 Hct-42.1 MCV-86 MCH-29.0 MCHC-33.7 RDW-13.2 RDWSD-41.3 Plt ___ ___ 06:55AM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-137 K-3.6 Cl-100 HCO3-24 AnGap-17 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO DAILY 2. Gabapentin 1200 mg PO TID 3. Calcium Carbonate 500 mg PO QID:PRN heartburn 4. Lidocaine 5% Patch 3 PTCH TD QAM back pain 5. Methocarbamol 500 mg PO Q6H:PRN pain, muscle spasm 6. Acetaminophen Dose is Unknown PO Frequency is Unknown 7. Ranitidine 300 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Calcium Carbonate 500 mg PO QID:PRN heartburn 3. DULoxetine 90 mg PO DAILY RX *duloxetine 30 mg 3 capsule(s) by mouth once a day Disp #*42 Capsule Refills:*0 4. Gabapentin 1200 mg PO TID 5. Methocarbamol 500 mg PO Q6H:PRN pain, muscle spasm 6. Ranitidine 300 mg PO BID 7. lidocaine HCl 3 % topical BID:PRN pain RX *lidocaine HCl 3 % apply to affected area twice a day Refills:*0 8. Melatin (melatonin) 3 mg oral QHS:PRN insomnia this is an over the counter medication to try to help you sleep Discharge Disposition: Home Discharge Diagnosis: # Orthostatic Hypotension / Neuropathy / Lower Extremity Pain # Delirium # Depression # GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with cough // eval for pneumonia TECHNIQUE: PA and lateral views the chest. COMPARISON: None. FINDINGS: The lungs are clear. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: B Leg pain Diagnosed with Orthostatic hypotension temperature: 98.3 heartrate: 105.0 resprate: 18.0 o2sat: 98.0 sbp: 164.0 dbp: 104.0 level of pain: 5 level of acuity: 3.0

Mr ___: It was a pleasure caring for you at ___. You were admitted with dizziness. You were seen by neurologists and given IV fluids. Your symptoms improved and your blood pressure improved. The neurologists recommended following up with them in clinic for additional testing--they will be in touch regarding scheduling a time. During your hospital stay you were were confused. You were seen by psychiatry who felt that this was a reaction to too much stress and not enough sleep. They recommended increasing the dose of your Cymbalta and considering using melatonin to help with your sleep. It is really important that you find health ways to manage your stress--please consider seeing a therapist to discuss this. You are now ready to leave the hospital.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Transfer for recurrent RP Bleed s/p failed R Renal aa embolization and right pleural effusion Major Surgical or Invasive Procedure: ___ Right pleural pigtail catheter placement ___ Right VATS decortication, evacuation of effusion History of Present Illness: ___ yo F hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b (RAS and HTN) w/ recent admission at ___ for angioplasty of right renal artery c/b by RP bleed (embolized ___ @___) presented to ___ for right flank and abd pain. ED course at ___ w/CT showing ?enlarged hematoma and a large right sided effusion. Patient refused transfer back to ___, thus transferred to ___ for further evaluation by ___ and thoracic surgery. In further discussion with patient predominant symptoms of dyspnea and R sided chest pain, RLQ abd pain. First noted ___ days ago and have progressively worsened. Endorses worsening pain, occasional lightheadedness w/o syncope, chest pain, palpitaitons. Denies fever/chills/n/v/myalgias. ED course also significant for consultations by both thoracic surgery and ___. Given no active extravasation on in house CT-A, a multidisciplinary plan was made to hold on ___ intervention, trend h/h and plan to have thoracics place pigtail cath early am for symptomatic relief non-urgently. Past Medical History: hep C IVDA PCKD - Previously managed at ___ s/p angioplasty of right renal artery c/b by RP bleed (embolized ___ @ ___) FMD c/b RAS and HTN HTN Social History: ___ Family History: -Father, deceased - ___ Cancer. Unknown if had PCKD. -Mother, living - also w/FMD w/o PCKD. CVA x2 at ages ___ and ___. Lives in ___. -Siblings: 1 sister 2 brothers. No medical conditions she's aware of. They have not been tested for PCKD -PGF: Cancer General: no fhx of DM, MI, early sudden cardiac death Physical Exam: Vitals- 98.0 PO 137 / 87 L Lying 91 28 96 RA GENERAL: somewhat cachectic appearing. AOx3, in significant discomfort. HEENT: some temporal wasting. PERRLA. EOMI. No conjunctival pallor or injection, sclera anicteric. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Left lung fields clear to auscultation. Right upper ___ clear, middle ___ diminished and lower ___ absent breath sounds. No rhochi or wheezing. BACK: Skin w/o rashes. tenderness of right flank to light percussion ABDOMEN: Clonidine patch from ___ on RLQ abdomen. Normal bowels sounds, non distended, mild tenderness to RLQ. No organomegaly. EXTREMITIES: wtp. No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy or infection. NEUROLOGIC: CN2-12 intact. Labs, Microbiology: reviewed, please see attached Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 04:55 5.1 4.07 10.6* 33.7* 83 26.0 31.5* 13.5 40.8 365 ___ 05:00 7.2 4.34 11.4 35.7 82 26.3 31.9* 13.5 41.1 452* ___ 06:15 5.2 4.17 11.2 34.3 82 26.9 32.7 13.5 40.8 430* ___ 05:20 5.3 4.27 11.3 35.0 82 26.5 32.3 13.6 40.4 414* ___ 10:16 5.6 4.24 11.8 35.4 84 27.8 33.3 14.0 42.2 390 ___ 01:00 6.3 4.25 11.4 34.9 82 26.8 32.7 13.8 41.3 423* Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 04:55 ___ 138 3.5 100 28 14 ___ 05:00 ___ 137 4.5 99 25 18 ___ 06:15 821 11 0.7 142 4.2 ___ ___ 10:16 ___ 140 4.0 ___ ___ 01:00 ___ 3.7 ___ ALT AST LD(___) CK(CPK) AlkPhos Amylase TotBili DirBili ___ 05:20 291* ___ 109* 36 0.7 ___ 2:45 pm PLEURAL FLUID RIGHT PLEURAL FLUID. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Imaging ___ CTA torso 1. Nonhemorrhagic large right pleural effusion causing near completely collapse of the right lung with moderate leftward mediastinal shift. 2. A large right perinephric hematoma encompasses the right kidney. There is no evidence of active arterial extravasation. Renal arteries are patent. No pseudoaneurysm. Metallic devices, likely related to coil embolization seen in the medial aspect of the right kidney. There are wedge-shaped infarcts within the posterior cortex of the right renal interpolar region. 3. The left kidney is severely atrophic with severe thinning of the cortical parenchyma and hydronephrosis with foci of calcification within the dependent portion of the lower pole calyces. Stranding of fat surrounding the left proximal ureter as well as ill-defined soft tissue stranding within the ipsilateral psoas muscle adjacent to the proximal ureter and enhancing lymph nodes in the left para-aortic region measuring up to 1 cm in short axis raise suspicion for chronic infection as an etiology for the above described findings. Comparison with any prior imaging if available is recommended to ascertain the exact cause for chronic renal atrophy on the left. 4. The liver demonstrates heterogeneous attenuation however without delayed phase imaging unable to distinguish between perfusional variant versus ischemic changes. 5. Mild splenomegaly. ___ CT chest Interval placement of a right-sided pleural drain. The right-sided pleural effusion has significantly decreased in size with decreased mediastinal shift and re-expansion of the right upper and middle lobes. However, a large right-sided effusion persists, with collapse of the right lower lobe. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. HydrALAZINE 100 mg PO TID 2. Ferrous Sulfate 325 mg PO DAILY 3. TraZODone 50 mg PO QHS:PRN insomnia 4. Carvedilol 25 mg PO BID 5. amLODIPine 10 mg PO DAILY 6. ClonazePAM 0.5 mg PO BID 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:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 3. Milk of Magnesia 30 mL PO Q12H:PRN constipation 4. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour 1 once a day Disp #*14 Patch Refills:*2 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN no bm for 48h 7. Senna 8.6 mg PO DAILY RX *sennosides [senna] 8.6 mg 1 tab by mouth once a day Disp #*30 Tablet Refills:*2 8. amLODIPine 10 mg PO DAILY 9. Carvedilol 25 mg PO BID 10. ClonazePAM 0.5 mg PO BID 11. Ferrous Sulfate 325 mg PO DAILY 12. HydrALAZINE 100 mg PO TID 13. TraZODone 50 mg PO QHS:PRN insomnia 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 EXAMINATION: CTA Torso INDICATION: History: ___ with R pleural effusion, recent RP bleed ___ renal stenosis procedure // Eval for active bleed, etiology of R pleural effusion TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast in the arterial phase. Then, imaging was obtained through the abdomen and pelvis in the arterial phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8 mGy-cm. 2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8 mGy-cm. 3) Spiral Acquisition 4.9 s, 53.0 cm; CTDIvol = 6.2 mGy (Body) DLP = 328.8 mGy-cm. 4) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 3.2 mGy (Body) DLP = 1.6 mGy-cm. 5) Spiral Acquisition 9.1 s, 71.1 cm; CTDIvol = 6.5 mGy (Body) DLP = 461.5 mGy-cm. Total DLP (Body) = 793 mGy-cm. COMPARISON: CT abdomen ___. Chest film ___. FINDINGS: CHEST: 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: The mediastinum is shifted to the left because of the massive right pleural effusion. No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: A large nonhemorrhagic right pleural effusion is slightly hyperdense and may represent the presense of proteinaceous debris, ___ not in the range of hemorrhagic products. LUNGS/AIRWAYS: The right lung is near completely collapsed by a right pleural effusion. The left lung is clear. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates heterogeneous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic biliary dilatation. Common bile duct is mildly enlarged measuring 6.0 cm and tapers towards the ampulla. 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 is enlarged measuring 14.3 cm, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: A large 10.1 x 9.2 cm retroperitoneal perinephric hematoma encompasses the right kidney, not significantly changed in size since ___. There is no evidence of active extravasation. There are wedge shaped areas of hypoattenuation of the posterior cortex of the right kidney compatible with infarcts. A few subcentimeter hypodensities are seen in the right kidney, too small to characterize, likely simple cysts. There is severe thinning of the left renal cortical parenchyma with severe hydronephrosis and multiple foci of calcification within the residual left renal cortex in the interpolar region as well as the lower pole. The left ureter is not markedly dilated, etiology for severe left renal atrophy is unclear based on this scan alone. Stranding of fat surrounding the left proximal ureter as well as ill-defined soft tissue stranding within the ipsilateral psoas muscle adjacent to the proximal ureter and enhancing lymph nodes in the left para-aortic region measuring up to 1 cm in short axis raise suspicion for chronic infection as an etiology for the above described findings. Comparison with any prior imaging if available is recommended to ascertain the exact cause for chronic renal atrophy on the left. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no free air. PELVIS: The urinary bladder and distal ureters are unremarkable. There is mild free fluid in the pelvis. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: There are multiple enlarged left para-aortic lymph nodes measuring up to 10 mm in short axis, of questionable etiology. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. The mesenteric vessels are patent. Embolization of a branch of the right renal artery is noted. The left renal artery is patent. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or acute fracture. There is an intramuscular lipoma within the right lateral abdominal wall muscles (series 4, image 167- 190). IMPRESSION: 1. Nonhemorrhagic large right pleural effusion causing near completely collapse of the right lung with moderate leftward mediastinal shift. 2. A large right perinephric hematoma encompasses the right kidney. There is no evidence of active arterial extravasation. Renal arteries are patent. No pseudoaneurysm. Metallic devices, likely related to coil embolization seen in the medial aspect of the right kidney. There are wedge-shaped infarcts within the posterior cortex of the right renal interpolar region. 3. The left kidney is severely atrophic with severe thinning of the cortical parenchyma and hydronephrosis with foci of calcification within the dependent portion of the lower pole calyces. Stranding of fat surrounding the left proximal ureter as well as ill-defined soft tissue stranding within the ipsilateral psoas muscle adjacent to the proximal ureter and enhancing lymph nodes in the left para-aortic region measuring up to 1 cm in short axis raise suspicion for chronic infection as an etiology for the above described findings. Comparison with any prior imaging if available is recommended to ascertain the exact cause for chronic renal atrophy on the left. 4. The liver demonstrates heterogeneous attenuation however without delayed phase imaging unable to distinguish between perfusional variant versus ischemic changes. 5. Mild splenomegaly. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with RP bleed and right pleural effusion // interval change post pig tail interval change pre pig tail IMPRESSION: Right pigtail catheter is in place. Large pleural effusion on the right has decreased since the prior study. There is small to moderate pneumothorax. Left lung is clear. Heart size is top-normal. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b (RAS and HTN) w/ recent admission at ___ for angioplasty of right renal artery c/b by RP bleed (embolized ___ @___) presented to ___ for right flank and abd pain found to have recurrent RP bleed w/o active bleeding on ___ imaging and right pleural effusion, dyspneic admitted for pig tail catheter placement. // Please evaluate pleural effusion Please evaluate pleural effusion IMPRESSION: Comparison to ___. Minimal decrease in extent of the known right pleural effusion. An air-fluid level at the right lung apex confirms the presence of intrapleural air. Mild leftward mediastinal shift. Normal size of the heart. Normal appearance of the left lung. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ yo F hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b (RAS and HTN) w/ recent admission at ___ for angioplasty of right renal artery c/b by RP bleed (embolized ___ @___) presented to ___ ___ for right flank and abd pain found to have recurrent RP bleed w/o active bleeding on ___ imaging and right pleural effusion, dyspneic admitted for pig tail catheter placement. // Please evaluate lung and R pleural effusion 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 ___ and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 9.7 s, 37.2 cm; CTDIvol = 6.9 mGy (Body) DLP = 246.3 mGy-cm. Total DLP (Body) = 258 mGy-cm. COMPARISON: CT torso from ___ FINDINGS: HEART AND VASCULATURE: 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 is noted. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. There is interval decreased mediastinal shift. PLEURAL SPACES: A right-sided pigtail catheter is noted within a large pleural effusion, which has significantly decreased in size compared to previous. Diffusion again demonstrates internal attenuation compatible with simple fluid. There is a small right-sided pneumothorax. LUNGS/AIRWAYS: There is interval re-expansion of the right upper and middle lobes. The right lower lobe remains collapsed. The left lung is clear. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen again demonstrates a partially visualized right perinephric hematoma. The visualized portions of the left kidney again demonstrates severe hydronephrosis and thinning of the left renal cortex. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: Interval placement of a right-sided pleural drain. The right-sided pleural effusion has significantly decreased in size with decreased mediastinal shift and re-expansion of the right upper and middle lobes. However, a large right-sided effusion persists, with collapse of the right lower lobe. Radiology Report INDICATION: ___ year old woman with R pleural effusion s/p R VATS decort // r/o ptx, htx, eval interval change in pleural effusion TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There has been interval placement of 2 right-sided chest tubes. Interval decrease in size of the right pleural effusion, now small to moderate in extent. There is overlying atelectasis in the right mid and lower lung zones. No discrete pneumothorax is identified and the left lung is grossly clear. The appearance of the cardiac silhouette is unchanged. IMPRESSION: Interval placement of 2 right-sided chest tubes. No discrete pneumothorax identified. Interval decrease in size of the right pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with large right pleural effusion, s/p R VATS decortication and evacuation of pleural effusion // eval for interval change, please obtain ___ AM eval for interval change, please obtain ___ AM IMPRESSION: Compared to chest radiographs ___ through ___. After pleural drainage procedure, auto before ___, moderate right pleural effusion persists common despite 2 right thoracostomy tubes. No pneumothorax. . Right lower lobe atelectasis is severe. Left lung is clear. Heart size is mildly enlarged. Mediastinum is midline. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with R pleural effusion s/p VAT decortication // Please evaluate for interval change.Please obtain at 0500, ___ for likely D/C of chest tubes early AM. Please evaluate for interval change.Please obtain at 0500, ___ for likely D/C of chest tubes early AM. IMPRESSION: In comparison with the study of ___, there is little change. Bilateral chest tubes are seen on the right following with surgery with no evidence of pneumothorax. Combination of pleural fluid and volume loss is seen at the right base. The left lung is clear. There is mild enlargement of the cardiac silhouette without appreciable pulmonary vascular congestion. Radiology Report INDICATION: ___ year old woman s/p R VATS decortication // R/O PTX post CT removal TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph since ___, most recent from ___ at 03:57 FINDINGS: There has been interval removal of right-sided chest tubes. No evidence of pneumothorax. Small right pleural effusion. Right consolidative opacities in the right lower lung field are consistent with expected atelectasis although could represent pneumonia. Follow-up x-ray is recommended to follow these opacities. The left lung is clear. Cardiac silhouette is top-normal in size. Mediastinal and hilar contours are normal. IMPRESSION: 1. Interval removal of right-sided chest tubes without evidence of pneumothorax. Small right pleural effusion. 2. Consolidative opacities in the right lower lung field are consistent with expected atelectasis although could represent pneumonia. Follow-up x-ray is recommended to follow these opacities. RECOMMENDATION(S): Follow-up x-ray to follow right lower lung field opacities. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: R Flank pain, Abd pain, Transfer Diagnosed with Pleural effusion, not elsewhere classified temperature: 97.6 heartrate: 90.0 resprate: 18.0 o2sat: 100.0 sbp: 132.0 dbp: 66.0 level of pain: 10 level of acuity: 2.0

* You were admitted to the hospital for evaluation of your right pleural effusion and eventually required lung surgery to drain the fluid and help to reexpand your lung. You are recovering well and are now ready for discharge. * 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 chest tube 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. The chest tube sutures will be removed at your appointment with Dr. ___ week. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol ___ mg every 6 hours in between your narcotic. * 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.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: aspirin / penicillin / Fosamax / ciprofloxacin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ ___ percutaneous nephrostomy tube ___ ___ for percutaneous cholecystoscopy tube ___ ex-lap, lysis of adhesions, enteroenterostomy History of Present Illness: ___ PMH bladder CA s/p pelvic exenteration & ileal conduit c/b SBO w/ exlap x2, recent C. diff, who presents with abdominal pain, nausea, vomiting, and diarrhea since ___. She states that her symptoms changes yesterday evening, when she stopped passing stool or flatus, and her abdominal pain and nausea worsened. She presented to the ___ ED for further care. A CT A/P showed a closed loop small bowel obstruction. ACS was consulted for surgical management. Past Medical History: Bladder Cancer Hydronephrosis CVA x2 Anemia Asthma Hypertension Abnormal uterine bleeding Pelvic carcinoma of unknown primary Hypothyroidism Depression Social History: ___ Family History: Sister died of cancer in ___, type unknown Positive for hypertension, diabetes. Physical Exam: Admission Physical Exam: Physical Exam: Vitals: 98.2F, 117, 148/71, 100% 2LNC GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: No respiratory distress ABD: Distended, tympanic, diffuse guarding, marked rebound tenderness. Well functioning urostomy and drain in place. Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: No respiratory distress ABD: Soft, nontender except for intermittently in right lower quadrant,nondistended, well-healed midline incision, ileal conduit draining and right percutaneous nephrostomy drainaing clear yellow urine, percutaneous cholecystostomy draining dark bilious fluid Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 6:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 9:48 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ (___) @ 13:15, ___. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C difficile by the Cepheid nucleic amplification assay. (Reference Range-Negative). ___ 9:17 am URINE Source: Kidney. **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 462-2300P ___. ___ 10:00 am BLOOD CULTURE NEW ALINE 1 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 11:24 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final ___: NO GROWTH. ___ 9:50 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 8 I MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ <=1 S ___ 2:32 am PLEURAL 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 ___: NO GROWTH. ___ 3:58 pm BILE BILE. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ 8:29 am URINE Source: Kidney. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ========================================================== RADIOLOGY: ___ CT ABDOMEN/PELVIS: 1. New closed loop small-bowel obstruction with transition point in the lower pelvis near the ileal conduit and neobladder with marked dilatation of a cluster of small intestinal loops which are fluid-filled.. No evidence of intra-abdominal perforation, fluid collection or abscess. 2. Persistent diffuse circumferential thickening of the descending, sigmoid colon and the rectum may be related to chronic colitis with infectious as well as ischemic etiologies in the differential diagnosis. No evidence for pneumatosis. 3. Status post right percutaneous nephrostomy and double-J catheter placement with pigtails in the right renal pelvis and neobladder, unchanged in configuration since ___. 4. Interval decrease in size in hepatic segment 8 hypodensity. ___ ECCHO: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No definite valvular pathology or pathologic flow identified. ___ CTA CHEST: 1. No evidence of pulmonary embolism. 2. Large bilateral pleural effusions with bibasilar atelectasis. 3. Colonic wall edema with mucosal hyperenhancement and loss of normal haustra. There is also wall edema and mucosal enhancement involving multiple small bowel loops. Findings in the colon are compatible with pseudomembranous colitis. Abnormal findings in the small bowel may also indicate enteritis. 4. Peripheral areas of hypoenhancement in the right kidney, some of which are new from prior exam suggestive of renal infarcts. ___ CT ABDOMEN PELVIS: 1. No evidence of active hemorrhage or hematoma in the abdomen and pelvis. 2. Small increase in right pneumothorax. Right pleural catheter in stable position. ___ Bilateral upper extremity ultrasounds: Of note, there is severely limited visualization of the left brachial and basilic veins due to a large known hematoma. Otherwise, no definite evidence of deep vein thrombosis in the left upper extremity. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Calcitriol 0.25 mcg PO EVERY OTHER DAY 3. Clopidogrel 75 mg PO DAILY 4. Cyanocobalamin 1000 mcg PO MONTHLY 5. Fentanyl Patch 50 mcg/h TD Q72H 6. Gabapentin 300 mg PO QHS 7. Gabapentin 100 mg PO BID 8. Levothyroxine Sodium 175 mcg PO DAILY 9. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain - Moderate 10. Senna 8.6 mg PO BID:PRN constipation 11. Vitamin D ___ UNIT PO 1X/WEEK (___) 12. Vancomycin Oral Liquid ___ mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Dronabinol 2.5 mg PO BID 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Heparin 5000 UNIT SC BID may discontinue when ambulatory 5. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 6. LORazepam 0.25 mg PO QHS:PRN insomnia 7. Metoprolol Tartrate 12.5 mg PO Q6H hold for systolic blood pressure <110, hr,60 8. Pantoprazole 40 mg PO Q24H 9. Polyethylene Glycol 17 g PO BID 10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 11. amLODIPine 10 mg PO DAILY 12. Calcitriol 0.25 mcg PO EVERY OTHER DAY 13. Clopidogrel 75 mg PO DAILY 14. Cyanocobalamin 1000 mcg PO MONTHLY 15. Fentanyl Patch 50 mcg/h TD Q72H 16. Gabapentin 300 mg PO QHS 17. Gabapentin 100 mg PO BID 18. Levothyroxine Sodium 175 mcg PO DAILY 19. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain - Moderate 20. Senna 8.6 mg PO BID:PRN constipation 21. Vancomycin Oral Liquid ___ mg PO Q6H last dose ___. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Small bowel obstruction clostridium difficile infection Urinary tract infection Pleural effusion acute cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with ex-lap, intubated// ETT, NG, right CVL placement Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ IMPRESSION: The tip of a new right internal jugular central venous catheter projects over the upper right atrium, approximately 1 cm beyond the cavoatrial junction. The tip of the endotracheal tube projects 2.1 cm from the carina. The enteric tube extends to the stomach. A drainage catheter is noted over the right upper quadrant. Ill-defined opacities in both lung apices may reflect underlying emphysematous change. No focal consolidation, pleural effusion or pneumothorax is identified. The size of the cardiomediastinal silhouette is within normal limits. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p exlap, intubated// ?interval change TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: NG tube tip isin the stomach. ET tube is in standard position. Right IJ catheter tip is at the cavoatrial junction. Cardiomediastinal contours are stable. There is no pneumothorax or enlarging pleural effusions. There is mild vascular congestion. Radiology Report INDICATION: ___ PMH bladder CA s/p pelvic exenteration ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel s/p ex-lap, enteroenterostomy with persistent tachycardia unresponsive to fluid resuscitation// ?pulmonary embolism TECHNIQUE: Axial multidetector CT images were obtained through the chest, abdomen and pelvis 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. Oral contrast was not administered. DOSE: Acquisition sequence: 1) Stationary Acquisition 1.0 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5 mGy-cm. 2) Spiral Acquisition 3.8 s, 29.8 cm; CTDIvol = 11.7 mGy (Body) DLP = 350.1 mGy-cm. 3) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 12.5 mGy (Body) DLP = 681.4 mGy-cm. Total DLP (Body) = 1,033 mGy-cm. COMPARISON: CT abdomen and pelvis ___. FINDINGS: CHEST: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland is not visualized. There is no evidence of pericardial effusion. There are large bilateral pleural effusions. There is atelectasis involving most of the right lower lobe and left lower lobe. The airways are patent to the subsegmental level. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is mild periportal edema, likely related to volume overload. Scattered subcentimeter hypodensities in the liver may represent hepatic cysts but are too small to characterize. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is distended without gallstones or wall thickening. There is mild upper abdominal ascites. 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 a right-sided internal/external nephrostomy tube/ureteral stent. There is no left-sided hydronephrosis. There are multiple peripheral hypoenhancing areas within the right kidney suggestive of renal cortical infarcts. Some of these are new from the prior exam. GASTROINTESTINAL: Hyperdense material within the stomach may be related to something ingested by the patient. There is a right lower quadrant ileostomy. Throughout the colon, there is abnormal wall edema with mucosal hyper enhancement and loss of normal haustral pattern. There are also multiple small bowel loops in the pelvis which demonstrate mucosal hyper enhancement and wall edema. PELVIS: The urinary bladder is decompressed. There is mild pelvic ascites. REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is seen. LYMPH NODES: No pathologic lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There is diffuse subcutaneous soft tissue edema. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Large bilateral pleural effusions with bibasilar atelectasis. 3. Colonic wall edema with mucosal hyperenhancement and loss of normal haustra. There is also wall edema and mucosal enhancement involving multiple small bowel loops. Findings in the colon are compatible with pseudomembranous colitis. Abnormal findings in the small bowel may also indicate enteritis. 4. Peripheral areas of hypoenhancement in the right kidney, some of which are new from prior exam suggestive of renal infarcts. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: 77W PMH bladder CA s/p pelvic exenteration ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel s/p ex-lap, enteroenterostomy now w/ tachycardia and large bilateral pleural effusions s/p right pigtail placement// right pigtail placement TECHNIQUE: Portable chest radiograph COMPARISON: ___ portable chest radiograph FINDINGS: The right pigtail catheter tip projects medially over the right posterior ninth rib. The ET tube and NG tubes have been removed. There is no evidence of pneumothorax. The lung volumes are low. There is a layering left-sided pleural effusion, new from ___. The heart size is normal. There is no pulmonary vascular congestion or pulmonary edema. The right IJ catheter is in stable position. IMPRESSION: 1. Right pigtail catheter tip projects over the posterior ninth rib; there is no evidence of pneumothorax. 2. Bilateral low lung volumes with small left layering pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with respiratory failure s/p intubation// intubation, eval ETT placement IMPRESSION: In comparison with the earlier study of this date, this and placement of an endotracheal tube with its tip approximately 3.3 cm above the carina. Nasogastric tube is now in place with the tip coiled within the upper fundus of the stomach. Otherwise, little change in the appearance of the heart and lungs. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST. INDICATION: ___ year old woman with SBO s/p ex lab, now with GI bleed, septic shock. Eval for anastomotic leakage, new fluid collection, or source of GI bleed. PLEASE DO WITH PO CONTAST ONLY, IV CONTRAST NOT NECESSARY// Eval for anastomotic leakage, new fluid collection, or source of GI bleed. PLEASE DO WITH PO CONTAST ONLY, IV CONTRAST NOT NECESSARY 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 3.6 s, 56.7 cm; CTDIvol = 14.1 mGy (Body) DLP = 799.7 mGy-cm. Total DLP (Body) = 800 mGy-cm. COMPARISON: CTA chest/abdomen/pelvis from earlier same day ___ 02:49 FINDINGS: LOWER CHEST: There has been interval placement of a posterior right chest pigtail drainage catheter with its tip looping adjacent to the esophagus within the azygo-esophageal recess. There has been near complete interval resolution of a right pleural effusion. The visualized right lung is re-expanded, with mild atelectasis remaining in the right lower lobe. A moderate left pleural effusion with associated left lower lobe consolidation is unchanged. Air bronchograms are seen within the consolidated lungs bilaterally. Coronary artery calcifications. The tip of a central venous catheter is seen at the SVC-right atrial junction. 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 moderately distended, similar to prior. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: An internal-external nephrostomy tube/ureteral stent is noted on the right, with loops in unchanged position. Previously described renal parenchymal areas of decreased enhancement were better seen on prior. There is no hydronephrosis on the left. There is moderate bilateral perinephric fat stranding. there is no nephrolithiasis. GASTROINTESTINAL: The stomach is moderately distended with oral contrast. Esophageal enteric catheter terminates in the gastric fundus. Layering hypoattenuating and hyperdense material within the gastric fundus is consistent with ingested material. Small bowel-small bowel anastomosis sutures are noted in the right lower quadrant, adjacent to an ileostomy. No evidence of anastomotic leak is seen. Enteric contrast is seen throughout the small bowel, exiting the ileostomy. No evidence of small bowel obstruction is identified. There is re-demonstration of diffuse colonic mural thickening and fat stranding, most consistent with infection.. There is moderate mesenteric fat stranding likely related to fluid resuscitation and/or colitis. Transverse colon measures 5.0 cm in diameter, compared with 4.3 cm on prior. There is no pneumoperitoneum. The appendix is not visualized. Rectal catheter is in place. PELVIS: Urinary bladder is not identified. There is mild free pelvic fluid. REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is seen. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. Surgical clips are noted along bilateral pelvic sidewalls. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. There is right femoral catheter in place. BONES: Degenerative changes are seen in the lumbar spine. SOFT TISSUES: There is diffuse body wall edema. IMPRESSION: 1. Status post right lower quadrant ileostomy. No evidence of leak. No evidence of small-bowel obstruction. 2. Re-demonstration of diffuse, pancolonic wall thickening, most likely infectious. No pneumoperitoneum. Transverse colon measures 5.0 cm in diameter. 3. Status post right chest tube placement with near complete resolution of right pleural effusion. 4. Unchanged moderate left pleural effusion and left lower lobe consolidation. 5. Previously seen areas of decreased enhancement of renal parenchyma are again seen, which may represent renal infarcts, consider pyelonephritis if clinically indicated. Radiology Report INDICATION: ___ year old woman with ?acalc cholecystitis// perc chole COMPARISON: CT of the abdomen pelvis ___ PROCEDURE: Ultrasound-guided drainage of the gallbladder. OPERATORS: Dr. ___, radiology trainee and Dr. ___ ___, attending radiologist. Dr. ___ personally supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the gallbladder. Based on the ultrasound findings an appropriate skin entry site percutaneous cholecystostomy was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, ___ Exodus drainage catheter was advanced via trocar technique into the gallbladder. A sample of fluid was aspirated, confirming catheter position within the gallbladder. The pigtail was deployed. The position of the pigtail was confirmed within the gallbladder via ultrasound. Approximately 200 cc of thick viscous dark bilious fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by the ICU team. FINDINGS: There is a distended gallbladder with mild wall thickening and trace pericholecystic fluid. IMPRESSION: Successful US-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: 77W PMH bladder CA s/p pelvic exenteration ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel s/p ex-lap, enteroenterostomy// please assess fluid status, pulmonary edema, pleural effusions please assess fluid status, pulmonary edema, pleural effusions IMPRESSION: Comparison to ___. Stable small left pleural effusion with left basilar atelectasis and retrocardiac atelectasis. Stable correct position of the monitoring and support devices, including the right-sided chest tube. New introduction of a feeding tube, the tip projects over the proximal parts of the stomach, the tube is coiled in the fundus. No new focal parenchymal changes. Stable appearance of the cardiac silhouette. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p extubation// ?interval change TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Cardiomediastinal contours are normal. Right IJ catheter tip is in the lower SVC. There are low lung volumes. Left apical parenchyma opacities have not improved. Moderate left pleural effusion and adjacent atelectasis are stable. Minimal opacities in the right base have improved. There is no evident pneumothorax. Catheter in the right pleura, catheters in the right upper quadrant are in place. NG tube tip is in the stomach. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with new line// new right PICC 41 ___ ___ Contact name: ___: ___ TECHNIQUE: Single frontal view of the chest COMPARISON: Chest radiograph ___ at 04:18. FINDINGS: The right PICC terminates in the cavoatrial junction. The right IJ catheter terminates in the low SVC. The enteric tube tip is curled in the upper abdomen projecting over the region of the gastroesophageal junction. Right-sided chest tube terminates in the medial aspect of the right lung, similar to the prior study. Ill-defined opacities in bilateral lung apices appear unchanged over multiple studies likely representing pleuroparenchymal scarring. Left basilar atelectasis and left pleural effusion are stable. Cardiac size is unchanged. There is no pneumothorax. IMPRESSION: The right PICC terminates in the cavoatrial junction and the enteric tube is curled in the upper abdomen with tip terminating over the region of the gastroesophageal junction. Otherwise, the study is unchanged compared to the prior. Radiology Report INDICATION: ___ PMH bladder CA s/p pelvic exenteration ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel s/p ex-lap, enteroenterostomy now w/ dropping H/H// W/ IV contrastlooking for source of bleeding/hematoma? 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 3.2 s, 50.7 cm; CTDIvol = 2.4 mGy (Body) DLP = 121.1 mGy-cm. 2) Spiral Acquisition 3.2 s, 50.7 cm; CTDIvol = 9.1 mGy (Body) DLP = 461.7 mGy-cm. 3) Spiral Acquisition 3.2 s, 50.7 cm; CTDIvol = 9.1 mGy (Body) DLP = 461.0 mGy-cm. 4) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 8.1 mGy (Body) DLP = 4.1 mGy-cm. Total DLP (Body) = 1,048 mGy-cm. COMPARISON: CT ___ FINDINGS: LOWER CHEST: There is a right pleural catheter in place. There is a small right pneumothorax, increased from prior exam. There is right lung base atelectasis. There is a moderate left pleural effusion with left lung base atelectasis. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Subcentimeter hypodensities in the liver may represent hepatic cysts/biliary hamartomas but are too small to characterize. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is collapsed around a percutaneous cholecystostomy tube. 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. Focal areas of decreased enhancement in the renal cortex bilaterally are less apparent than on the prior exam. There is no perinephric abnormality. GASTROINTESTINAL: There is an enteric tube which terminates in the stomach. The patient has had multiple prior small bowel surgeries. There is no current evidence of bowel obstruction. There is residual oral contrast in the colon. Wall thickening and mucosal hyperenhancement in the colon appears mildly improved although still present in the sigmoid colon and rectum. There is no evidence of an intraperitoneal or retroperitoneal bleed. PELVIS: The patient is status post total cystectomy with a loop ileostomy. There is a small amount of interloop fluid and fluid along the anterior abdominal wall with enhancement. These findings may be postsurgical. 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 diffuse bony demineralization. SOFT TISSUES: There is diffuse subcutaneous edema. There are postsurgical changes in the anterior abdominal wall. IMPRESSION: 1. No evidence of active hemorrhage or hematoma in the abdomen and pelvis. 2. Small increase in right pneumothorax. Right pleural catheter in stable position. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:18 pm, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with recently accidentally removed R PCN// Please replace R PCN COMPARISON: CT abdomen pelvis from ___ and ___.. TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___, ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: ANESTHESIA: General anesthesia was administered by the anesthesiology department. Please refer to anesthesiology notes for details. MEDICATIONS: None CONTRAST: 15 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 3.5 min, 14 mGy PROCEDURE: 1. Right diagnostic antegrade nephrostogram. 2. Right 8 ___, 24 cm nephroureteral stent replacement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the healthcare proxy.The patient was then brought to the angiography suite and placed prone on the exam table. A pre-procedure time-out was performed per ___ protocol. The right flank was prepped and draped in the usual sterile fashion. A Glidewire was advanced through the nephrostomy tract using the ___, under continuous fluoroscopic guidance. Guidewire was advanced into the expected region of the renal collecting system and ureter diluted contrast was injected into the right nephrostomy to confirm catheter position. The image was stored on PACS. Local anesthesia was administered with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The catheter was cut. A ___ wire was advanced into the right nephrostomy tube and advanced into the distal ureter. The stay sutures were cut and the catheter was removed over the wire. A new 8 ___ nephrostomy catheter was flushed and advanced with its plastic stiffener over the wire into appropriate position. The wire and stiffener were removed and the pigtail was formed. Contrast injection confirmed appropriate positioning. The final image was saved. The catheter was then flushed, stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The catheter was attached to a bag for drainage. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Right antegrade nephrostogram shows delayed contrast drainage into the ileal conduit. 2. Appropriate final position of Right 8 ___ x 24 cm nephroureteral stent. IMPRESSION: Technically successful Right 8 ___ nephroureteral stent replacement. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with PMH bladder CA s/p pelvic exenteration ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel s/p ex-lap, enteroenterostomy and chest tube for pleural effusion, and now pneumothorax, now transitioned to suction// ****To be done at 2300 please****Evaluate interval changes, CT to suction TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Small right pneumothorax is probably unchanged. Cardiac size normal. Small to moderate left pleural effusion and adjacent atelectasis is stable. Opacities in the right base have minimally increased could be atelectasis or pneumonia. Right PICC tip is at the cavoatrial junction. Right basal pigtail catheter is in place. NG tube tip is out of view below the diaphragm Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ year old woman with PMH bladder CA s/p pelvic exenteration ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel s/p ex-lap, enteroenterostomy. Now with left upper extremity swelling, ecchymosis, pain.// Please evaluate left upper extremity 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 and augmentation. Along the medial left arm is an approximately 7.5 x 1.2 heterogeneous fluid collection. There is moderate subcutaneous edema within the left upper extremity. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Moderate subcutaneous edema within the left upper extremity as well as a large heterogeneous fluid collection tracking along the medial left arm which may reflect a hematoma. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with R pneumothorax with chest tube now to waterseal. Please do at 10:30 AM// f/u interval change of pneumothoraxPlease do at 10:30 AM TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Small to moderate left pleural effusion is minimally increased with increasing adjacent atelectasis. Right lower lobe atelectasis have improved. Cardiac size is normal. NG tube is coiled in the stomach. Right PICC tip is at the cavoatrial junction. Right pigtail catheter and catheters in the right upper abdomen are in place. Radiology Report EXAMINATION: Chest Radiograph INDICATION: ___ year old woman with pneumothorax with CT. Please do at 10:30 AM, re-assess pneumothorax s/p watersea linterval change? Please do at 10:30 AM TECHNIQUE: AP and Lateral COMPARISON: Chest radiographs dating back to ___, abdominal and pelvic CT from ___ FINDINGS: Right basilar chest tube unchanged in position. Known pneumothorax documented on abdominal and pelvic CT from ___, is not visible on chest radiographs dating back to ___. Right PICC ends at the cavoatrial junction. A moderate left pleural effusion has increased. There is persistent retrocardiac atelectasis. Abdominal pigtail catheters are in place. IMPRESSION: 1. No radiographic evidence of pneumothorax. Notably, pneumothorax seen on prior abdominal and pelvic CT was not visible radiographically. 2. Enlarging left pleural effusion. Radiology Report INDICATION: ___ year old woman with pneumo s/p chest tube pigtail dc-ed. 6:30 ___ please// re-eval for pneumothorax s/p pigtail dc. 6:30 ___ please TECHNIQUE: AP and lateral portable chest radiographs COMPARISON: ___ from earlier in the day FINDINGS: The right chest tube has been removed. There is no discrete pneumothorax identified. The tip of the right PICC line projects over the cavoatrial junction, unchanged. The right lung is clear. There is an unchanged moderate layering left pleural effusion with overlying atelectasis. No left pneumothorax. The size of the cardiomediastinal silhouette is within normal limits. IMPRESSION: Interval removal of the right chest tube. No discrete pneumothorax is identified. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old woman with upper extremity swelling, concerning for DVT. Worsening in last 3 days (prior LUE u/s was neg for DVT)// r/o dvt and/or hematoma TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: Upper extremity ultrasound from ___ 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. There is severely limited visualization of the left brachial and basilic veins due to a large hematoma measuring 3.3 x 4.6 x 1.5 cm in the medial upper arm. Given this limitation, the imaged left brachial and basilic veins demonstrate patency, normal color flow and compressibility. Left cephalic veins are patent and show normal color flow and augmentation. IMPRESSION: Of note, there is severely limited visualization of the left brachial and basilic veins due to a large known hematoma. Otherwise, no definite evidence of deep vein thrombosis in the left upper extremity. Radiology Report INDICATION: ___ year old woman with s/p ex-lap enteroenterostomy, chronic c.diff, with abdominal dissension.// ? Fecal impaction vs ileus compare to prior TECHNIQUE: Supine and left lateral decubitus abdominal radiograph was obtained. COMPARISON: CT abdomen and pelvis ___. FINDINGS: Dilated air-filled loops of small and large bowel with multiple air-fluid levels on left lateral decubitus view consistent with ileus. There is no free intraperitoneal air. Osseous structures are unremarkable. Percutaneous cholecystostomy tube is noted. Skin staples are noted to the left of the midline. Multiple surgical clips are noted in the pelvis. Suture line noted in the lower pelvis. A right percutaneous nephroureteral stent is noted. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Dilated air-filled loops of small and large bowel consistent with ileus. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with s/p exploratory laparotomy, extensive lysis of adhesions and a side-to-side enteroenterostomy with abdominal distention no bowel function x7 days and nausea// ?abscess/fluid collection ?obstructions. IV and PO contrast. 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 3.1 s, 49.7 cm; CTDIvol = 13.3 mGy (Body) DLP = 660.2 mGy-cm. 2) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 8.4 mGy (Body) DLP = 4.2 mGy-cm. Total DLP (Body) = 664 mGy-cm. COMPARISON: CT dated ___. FINDINGS: LOWER CHEST: Bilateral pleural effusions are seen with associated atelectasis. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Multiple subcentimeter hypodensities are again seen, too small to characterize on CT. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is collapsed around a percutaneous cholecystostomy tube. 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 patient is status post multiple prior small bowel surgeries, and recent ex lap with side-to-side enteroenterostomy. There is dilation of the small and large bowel, to the level of the sigmoid colon. PELVIS: The patient is status post total cystectomy with right-sided nephrostomy tube. 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: Diffuse bony demineralization is again seen. SOFT TISSUES: Diffuse subcutaneous edema, consistent with anasarca, and postsurgical changes in the anterior abdominal wall. IMPRESSION: 1. Dilation of the small and large bowel is consistent with ileus. 2. Anasarca. 3. Bilateral pleural effusions with associated atelectasis. Radiology Report INDICATION: ___ PMH bladder CA s/p pelvic exenteration ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel s/p ex-lap, enteroenterostomy// ?interval change TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Abdominal radiograph ___. FINDINGS: Again demonstrated are loops of air-filled dilated large and small bowel, slightly improved since prior radiograph. Assessment for free intraperitoneal air is limited on supine radiographs. If there is clinical concern for pneumoperitoneum, advise upright or left lateral decubitus radiograph, or cross-sectional imaging. Osseous structures are unremarkable. Skin staples are noted along the midline. Surgical staples are noted in the pelvis. There is re-demonstration of percutaneous cholecystostomy tube and right percutaneous nephroureteral stent. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Slight interval improvement in dilated loops of small and large bowel. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p xlap with ileus and vomiting with increased respiratory rate.// ?pulmonary edema, ?effusion IMPRESSION: In comparison with the study of ___, there has been placement of a nasogastric tube that coils in the upper fundus of the stomach. Right subclavian catheter again extends to the region of the cavoatrial junction. The left hemidiaphragm is now sharply seen, consistent with improvement in the left pleural effusion and atelectatic changes. However, there are increasing atelectatic changes at the right base. No evidence of appreciable vascular congestion or acute focal pneumonia. Significant dilatation of gas filled loops of bowel are again seen in the abdomen. Radiology Report INDICATION: ___ year old woman s/p xlap with ileus vomiting s/p ngt placement.// s/p NGT placement ? ileius, NGT placement TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Abdominal radiograph ___. FINDINGS: Re-demonstration of air-filled dilated loops of small and large bowel, minimally improved compared to prior radiograph. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are notable for multilevel degenerative changes of the lumbar spine and bilateral hips. NG tube terminates at the gastroesophageal junction and can be advanced further. Skin staples are again noted to the right of the midline. Surgical staples are noted in the pelvis. Percutaneous cholecystostomy tube and right percutaneous nephroureteral stent are again noted. IMPRESSION: NG tube terminates in the gastroesophageal junction and should be advanced further. Re-demonstration of dilated loops of small and large bowel, slightly improved compared to the day prior. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 8:57 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT INDICATION: ___ year old woman with left upper extremity tenderness and swelling.// ? 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 subclavian veins bilaterally. The left internal jugular, axillary and brachial veins are patent, show normal color flow and compressibility. The left basilic and cephalic veins are patent. A large hematoma is noted in the superficial tissues of the medial left upper arm extending from the axilla to the antecubital fossa. IMPRESSION: 1. No DVT identified in the left arm. 2. Large hematoma extending in the medial left upper arm from the axilla to the antecubital fossa. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with SBO s/p bowel resection and LOA 35 days ago, now with chills and sustained tachycardia in 140s// ?acute cardiopulm processes TECHNIQUE: Chest single view COMPARISON: ___ FINDINGS: Right PICC line tip 2.5 cm above cavoatrial junction. Normal heart size, pulmonary vascularity. No edema. Trace left pleural effusion, improved. Bibasilar opacities have resolved since prior. No consolidations. No pneumothorax. Degenerative arthritis bilateral shoulders. IMPRESSION: No acute findings in the chest. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old woman with SBO s/p bowel resection and LOA, now with chills and sustained HR 150s// ? intraabdominal process TECHNIQUE: Abdomen single view COMPARISON: ___ FINDINGS: Right lateral abdominal percutaneous catheter in place. Right ureteral stent in place. Surgical clips pelvis. Previously seen distended bowel loops have resolved. No bowel dilatation today. Few mildly distended bowel loops are seen. Presumed right lower quadrant stoma. Degenerative changes spine. IMPRESSION: No evidence of bowel obstruction. Radiology Report EXAMINATION: T-TUBE CHOLANGIO (POST-OP) INDICATION: ___ year old woman with perc cholecystostomy tube placement on ___// compare to prior study. TECHNIQUE: Water soluble contrast was hand injected into the pre-existing cholecystostomy tube. Selected fluoroscopic images were obtained. DOSE: Acc air kerma: 4 mGy; Accum DAP: 55.37 uGym2; Fluoro time: 02:10 minutes COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: Contrast readily opacified a stone filled gallbladder and the cystic duct, passing freely into the common bile duct and proximal small bowel. No filling defects or ductal irregularity were identified. IMPRESSION: Patent cystic duct with contrast passing into the small bowel. Radiology Report EXAMINATION: CT abdomen pelvis with contrast. INDICATION: ___ year old woman s/p multiple operations, SBO, exlap, enterenterostomy, cholangiogram drain, nephrostomy, new abd pain// ? acute process, biloma?, urinoma? patient has history of bladder cancer (___) treated with ileal conduit, complicated by renal obstruction resulting in right PCN. Patient underwent radiation, with subsequent small-bowel obstructions requiring exploratory laparotomy. 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) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 4.5 s, 49.9 cm; CTDIvol = 6.3 mGy (Body) DLP = 312.6 mGy-cm. Total DLP (Body) = 321 mGy-cm. COMPARISON: CT abdomen pelvis dated ___, ___. FINDINGS: LOWER CHEST: Trace right lower lobe atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Small hypodensities scattered throughout the liver too small to accurately characterize but likely represent cysts or biliary hamartomas. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is collapsed around a percutaneous cholecystostomy tube. 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 normal. PELVIS: Postsurgical changes in the lower pelvis related to cystectomy. Right-sided nephroureteral stent is in-situ, in appropriate position. A duplex collecting system is noted in the left kidney. Mild prominence of the bilateral ureters is unchanged in this patient with known ileal conduit. A small fluid collection adjacent to the right distal ureter measures 8 x 13 mm, decreased when compared to the prior study and likely a small urinoma (601:23, 2:59). No focal drainable fluid collection is identified. 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. Postsurgical changes in the right anterior abdominal wall. Interval decrease in diffuse anasarca in comparison to the prior study. IMPRESSION: 1. No acute intra-abdominal process identified. 2. Persistent prominence both ureters in this patient with known ileal conduit. No focal drainable fluid collection is identified. 3. Post cystectomy, with postsurgical changes in the lower pelvis. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Abd pain, Tachycardia Diagnosed with Unspecified intestinal obstruction temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: ua level of acuity: 1.0

Dear Ms. ___, You were admitted to the Acute Care Surgery service on ___ with a small bowel obstruction. You were taken to the operating room for an exploratory laparotomy with extensive lysis of adhesions and a connection made between your intestines to bypass the obstructed area. After surgery you continued to show signs of infection and a CT scan showed an acute infection in your gallbladder. You were too sick to undergo a second operation at this time and therefore you were given IV antibiotics and had a drain places to remove the infected fluid. You were also found to have infection in your urine and stool for which you were treated with appropriate antibitoics based on the cultures. While in the hospital you developed fluid in your lung for which you had a pigtail drain placed to help improve your breathing. Once the fluid was removed, the drain was taken out and your lungs remained inflated. Your existing percutaneous nephrostomy tube accidently became dislodged and was replaced by the interventional radiologists on ___. The lower portion of your surgical wound was opened to allow extra fluid to drain and prevent infection. You should continue to pack this wound with dry kerlex to allow it to heal from the inside. Due to your extended stay in the hospital, you became deconditioned. The physical therapy team worked with you and recommended discharge to an acute rehab to continue your recovery. You are now doing better, tolerating a regular diet, breathing comfortably on room air, and your infections are improving with antibiotic treatment. You are now ready to be discharged to rehab with the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. 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: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Mr. ___ is a ___ yo man with CAD s/p anterior MI s/p CABG (LIMA-LAD, SVG-RPDA, SVG-D1), iCM (LVEF 25%), A Fib on warfarin, VT s/p ICD in ___ who presented with hypotension in the setting of A Fib with RVR and recent cystoscopy. Major Surgical or Invasive Procedure: Extraction of retained foley catheter (___) RIJ placement and removal History of Present Illness: Mr. ___ is a ___ old with CAD s/p anterior MI ___ s/p CABG (LIMA-LAD, SVG-RPDA, SVG-D1), iCM (LVEF 25%), afib on warfarin, VT s/p ICD in ___, CML, and hx of prostate cancer s/p brachytherapy, who presented with hematuria following cystoscopy, developed afib w/ RVR and hypotension requiring ICU admission. The patient reports he has been followed by urology for several years following a traumatic foley insertion a couple years ago. He had a routine cystoscopy two days prior to presentation evaluating for scar tissue, which he reports was overall normal. Following the procedure, he developed a small amount of hematuria which became significant and associated with clots yesterday. He also describes mild abdominal pain and mild dysuria. No increased urinary frequency, urinary retention, flank pain, fever, chills, chest pain, shortness of breath, cough, nausea, vomiting, and diarrhea. He has been taking his Coumadin daily without missing doses. Past Medical History: Hypertension Hyperlipidemia CAD s/p anterior MI s/p CABG x3 (LIMA to LAD, SVG to PDA, SVG to D1) ___ S/p ___ ICD placement in ___ Ischemic cardiomyopathy (LVEF 25%) Atrial fibrillation Gout Prostate cancer s/p brachytherapy (___) Erectile dysfunction Skin cancers Diverticulosis Chronic myeloid leukemia Cataract Social History: ___ Family History: Mother deceased at ___ years old from myocardial infarction; brother deceased at ___ years old from myocardial infarction; brother deceased at ___ years old from sudden death. Physical Exam: Admission physical exam: Vitals: Temp 99.1 BP 112/74 on levophed HR 107 RR 30 95% on RA GEN: Elderly male in NAD. Lying comfortably in bed. HEENT: Conjunctiva clear, PERRL, MMM. Oropharynx clear. NECK: Supple, right IJ line in place with mild bleeding around site. LUNGS: Normal respiratory effort. CTAB without wheezes, rales or rhonchi. HEART: Irregularly irregular rhythm, tachycardic. Normal S1 and S2. No murmurs, rubs or gallops. ABD: Abdomen soft, mildly distended, mild TTP over suprapubic region. No rebound or guarding. GU: No CVA TTP bilaterally. Foley catheter with minimal bloody output. EXTREMITIES: Warm, well perfused. No ___ edema or erythema. SKIN: Warm, dry. No rashes. NEURO: Alert and interactive. CN II-XII grossly intact. Moves all extremities. Discharge physical exam: VSS 98.3 PO ___ 18 99 RA GENERAL: Alert and in no apparent distress EYES: sclera anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Irreg irregular, nl S1, S2, ___ systolic murmur, no JVD, ICD L chest wall RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation; EXT: Lower ext warm without edema, SKIN: No rashes or ulcerations noted NEURO: AOx3, CN II-XII intact, ___ strength all ext PSYCH: appropriate affect Pertinent Results: Admission labs: ___ 02:20PM BLOOD WBC-7.1 RBC-3.38* Hgb-9.7* Hct-30.4* MCV-90 MCH-28.7 MCHC-31.9* RDW-17.0* RDWSD-54.9* Plt ___ ___ 02:20PM BLOOD ___ PTT-38.9* ___ ___ 02:20PM BLOOD Glucose-134* UreaN-41* Creat-1.8* Na-139 K-4.6 Cl-102 HCO3-23 AnGap-14 ___ 10:47PM BLOOD Digoxin-0.9 ___ 11:01PM BLOOD Lactate-2.8* Discharge labs: ___ 08:49AM 19.6* INR 1.8* ___ 06:17AM BLOOD WBC-6.7 RBC-3.00* Hgb-8.4* Hct-26.7* MCV-89 MCH-28.0 MCHC-31.5* RDW-17.6* RDWSD-55.8* Plt ___ ___ 06:49AM BLOOD WBC-6.5 RBC-2.93* Hgb-8.2* Hct-26.2* MCV-89 MCH-28.0 MCHC-31.3* RDW-17.4* RDWSD-56.4* Plt ___ ___ 07:22AM BLOOD WBC-7.9 RBC-2.99* Hgb-8.3* Hct-26.0* MCV-87 MCH-27.8 MCHC-31.9* RDW-17.2* RDWSD-53.1* Plt ___ ___ 06:17AM BLOOD Plt ___ ___ 06:17AM BLOOD ___ ___ 06:17AM BLOOD Glucose-108* UreaN-38* Creat-1.8* Na-143 K-4.2 Cl-105 HCO3-23 AnGap-15 ___ 06:49AM BLOOD Glucose-128* UreaN-41* Creat-2.0* Na-142 K-4.4 Cl-106 HCO3-24 AnGap-12 ___ 07:22AM BLOOD ALT-44* AST-33 AlkPhos-119 TotBili-1.6* ___ 04:31PM BLOOD CK-MB-9 cTropnT-0.18* ___ 11:07AM BLOOD CK-MB-9 cTropnT-0.20* ___ 06:17AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0 ___ 03:55AM BLOOD Hapto-159 ___ 08:20PM BLOOD O2 Sat-59 ___ 07:34AM BLOOD O2 Sat-87 ___ 08:09AM BLOOD freeCa-1.10* ___ 12:07PM BLOOD freeCa-1.14 Other notable: Trop 0.2 -> 0.18 Hapto 159, LDH 260 PTH 142 Dig 0.9 Lact 2.8 -> 6.3 -> 1.6 UA (___): mod bld, neg nit, lg ___, 30 prot, >182 RBCs, 176 WBCs, few bact BCx (___): neg x 2 UCx (___): E.coli >100K _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: ======== - Renal ultrasound (___): 1. The bladder is only minimally distended and cannot be fully assessed on the current study. Within this limitation, there is no sonographic evidence of clot within the bladder. 2. No hydronephrosis. 3. There is trace perihepatic free fluid. 4. Prostate is suboptimally evaluated, but appears markedly heterogeneous in echogenicity. Clinical correlation is recommended. - CXR (___): 1. Stable cardiomegaly without evidence of pulmonary vascular congestion. 2. No evidence of focal consolidation. - CT A/P with contrast (___): 1. Foley catheter in place within a partially decompressed urinary bladder, which contains slightly increased density consistent with blood products. 2. Small to moderate fluid within the pelvis, as well as trace perihepatic and perisplenic ascites. No rim enhancing fluid collections identified. 3. Small right pleural effusion and trace left pleural effusion with adjacent bibasilar atelectasis. 4. Minimally complex cyst in the left upper renal pole measuring 3.3 cm and containing a thin internal septation, compatible with Bosniak II. 5. Cholelithiasis without evidence of acute cholecystitis. 6. Diverticulosis without evidence for acute diverticulitis. - CXR (___): 1. Interval placement of a right internal jugular central venous catheter, with tip extending to the mid SVC. 2. No evidence of pneumothorax. - TTE (___): Severe global LV systolic dysfunction, with areas of relative akinesis, lateral wall contracts best. Dilated RV with severe dysfunction. Can not exclude LV apical thrombus (images 53, 54). Probable moderate mitral regurgiation. Severe tricuspid regurgitation. At least moderate pulmonary hypertension, likely underestimated. - TTE (___): Compared with the prior TTE (images reviewed) of ___, contrast administration suggests no apical left ventricular mass as possibly suggested in the prior images. The degrees of mitral and tricuspid regurgitation may be similar but focused / limited views preclude full comparison. ___ 08:49AM BLOOD WBC-7.0 RBC-3.13* Hgb-8.8* Hct-28.2* MCV-90 MCH-28.1 MCHC-31.2* RDW-18.1* RDWSD-57.8* Plt ___ ___ 08:49AM BLOOD WBC-7.0 RBC-3.13* Hgb-8.8* Hct-28.2* MCV-90 MCH-28.1 MCHC-31.2* RDW-18.1* RDWSD-57.8* Plt ___ ___ 08:49AM BLOOD Neuts-74.8* Lymphs-12.6* Monos-8.3 Eos-2.3 Baso-0.7 Im ___ AbsNeut-5.25 AbsLymp-0.88* AbsMono-0.58 AbsEos-0.16 AbsBaso-0.05 ___ 08:49AM BLOOD ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Tasigna (nilotinib) 300 mg oral BID 3. Allopurinol ___ mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Calcitriol 0.25 mcg PO 3X/WEEK (___) 6. Vitamin D 1000 UNIT PO DAILY 7. Digoxin 0.125 mg PO EVERY OTHER DAY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Metoprolol Succinate XL 50 mg PO QHS 10. Quinapril 10 mg PO DAILY 11. Torsemide 60 mg PO DAILY 12. Warfarin 2 mg PO 3X/WEEK (___) 13. Warfarin 1 mg PO 4X/WEEK (___) Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 1 Day Take on ___ RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0 2. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 3. Atorvastatin 40 mg PO QPM 4. Calcitriol 0.25 mcg PO 3X/WEEK (___) 5. Digoxin 0.125 mg PO EVERY OTHER DAY 6. Fluticasone Propionate NASAL 1 SPRY NU BID 7. Metoprolol Succinate XL 50 mg PO QHS 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Quinapril 10 mg PO DAILY 10. Tasigna (nilotinib) 300 mg oral BID 11. Torsemide 60 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. Warfarin 1 mg PO 4X/WEEK (___) 14. Warfarin 2 mg PO 3X/WEEK (___) ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urinary tract infection Gross hematuria Sepsis with septic shock Chronic systolic heart failure Atrial fibrillation Coronary artery disease CML Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: RENAL U.S. PORT INDICATION: History: ___ with hematuria s/p cystoscopy, no pain// Bladder clots TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CT dated ___. FINDINGS: There is no hydronephrosis, stones, or masses bilaterally. There are multiple bilateral simple renal cysts, the largest on the right measuring up to 3.7 cm in the upper pole and the largest on the left measuring up to 3.2 cm in the lower pole. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 9.9 cm Left kidney: 10.1 cm The bladder is only minimally distended and can not be fully assessed on the current study, though there is no evidence of clots. There is trace perihepatic free fluid noted. The prostate gland is not well-visualized, though measures approximately 3.2 x 3.1 x 3.0 cm with prostate volume of 15.1 cc. The visualized portions appear heterogeneous. IMPRESSION: 1. The bladder is only minimally distended and cannot be fully assessed on the current study. Within this limitation, there is no sonographic evidence of clot within the bladder. 2. No hydronephrosis. 3. There is trace perihepatic free fluid. 4. Prostate is suboptimally evaluated, but appears markedly heterogeneous in echogenicity. Clinical correlation is recommended. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with hypoxia. Evaluation for infection, edema. TECHNIQUE: Chest AP portable upright COMPARISON: Comparison to prior chest radiograph from ___. FINDINGS: Median sternotomy wires are intact and well aligned. Cardiac device projects over the left upper chest wall, with leads extending to the right atrium and right ventricle. Few surgical clips project over the upper mediastinum. Stable enlargement of the cardiac silhouette, without vascular congestion. No evidence of focal consolidation. No pleural effusion or pneumothorax is seen. IMPRESSION: 1. Stable cardiomegaly without evidence of pulmonary vascular congestion. 2. No evidence of focal consolidation. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with hematuria, hypotension and tachycardia, s/p cystoscopy. Evaluation for signs of abscess. TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 72.2 mGy (Body) DLP = 36.1 mGy-cm. 2) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 17.8 mGy (Body) DLP = 906.4 mGy-cm. Total DLP (Body) = 943 mGy-cm. COMPARISON: Comparison to CT abdomen/pelvis from ___. FINDINGS: LOWER CHEST: Small right pleural effusion and trace left pleural effusion with adjacent bibasilar atelectasis. No pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder appears decompressed and contains hyperdense gallstones. Trace perihepatic ascites. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. Small amount of perisplenic ascites. 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 a minimally complex cyst at the left upper renal pole measuring 3.3 cm (2:27, 601:38), containing a thin internal septation, compatible with ___ II. There is a 3.4 cm simple cyst at the right upper pole. Few additional subcentimeter hypodensities are too small to characterize, likely compatible with simple cysts. There is no evidence of hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. PELVIS: The urinary bladder is decompressed with a Foley catheter in place. Slightly increased density within the bladder lumen is consistent with blood products. Air within the bladder is consistent with history of instrumentation. There is moderate free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate contains numerous brachytherapy seeds. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. Few mildly prominent retroperitoneal lymph nodes are not pathologically enlarged by CT size criteria. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. Air within the bilateral common femoral veins, likely compatible with instrumentation. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Moderate multilevel degenerative change of the lumbar spine. A sclerotic focus within the left humeral head is consistent with a bone island. Unchanged appearance of a bone island within the lateral aspect of the left tenth rib (02:27). SOFT TISSUES: A left inguinal hernia containing fat is noted. IMPRESSION: 1. Foley catheter in place within a partially decompressed urinary bladder, which contains slightly increased density consistent with blood products. 2. Small to moderate fluid within the pelvis, as well as trace perihepatic and perisplenic ascites. No rim enhancing fluid collections identified. 3. Small right pleural effusion and trace left pleural effusion with adjacent bibasilar atelectasis. 4. Minimally complex cyst in the left upper renal pole measuring 3.3 cm and containing a thin internal septation, compatible with Bosniak II. 5. Cholelithiasis without evidence of acute cholecystitis. 6. Diverticulosis without evidence for acute diverticulitis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with CVL placement. Evaluation for CVL placement. TECHNIQUE: Chest AP portable upright COMPARISON: Comparison to multiple prior chest radiographs, most recently from ___. FINDINGS: Median sternotomy wires are intact and well aligned. Cardiac device projects over the upper left chest wall, with pacer leads extending to the right atrium and right ventricle. Few surgical clips project over the upper mediastinum. Interval placement of a right internal jugular central venous catheter, with tip projecting over the mid SVC. Stable enlargement of the cardiac silhouette. No definite evidence of focal consolidation. No pleural effusion or pneumothorax. IMPRESSION: 1. Interval placement of a right internal jugular central venous catheter, with tip extending to the mid SVC. 2. No evidence of pneumothorax. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Hematuria Diagnosed with Hematuria, unspecified, Anemia, unspecified, Tachycardia, unspecified temperature: 98.2 heartrate: 84.0 resprate: 18.0 o2sat: 95.0 sbp: 131.0 dbp: 74.0 level of pain: 4 level of acuity: 2.0

Dear Mr. ___, You were hospitalized with blood in your urine after an outpatient cystoscopy. Due to retained blood clots, you developed a urinary tract infection and sepsis, for which you required treatment in the ICU. You improved with antibiotics and had no further evidence of bleeding after removal of your foley catheter. You will need to complete a course of antibiotics through ___ and follow up with your outpatient urologist. Please continue to take your medications as prescribed. With very best wishes for a speedy recovery, ___ medicine

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: telaprevir / Nafcillin / vancomycin Attending: ___. Chief Complaint: L-sided abd pain 10 days s/p splenic embolization Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ with chronic HCV presents as a transfer from an OSH in ___ for evaluation for a splenic laceration s/p coil embolization. She presented to a hospital in ___ on ___ due to syncope in the bathroom, one week after tripping and falling while attempting to catch a bus. She reports she fell on her left side injuring her left rib cage and hitting her head. She felt well overall and decided not to seek medical care. She thereafter left to go ___ for vacation (Hepatitis C support convention, also to visit a friend with liver transplant) and had a syncopalepisode in the bathroom, prompting her admission. While there, undergone splenic ___ embolization after a hematoma was discovered on a CT of her abdomen. She then decided to come here for further care, got on a plane, and was even upgraded to business class. Also, of note The patient was discharged to rehab on nafcillin after having a bacteremia and a reaction to vancomycin, and was discharged home after she completed that course. Her last injection was on ___. In the ED, initial VS were:5 99.7 98 146/77 18 96% -Patient was seen by transplant team in the ED, who recommended to obtain OSH records especially discharge summary to determine need for admission. If requires admission, recommend admission to medicine/hepatology (Hep C cirrhosis). No active surgical issues at this time. Discussed with Dr. ___ attending. - Labwork was significant for 136 103 7 ---------<115 4.2 25 0.5 ALT/AST ___ AP 108 Tbili 0.9 Alb 3.1 WBC 10.3 HCT 37.7 VS prior to transfer were:99.3 70 18 140/70 98% ra On arrival to the floor,98.6 145/87 HR 90 RR 18 97%RA. She felt well, other than pain in her abdomen over her spleen. REVIEW OF SYSTEMS: reprted having some fevers up to 102 recently, but not in the past day,Denies headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HEPATITIS C CIRRHOSIS HYPOTHYROIDISM DEPRESSION OBESITY MIGRAINE HEADACHES PERIPHERAL EDEMA *S/P ADJ GASTRIC BAND (VG) & HIATAL HERNIA REPAIR ___ s/p hystorectomy due to excessive vaginal bleeding and ?precanerous condition ANEMIA AFIB CHADS risk score 0 Social History: ___ Family History: Family History: husband also has hep C, but patient had Hep C prior to meeting husband. Physical Exam: ADMISSION PE: VS T 98.7 BP 126/85 HR 80 RR 18 O2Sat 93RA GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, rales at bases, otherwise CTAB no wheezes, rhonchi CV Irregular rate normal S1/S2, no mrg ABD soft Tender esp in L upper quadrant, but also more diffusely, ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, 2+ pitting edema, no c/c NEURO CNs2-12 intact, motor function grossly normal, gait appeared grossly norml, no asterixis SKIN no ulcers or lesions DISCHARGE PE: VS 94.5 BO 132/61 HR 82 RR 20 99RA GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, rales at bases, otherwise CTAB no wheezes, rhonchi CV Irregular rate normal S1/S2, no mrg ABD soft Decreased, diffuse tenderness esp in L upper quadrant, ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, 2+ pitting edema, no c/c NEURO CNs2-12 intact, motor function grossly normal, gait appeared grossly norml, no asterixis SKIN no ulcers or lesions Pertinent Results: ADMISSION LABS: ___ 03:00PM BLOOD WBC-10.3# RBC-3.64* Hgb-11.6* Hct-37.7 MCV-104* MCH-31.8 MCHC-30.7* RDW-17.4* Plt ___ ___ 03:00PM BLOOD Neuts-77.1* Lymphs-9.3* Monos-11.2* Eos-1.8 Baso-0.7 ___ 03:00PM BLOOD ___ PTT-36.5 ___ ___ 03:00PM BLOOD Glucose-115* UreaN-7 Creat-0.5 Na-136 K-4.2 Cl-103 HCO3-25 AnGap-12 ___ 03:00PM BLOOD ALT-10 AST-29 AlkPhos-108* TotBili-0.9 ___ 06:10AM BLOOD GGT-28 ___ 03:00PM BLOOD Albumin-3.1* DISCHARGE LABS: ___ 07:00AM BLOOD WBC-11.0 RBC-3.53* Hgb-11.4* Hct-35.7* MCV-101* MCH-32.2* MCHC-31.8 RDW-16.9* Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-74 UreaN-6 Creat-0.5 Na-134 K-4.5 Cl-103 HCO3-23 AnGap-13 ___ 07:00AM BLOOD ALT-10 AST-49* AlkPhos-92 TotBili-1.0 ___ 07:00AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.5* CT ABD/PELVIS WITH CONTRAST ___: . Splenic enlargement compared to prior likely secondary to an intracapsular hematoma and liquification status post embolization. Minimal amount of residual enhancing splenic tissue is noted. Superinfection is not excluded, although lack of a thickened and enhancing rim would make this less likely. There is no evidence of extracapsular extension. 2. Cirrhosis with a mild amount of ascites. 3. Bilateral pleural effusions, small on the right and moderate on the left, with lobar collapse in the left lower lung. 4. Gastric band. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) unknown Oral daily 2. Docusate Sodium 100 mg PO BID 3. Venlafaxine XR 150 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 7. Spironolactone Dose is Unknown PO PRN leg swelling 8. Ciprofloxacin HCl 500 mg PO Q12H s/p splenic embolization 9. MetRONIDAZOLE (FLagyl) 500 mg PO TID s/p splenic embolization Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Venlafaxine XR 150 mg PO DAILY 5. Ciprofloxacin HCl 500 mg PO Q12H s/p splenic embolization to be taken through ___ RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice daily Disp #*40 Tablet Refills:*0 6. MetRONIDAZOLE (FLagyl) 500 mg PO TID s/p splenic embolization to be taken through ___ RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*60 Tablet Refills:*0 7. Acetaminophen 650 mg PO Q8H pain do not take more than 2 grams total per day RX *acetaminophen 650 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 8. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 1 tab ORAL DAILY 9. Senna 1 TAB PO BID:PRN constipation RX *senna 8.6 mg 1 tab(s) by mouth twice daily Disp #*60 Tablet Refills:*0 10. Polyethylene Glycol 17 g PO DAILY RX *Miralax 17 gram/dose 17 g(s) by mouth daily Disp #*1 Bottle Refills:*0 11. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain Duration: 14 Days RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 12. Spironolactone 0 mg PO PRN leg swelling Discharge Disposition: Home Discharge Diagnosis: splenic laceration status post splenic artery embolization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with HCV cirrhosis, status post splenic rupture three weeks prior and splenic artery embolization, now with continuing pain, assess for phlegmon. COMPARISONS: CT abdomen and pelvis from ___ dated ___. TECHNIQUE: MDCT-acquired axial images were obtained from the dome of the liver to the pubic symphysis after the uneventful administration of 130 mL of Omnipaque. Oral contrast was also administered. Coronal and sagittal reformations were provided and reviewed. DLP: 587.69 mGy-cm. CHEST: The visualized lung bases demonstrate bilateral pleural effusions, small on the right and moderate sized on the left. There is left lower lobar atelectasis seen within the left lung and adjacent compressive atelectasis seen on the right. There are no pulmonary nodules or masses. The visualized portion of the heart is top normal in size, and there is no pericardial effusion. ABDOMEN: A nodular contour to the liver is compatible with known diagnosis of hepatitis C cirrhosis. The gallbladder is normal, and there is no intrahepatic biliary ductal dilatation. The adrenal glands are normal. The kidneys enhance symmetrically and excrete contrast without hydronephrosis. Streak artifact from splenic artery embolization limits complete evaluation of the pancreas, although to the extent visualized, it appears normal. A gastric band is present with its port in the left anterior subcutaneous tissues. The small and large bowel are normal without evidence of bowel wall thickening. There is a trace amount of intra-abdominal ascites. There is no free air. The spleen is enlarged, measuring 18 cm in the craniocaudal dimension which has increased slightly from prior. Embolization coils are seen at the splenic hilum within the renal artery. There is a large subcapsular hematoma/liquified splenic tissue with minimal residual enhancing splenic tissue. There is no evidence for extracapsular extension. PELVIS: Free fluid from the abdomen is noted in the posterior cul-de-sac. The bladder, rectum and sigmoid are normal. The uterus and adnexa are not definitively identified. There is no inguinal or pelvic sidewall lymphadenopathy. BONES: There are no suspicious osseous lesions. A sclerotic focus seen in the posterior portion of the right iliac wing likely represents a bone island. Degenerative changes of the lower lumbar spine are marked by disc space narrowing and vacuum phenomenon seen between L3-L4. IMPRESSION: 1. Splenic enlargement compared to prior likely secondary to an intracapsular hematoma and liquification status post embolization. Minimal amount of residual enhancing splenic tissue is noted. Superinfection is not excluded, although lack of a thickened and enhancing rim would make this less likely. There is no evidence of extracapsular extension. 2. Cirrhosis with a mild amount of ascites. 3. Bilateral pleural effusions, small on the right and moderate on the left, with lobar collapse in the left lower lung. 4. Gastric band. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SPLENIC LAC Diagnosed with SPLEEN PARENCHYMA LACER, UNSPECIFIED FALL temperature: 99.7 heartrate: 98.0 resprate: 18.0 o2sat: 96.0 sbp: 146.0 dbp: 77.0 level of pain: 5 level of acuity: 3.0

Dear Ms. ___, . It was a pleasure taking care of you at ___ ___ in ___. You were admitted with abdominal pain after having had a splenic artery embolization at a hospital in ___. While you were admitted, we obtained another cat scan of your abdomen which showed a collection of blood around the spleen which is stable, and no active bleeding. The surgeons evaluated you but do not feel that there is any surgical intervention needed. . Please make the following changes to your medications: 1. start tylenol ___ every 8 hours as needed for pain (do not exceed a total of 2 grams per day) 2. start oxycodone ___ every 6 hours as needed for pain 3. start senna and polyethylene glycol to prevent constipation while you are taking the oxycodone 4. continue the ciprofloxacin and flagyl through ___ in order to complete a total of 28 days of the antibiotics

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Fall and left-sided weakness Major Surgical or Invasive Procedure: ___ Percutaneous endoscopic gastrostomy tube placement History of Present Illness: The patient is a ___ gentleman with past medical history significant for hypertension and CLL in remission recently completed chemo, history of prior hypertensive stroke ___ years ago with residual right foot drop who presents as an outside hospital transfer for further evaluation of IPH. Briefly, per wife patient and wife were just about to go to do errands, he was walkign to the car with his walker when he noticed he forgot something in the house. He walked back to the house without his walker. His wife was walking behind him. He was walking very fast so she told him to slow down and when he turned around he suddenly fell and hit his head. She states that prior to this he was in his usual states of health. he has residual left sided weakness from a stroke ___ years ago and a known right foot drop. He was getting ___ and speech therapy (at baseline does not speak very clear) after a fall in ___. Since then he walks with a cane. He is independent of ADL's. The wife denies any complains of headache, altereted mental status, or new neuro defcits. In fact she ___ that ___ was just there earlier stating how well he was doing. No recent fevers or unexplained weight loss. After the fall she called she EMS. Per there report the patient reportedly had expressive aphasia, left-sided neglect, and left upper and left lower extremity weakness. He was brought to ___ where his blood pressure was noted to be 144/77 heart rate 63 satting on room air. CT head showed a right basal ganglia bleed with intraventricular extension. He was given 1 g of Keppra and transferred to ___ for further evaluation. Upon arrival to ___'s vitals were Blood pressure 142/73 heart rate 65 satting 100% on room air. GCS was 14. Plts 57, INR 1.3 He has a hx of leukemia and had his last chemo in ___. He has completed chemo. Past Medical History: Prior stroke ___ years ago with residual right foot drop Hypertension CLL with remission and then recurrent skin leukemia Social History: Married. Used to work as ___. Lives with wife. Walks with a walker. Smoked in past, etoh occasionally, no illicit drugs. - Modified Rankin Scale: [] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [x] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: Unknown Physical Exam: ADMISSION EXAMINATION ===================== Vitals: T: 97.8 P: 65 r: 16 BP: 142/73 SaO2: 100% room air - General: Awake, cooperative, NAD. - HEENT: NC/AT - Neck: Supple - Pulmonary: no increased WOB - Cardiac: well perfused - Abdomen: soft, nontender, nondistended - Extremities: no edema, pulses palpated - Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, not oriented to time or place, says he is ___ and that it is ___. Unable to relate history. Inattentive unable to name ___ backward without difficulty. Unable to name, decreased verbal fluency, intact comprehension. Speech was not dysarthric. Able to follow both midline and appendicular commands. reagrds examiner on rigth and left side. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: Mild right gaze preference but able to cross midline easily. V: Facial sensation intact to light touch. VII: mild left lower facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. No asterixis noted. LUE drift. Patient did not fully participate in confrontational exam but was able to move all 4 extremities antigravity. Right upper and right lower extremity 5 out of 5, except for RLE distally. LUE ___, LLE 4+/5. -Sensory: No deficits to light touch, pinprick throughout. Difficult to assess for extinction. -Coordination: No dysmetria on finger to nose bilaterally -Gait: Deferred DISCHARGE EXAMINATION ===================== Vitals: Temp: 97.3 (Tm 98.1), BP: 154/75 (148-173/72-82), HR: 61 (56-61), RR: 20 (___), O2 sat: 100% (95-100), O2 delivery: RA General: awake, cooperative, NAD HEENT: resolving forehead and lateral periorbital hematoma, no scleral icterus noted, MMM Pulmonary: breathing comfortably, no tachypnea or increased WOB Cardiac: skin warm, well-perfused Abdomen: soft, ND Extremities: symmetric, no edema Neurologic: -Mental Status: Awake, alert, oriented to place (hospital) but not city or time. Mildly inattentive. Language is sparse though fluent with intact comprehension. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL. EOMI without nystagmus. Subtle R NLFF. Palatal elevation symmetric. Hearing intact to conversation. Tongue protrusion in midline. -Motor: Limited by motor impersistence, full on left and at least 4+/5 throughout RUE/RLE aside from R TA, chronically ___ from foot drop. -Sensory: Symmetric to LT. -DTRs: ___. -Coordination: Deferred. Pertinent Results: ___ 05:16AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.3* Hct-28.5* MCV-98 MCH-32.0 MCHC-32.6 RDW-14.4 RDWSD-50.3* Plt Ct-56* ___ 05:16AM BLOOD Glucose-88 UreaN-15 Creat-0.7 Na-144 K-3.7 Cl-112* HCO3-21* AnGap-11 ___ 05:16AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.9 ___ 05:50AM BLOOD %HbA1c-4.8 eAG-91 ___ 05:50AM BLOOD Triglyc-73 HDL-25* CHOL/HD-5.3 LDLcalc-93 ___ 5:41 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). ___ 3:15 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 3:15 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:32 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS FAECALIS. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=0.5 S ___ 5:43 ___ CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS 1. Slight increase in moderate amount of intraventricular blood described above. Of note, on CTA there is evidence a potential spot sign in the region of the right lateral ventricle occipital horn raising concern for potential active bleeding. 2. Redemonstrated evidence of intraparenchymal extension blood just superior to right lateral ventricle temporal horn in the region of the basal ganglia where there is mild surrounding vasogenic edema. 3. Evidence of mild-to-moderate white matter small vessel disease. 4. Small old infarct abutting the body of the right caudate nucleus. 5. Extensive cervical lymphadenopathy likely correlates with the patient's history of CLL. 6. A 2 mm left upper lobe pulmonary nodule for which no imaging follow-up is recommended in low risk patients. High-risk patients may receive an optional follow-up CT in 12 months per the ___ criteria. 7. Couple thyroid nodules measuring up to 1.4 cm for which no follow-up imaging is recommended. ___ 8:00 ___ MR HEAD W & W/O CONTRAST 1. Stable hematoma in the right basal ganglia and medial temporal lobe with stable surrounding edema and stable intraventricular extension. 2. Several small foci of contrast enhancement within the basal ganglia and medial temporal lobe portions of the hematoma, without peripheral masslike enhancement outside the margins of the hematoma, are of uncertain clinical significance. Follow-up imaging is needed to exclude an underlying mass. 3. Extensive supratentorial white matter and pontine signal abnormalities, nonspecific but likely sequela of small vessel disease. Small chronic infarcts within bilateral corona radiata, left centrum semiovale, and left pons. ___ 10:01 AM VIDEO OROPHARYNGEAL SWALLOW Penetration with thin liquids and nectar thick liquids without aspiration. Medications on Admission: 1. Aspirin EC 81 mg PO DAILY 2. Potassium Chloride 20 mEq PO DAILY 3. Spironolactone 25 mg PO DAILY 4. Metoprolol Tartrate 50 mg PO BID Discharge Medications: 1. Lisinopril 20 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Metoprolol Tartrate 50 mg PO BID 4. Potassium Chloride 20 mEq PO DAILY Hold for K > 4 5. Spironolactone 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Right basal ganglia intraparenchymal hemorrhage 2. Dysphagia s/p PEG placement 3. Hypertension 4. E. faecalis UTI 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: ___ with fall. Evaluate for acute thoracic process. TECHNIQUE: Chest PA and lateral COMPARISON: Chest x-ray ___, performed at an outside facility. FINDINGS: The heart size is normal. A right-sided Port-A-Cath terminates in the right atrium. Mild bibasilar atelectasis. Otherwise, the lungs are clear. No pleural effusion or pneumothorax. A deformity of the left seventh posterior rib is likely chronic. IMPRESSION: Mild bibasilar atelectasis. No focal consolidations or pneumothorax. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with right basal ganglia hemorrhagic stroke// avm, aneurysm TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. 2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7 mGy-cm. 3) Stationary Acquisition 5.5 s, 1.0 cm; CTDIvol = 41.1 mGy (Head) DLP = 41.1 mGy-cm. 4) Spiral Acquisition 9.8 s, 37.5 cm; CTDIvol = 37.9 mGy (Head) DLP = 1,361.1 mGy-cm. Total DLP (Head) = 2,263 mGy-cm. COMPARISON: CT head without contrast ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There has been a slight increase in the moderate amount of blood pooling within the temporal and occipital horns of the right lateral ventricle with the temporal horn being slightly expanded, as before. New trace amount of blood is also present within the left lateral ventricle occipital horn. Redemonstrated is intraparenchymal extension of blood just superior to the right lateral ventricle temporal horn in the region of the basal ganglia where there is mild surrounding vasogenic edema. There is mild-to-moderate subcortical and periventricular white matter hypoattenuation compatible with small vessel disease. Abutting the body of the right caudate nucleus is a small old infarct (03:27). 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 evidence of a spot sign within the occipital the right lateral ventricle (7:301). 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: There are atherosclerotic calcifications of the intracranial vertebral arteries as well as of the origin and mid right cervical vertebral artery. The carotid and vertebral arteries and their major branches appear otherwise normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: There is a 2 mm left upper lobe pulmonary nodule adjacent to the major fissure (07:12). There are a couple bilateral thyroid nodules measuring up to 1.4 cm in the left thyroid lobe. There are several prominent and enlarged nodes involving nearly all cervical stations. Largest lymph node is present within the right submandibular station measuring 1.2 x 2.6 cm in greatest axial ___. IMPRESSION: 1. Slight increase in moderate amount of intraventricular blood described above. Of note, on CTA there is evidence a potential spot sign in the region of the right lateral ventricle occipital horn raising concern for potential active bleeding. 2. Redemonstrated evidence of intraparenchymal extension blood just superior to right lateral ventricle temporal horn in the region of the basal ganglia where there is mild surrounding vasogenic edema. 3. Evidence of mild-to-moderate white matter small vessel disease. 4. Small old infarct abutting the body of the right caudate nucleus. 5. Extensive cervical lymphadenopathy likely correlates with the patient's history of CLL. 6. A 2 mm left upper lobe pulmonary nodule for which no imaging follow-up is recommended in low risk patients. High-risk patients may receive an optional follow-up CT in 12 months per the ___ ___ criteria. 7. Couple thyroid nodules measuring up to 1.4 cm for which no follow-up imaging is recommended. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or older. 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. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:32 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with intraventricular hemorrhage. Evaluate for underlying mass. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head without contrast from ___. CTA head and neck from ___. FINDINGS: No significant change in the parenchymal hematoma centered within the basal ganglia and extending into the medial right temporal lobe, with stable surrounding edema, compared to the earlier same-day CT. Extension of hemorrhage into the temporal and occipital horns of the right lateral ventricle, and occipital horn of left lateral ventricle, is stable. Temporal horn of the right lateral ventricle remains compressed. The remainder of the ventricular system is mildly prominent, unchanged, which may be due to global parenchymal volume loss. There is commensurate mild prominence of the sulci. The above described parenchymal hematoma demonstrates isointensity to minimal hyperintensity on precontrast T1 weighted images. No postcontrast T1 weighted images were performed due to technical air. Postcontrast MP RAGE images demonstrate small foci of contrast enhancement within the lentiform nucleus as well as medial temporal portions of the hematoma. Diffusion-weighted images demonstrate patchy signal abnormality throughout the parenchymal hematoma, which may in part be related to susceptibility artifact, without evidence for slow diffusion outside the margins of the hematoma. Extensive bilateral T2/FLAIR hyperintensities in the subcortical, deep, and periventricular white matter of the cerebral hemispheres, as well as in the bilateral pons, are nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. There are several chronic infarcts in the right corona radiata, left frontal corona radiata and centrum semiovale, and left pons. 2 mm rounded focus of relatively low signal (but not flow void) to the right of the distal basilar artery flow void on image 8:7 is likely artifactual, as no abnormality is seen on this location on the ___ CTA. The major intracranial vascular flow voids are otherwise grossly preserved. Dural venous sinuses appear patent on postcontrast MP RAGE images. There is mild mucosal thickening of the ethmoid air cells and maxillary sinuses. IMPRESSION: 1. Stable hematoma in the right basal ganglia and medial temporal lobe with stable surrounding edema and stable intraventricular extension. 2. Several small foci of contrast enhancement within the basal ganglia and medial temporal lobe portions of the hematoma, without peripheral masslike enhancement outside the margins of the hematoma, are of uncertain clinical significance. Follow-up imaging is needed to exclude an underlying mass. 3. Extensive supratentorial white matter and pontine signal abnormalities, nonspecific but likely sequela of small vessel disease. Small chronic infarcts within bilateral corona radiata, left centrum semiovale, and left pons. RECOMMENDATION(S): Follow up MRI with and without contrast to assess for resolution of contrast enhancement at the site of the right basal ganglia/medial temporal lobe hematoma. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with R BG IPH w/ ?spot sign// Assess for progression of hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP = 911.9 mGy-cm. 2) Sequenced Acquisition 3.0 s, 5.1 cm; CTDIvol = 48.8 mGy (Head) DLP = 248.7 mGy-cm. Total DLP (Head) = 1,175 mGy-cm. COMPARISON: CTA head and neck ___ at 17:45 FINDINGS: There has been minimal discernible change with minimal redistribution in the intraparenchymal hemorrhage in the region of right basal ganglia with breakthrough in layering into the temporal and occipital horns of the right lateral ventricle and occipital horn of the left lateral ventricle. Surrounding vasogenic edema is also similar to prior. No discernible midline shift. Basal cisterns remain patent. There is unchanged hypodensity adjacent to the body of the right caudate nucleus, likely prior lacune. Mild-to-moderate subcortical, periventricular, and deep white matter hypodensities are similar to prior and likely represent sequela of chronic microvascular ischemic disease. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: Essentially unchanged intraparenchymal hemorrhage with only minimal redistribution in the region of the right basal ganglia with breakthrough and layering into the temporal and occipital horns of the right lateral ventricle and occipital horn left lateral ventricle. Similar surrounding vasogenic edema. No discernible midline shift. Basal cisterns remain patent. Radiology Report INDICATION: ___ year old man with new dobhoff// Eval tube location TECHNIQUE: Portable frontal view of the chest/abdomen. COMPARISON: Chest radiograph ___. IMPRESSION: There has been interval placement of a Dobhoff tube with the last image demonstrating the tip in the proximal gastric body, satisfactory. Right-sided port is unchanged, satisfactory. There is mild cardiomegaly and unfolding of the thoracic aorta. Hilar contours are preserved. There is minimal bibasilar atelectasis. The visualized lung fields are otherwise clear. There is no large effusion or appreciable pneumothorax. Radiology Report INDICATION: ___ year old man with R BG IPH// Check NGT TECHNIQUE: Frontal abdominal radiographs were obtained. COMPARISON: None FINDINGS: The enteric tube tip projects over the left upper quadrant presumably within the stomach. The bowel gas pattern is unremarkable with gas seen in nondistended loops of large and small bowel. Partially visualized lower chest demonstrates no focal consolidation. The bony structures are unremarkable. IMPRESSION: 1. The enteric tube tip projects over the left upper quadrant presumably within the stomach. 2. The right chest wall Port-A-Cath tip projects over the distal right atrium. 3. Nonspecific and nonobstructive bowel gas pattern. Radiology Report INDICATION: ___ year old man with R IPH, dysphagia// evaluate for aspiration TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the Speech-Language Pathologist from the Voice, Speech & Swallowing Service. Multiple consistencies of barium were administered. DOSE: Fluoro time: 4 minutes and 51 seconds COMPARISON: None FINDINGS: There is penetration with thin liquids and nectar thick liquids without aspiration. IMPRESSION: Penetration with thin liquids and nectar thick liquids 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). Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CVA, Transfer Diagnosed with Traum hemor right cerebrum w/o loss of consciousness, init, Other fall on same level, initial encounter temperature: 97.8 heartrate: 65.0 resprate: 16.0 o2sat: 100.0 sbp: 142.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ for evaluation of a fall and left-sided weakness. Imaging of your brain with CT and MRI showed that your weakness was due to a bleed on the right side of your brain. It is likely that your bleeding was due to high blood pressure, for which your blood pressure medications were adjusted during your stay. As a result of your brain bleed, you also had difficulty swallowing safely. A tube was temporarily placed in your stomach to assist with feeding and administration of medications. During your stay, you also had a urinary tract infection treated with antibiotics. Please follow up with your primary care provider within one week of discharge from your acute rehabilitation facility. Please also follow up with Neurology at the appointment listed below. It was pleasure taking care of you at ___. Sincerely, ___ Neurology

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: spironolactone / metoprolol Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/PMHx COPD, dCHF/sCHF (EF ___ ___ CRT ___, presents with shortness of breath x several days, much worse today. Said at baseline, she is ually able to walk around the house and get chores done all day without feeling short of breath. However, today she had a very difficult time breathing. She denies any recent illnesses, or associated fevers or cough. Also denies any sick contact. Of note, patient's lisinopril dose was increased from 5 to 10mg a few months ago. Otherwise, no recent change in medications. In the ED initial vitals were: 97.6 88 115/78 22 100% 15L. She initially triggered for a desat into 70's. - Labs were significant for K 5.5, creatinine 1.5, BNP 1765, trop <.01. - Patient was given albuterol, ipratropium and prednisone Vitals prior to transfer were: 97.5 77 94/60 18 94% RA On the floor, patient reports she pretty much feels back to her baseline. Past Medical History: - CAD ___ NSTEMI ___ (60% RCA lesion) - Severe non-ischemic dilated cardiomyopathy - Chronic systolic (LVEF ___ and diastolic CHF - LBBB with ventricular mechanical dys-synchrony - 3+ Mitral Regurgitation - COPD - Hypertension - Hypercholesterolemia - ICD (epicardial lead implanted ___ Social History: ___ Family History: DMII and HTN in multiple family members. No FH kidney disease, cancer, stroke. Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== Vitals - T:97.8 BP:129/68 HR:83 RR:18 02 sat:94RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, PMI laterally displaced. Device in good position with no surrounding erythema LUNG: Inspiratory crackles throughout, most prominent at bases ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes PHYSICAL EXAM ON DISCHARGE: ========================== Vitals: 97.4 94/61 69 18 95% on RA I/O: ___ weight 66.8 kg GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, PMI laterally displaced. Device in good position with no surrounding erythema LUNG: Inspiratory crackles throughout, most prominent at bases ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: LABS ON ADMISSION: ===================== ___ 05:30AM GLUCOSE-247* UREA N-36* CREAT-1.6* SODIUM-139 POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-28 ANION GAP-23* ___ 05:30AM CALCIUM-10.3 PHOSPHATE-2.6* MAGNESIUM-2.3 ___ 05:30AM WBC-5.6 RBC-4.41 HGB-13.1 HCT-38.6 MCV-88 MCH-29.6 MCHC-33.8 RDW-13.1 ___ 05:30AM PLT COUNT-244 ___ 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 11:30PM URINE RBC-3* WBC-15* BACTERIA-FEW YEAST-NONE EPI-4 ___ 11:30PM URINE HYALINE-20* ___ 09:49PM ___ PO2-42* PCO2-58* PH-7.38 TOTAL CO2-36* BASE XS-6 ___ 09:49PM LACTATE-1.6 ___ 09:49PM O2 SAT-73 ___ 09:40PM GLUCOSE-166* UREA N-35* CREAT-1.5* SODIUM-133 POTASSIUM-5.5* CHLORIDE-92* TOTAL CO2-30 ANION GAP-17 ___ 09:40PM cTropnT-<0.01 ___ 09:40PM proBNP-1765* ___ 09:40PM WBC-7.8 RBC-4.87 HGB-14.1 HCT-41.7 MCV-86 MCH-28.9 MCHC-33.7 RDW-12.9 ___ 09:40PM NEUTS-56.7 ___ MONOS-7.6 EOS-7.5* BASOS-0.9 ___ 09:40PM PLT COUNT-277 ___ 09:40PM ___ PTT-28.4 ___ LABS ON DISCHARGE: ================== ___ 05:44AM BLOOD WBC-13.2* RBC-4.59 Hgb-13.5 Hct-39.4 MCV-86 MCH-29.4 MCHC-34.2 RDW-13.0 Plt ___ ___ 05:44AM BLOOD Plt ___ ___ 05:44AM BLOOD Glucose-84 UreaN-55* Creat-1.4* Na-135 K-3.4 Cl-92* HCO3-31 AnGap-15 ___ 05:44AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3 PERTINENT LABS: ============== NONE MICROBIOLOGY: ============= ___ 10:25 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 10:00 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 1:10 am BLOOD CULTURE Blood Culture, Routine (Preliminary): PROBABLE MICROCOCCUS SPECIES. Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ (___) 4:35AM ___. __________________________________________________________ ___ 9:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): STUDIES: ======== CXR ___: As compared to the previous radiograph, no relevant change is noted. The size of the cardiac silhouette has slightly increased, caused by LS a inspiratory air Ford. There is no evidence of pneumonia, pulmonary edema or pleural effusions. The pacemaker leads are constant in position. CXR ___: Left chest wall pacer defibrillator has leads terminating in the right atrium and right ventricle as well as epicardial leads on the left ventricle. The lungs are slightly hyperexpanded with flattening of the hemidiaphragms similar to the prior study. The heart is not enlarged. The mediastinal and hilar contours are normal. There is no pleural effusion or pneumothorax. There is no focal airspace opacity to suggest pneumonia and no evidence of pulmonary edema. IMPRESSION: No acute cardiopulmonary abnormality. No evidence of pneumonia or pulmonary edema. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 2. Carvedilol 25 mg PO BID 3. Colchicine 0.6 mg PO DAILY 4. Digoxin 0.125 mg PO EVERY OTHER DAY 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Lisinopril 10 mg PO DAILY 7. Pravastatin 80 mg PO DAILY 8. Torsemide 60 mg PO DAILY 9. Aspirin 81 mg PO DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 2. Aspirin 81 mg PO DAILY 3. Carvedilol 25 mg PO BID 4. Colchicine 0.6 mg PO DAILY 5. Digoxin 0.125 mg PO EVERY OTHER DAY 6. Pravastatin 80 mg PO DAILY 7. Torsemide 60 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose one puff inh twice a day Disp #*1 Disk Refills:*0 9. Fluticasone Propionate 110mcg 2 PUFF IH BID 10. PredniSONE 40 mg PO DAILY Duration: 1 Day RX *prednisone 20 mg two tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 11. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 12. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg one cap inh daily Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ACUTE DIAGNOSES: 1. COPD exacerbation 2. CHF exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with CHF and COPD exacerbation and new cough // pneumonia, edema, effusion COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, no relevant change is noted. The size of the cardiac silhouette has slightly increased, caused by LS a inspiratory air Ford. There is no evidence of pneumonia, pulmonary edema or pleural effusions. The pacemaker leads are constant in position. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with severe constipation and dropping Hct // NGT placement COMPARISON: ___ IMPRESSION: FINDINGS: As compared to the previous radiograph, the size of the cardiac silhouette has minimally decreased and the lung volumes have minimally increased, likely reflecting a stronger inspiratory effort Ford. There is no evidence of pneumonia. No pulmonary edema. No pleural effusions. Unchanged course of the pacemaker leads. On the current radiograph. There is no evidence for nasogastric tube placement. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea, Hypoxia Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION temperature: 97.6 heartrate: 88.0 resprate: 22.0 o2sat: 100.0 sbp: 115.0 dbp: 78.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You presented to us with worsening shortness of breath. You were found to be volume overloaded as well as COPD exacerbation. You were treated with nebulizer treatment and steroids in addition to more aggressive diuresis. Your symptoms improved and you were able to be discharged. Please take all your medications as instructed. Please attend all your follow up appointments. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. All the best, your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ABDOMINAL PAIN Major Surgical or Invasive Procedure: 1. Cystoscopy. 2. Left ureteroscopy. 3. Left ureteral stent placement. 4. Basket extraction of stone History of Present Illness: ___ yo F with CAD, asthma, metastatic colon cancer undergoing chemotherapy, who presented to the ED with abdominal pain 2 days prior and was found to have a 2 mm UVJ stone on CT scan. Pain was controlled and she was discharged with pain medications and flomax. She presented to the ED today with cough and weakness. CXR was negative for pneumonia. She was afebrile and hemodynamically stable, without leukocytosis or evidence of ___, dirty UA. In this setting urology was consulted and the patient was admitted for observation in the ED for IVF and pain control. Additionally, she recieved IV ceftriaxone in the ED. When the patient was seen, her pain was much improved ___ located in her left flank, radiating to left groin. Little nausea, but feeling hungry. No vomiting. She denied f/c/n/v/hematuria, urgency, frequency, and dysuria. She denies passing any stones overnight. Past Medical History: PMH: Metastatic colon cancer CAD s/p Stent ___ HTN Asthma PSH: Ex lap, right colectomy, LOA, umbilical hernia repair ___ Chole Hysteroscopy with diagnostic D&C Port placement ONCOLOGIC HISTORY: -___: Fe-deficiency anemia. Colonoscopy revealed a partially obstructing and bleeding 5-cm mass, biopsied adenocarcinoma. -___: Right hemicolectomy and hernia repair. Pathology T3, N1, M0 stage III with 1 out of 18 lymph nodes positive. -___: Completed 12 cycles FOLFOX adjuvant chemotherapy. -___: Rising CEA to 5.8. CT showed interval development of bilateral pulmonary nodules, an ill-defined focus of increased enhancement involving segment VI of liver, increase in size of nodal mass at the base of the mesentery, and interval development of paraaortic-retroperitoneal adenopathy. ___: Retroperitoneal node biopsy confirmed metastatic colon. ___: FOLFOX started. ___: Leucovorin and bolus infusional ___ were dose reduced by 25% with cycle 2 Day 15. ___: CT showed interval decrease in size and number of bilateral pulmonary nodules, mesenteric and nodal mass and retroperitoneal lymphadenopathy. ___: Oxaliplatin was discontinued from FOLFOX with cycle 9 due to neuropathy. ___: CT showed progression of disease and she was begun on Irinotecan. . OTHER PMHx: CAD, s/p MI and stent ___. HTN Hyperlipidemia Asthma Cesarean section Cholecystectomy Social History: ___ Family History: Brother died of MI at ___. No other FHx of CAD or sudden death. Denies family history of kidney stones, bladder/kidney cancer. Physical Exam: WDWN female, NAD, AVSS Abdomen soft, nt/nd ___ speaking, pleasant, cooperative No lower extremity pitting/edema Pertinent Results: ___ 6:36 pm URINE Site: NOT SPECIFIED ADDED TO HOLD ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 8:30 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 06:00AM BLOOD WBC-4.6 RBC-3.90* Hgb-10.3* Hct-31.5* MCV-81* MCH-26.3* MCHC-32.6 RDW-16.3* Plt ___ ___ 04:55PM BLOOD WBC-5.0 RBC-3.93* Hgb-10.6* Hct-33.5* MCV-85 MCH-26.9* MCHC-31.6 RDW-15.4 Plt ___ ___ 05:30AM BLOOD WBC-6.3 RBC-3.91* Hgb-10.8* Hct-33.3* MCV-85 MCH-27.5 MCHC-32.3 RDW-15.6* Plt ___ ___ 04:55PM BLOOD Neuts-43.4* Lymphs-44.1* Monos-5.6 Eos-6.5* Baso-0.5 ___ 05:30AM BLOOD Neuts-40.7* Lymphs-46.8* Monos-6.3 Eos-5.7* Baso-0.7 ___ 06:00AM BLOOD Glucose-147* UreaN-7 Creat-0.6 Na-142 K-3.9 Cl-108 HCO3-28 AnGap-10 ___ 04:55PM BLOOD Glucose-95 UreaN-8 Creat-0.5 Na-143 K-3.5 Cl-108 HCO3-30 AnGap-9 ___ 05:30AM BLOOD Glucose-126* UreaN-12 Creat-0.7 Na-141 K-3.6 Cl-108 HCO3-24 AnGap-13 ___ 05:43AM BLOOD Lactate-1.0 Medications on Admission: benzonatate 100 mg capsule (One) Capsule(s) by mouth three times a day as needed for cough codeine-guaifenesin 100 mg-10 mg/5 mL Liquid 5 ml(s) by mouth three times a day as needed for cough diphenoxylate-atropine 2.5 mg-0.025 mg tablet 1 (One) Tablet(s) by mouth every four (4) to six (6) hours as needed for chemotherapy related diarrhea ICD: 153.9 (colon cancer) fluticasone 50 mcg Spray, Suspension puffs in each nostril daily fluticasone [Flovent Diskus] 250 mcg Disk with Device puff inhaler twice daily metoprolol succinate 50 mg Tablet Sustained Release 24 hr 1 Tablet(s) by mouth twice a day montelukast 10 mg Tablet Tablet(s) by mouth once daily naproxen 375 mg tablet tablet(s) by mouth Twice a day omeprazole 20 mg capsule,delayed ___ Capsule(s) by mouth once daily oxycodone 5 mg tablet Tablet(s) by mouth every 6 hours as needed for pain prochlorperazine maleate 10 mg Tablet 1 (One) Tablet(s) by mouth every six (6) hours as needed for nausea salmeterol [Serevent Diskus] 50 mcg Disk with Device puff inhaler twice daily valsartan [Diovan] 160 mg tablet (One) Tablet(s) by mouth daily zopidem 5 mg tab (One) Tab by mouth at bedtime as needed for insomnia aspirin 81 mg Tablet, Delayed Release (E.C.)1 Tablet(s) by mouth once daily loperamide [Anti-Diarrhea] 2 mg tablet -2 tablet(s) by mouth PRN diarrhea loratadine 10 mg Tablet (One) Tablet(s) by mouth once a day magnesium oxide-Mg AA chelate [Mg-Plus-Protein] 133 mg tablet 3 (Three) Tablet(s) by mouth three times a day Take with meals acetaminophen [Tylenol] albuterol sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler puff QID prn Camptosar * patient unable to identify actual drug name * taken every ___ as directed Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 2. Benzonatate 100 mg PO TID:PRN cough 3. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea for chemotherapy related diarrhea 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Montelukast Sodium 10 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain greater than 4 12. Valsartan 160 mg PO DAILY 13. Zolpidem Tartrate 5 mg PO HS insomnia 14. Aspirin 81 mg PO DAILY Resume when the ureteral stent is removed or your are advised by your PCP/Urologist 15. Prochlorperazine 10 mg PO Q6H:PRN nausea 16. Naproxen 375 mg PO Q12H:PRN pain 17. Loratadine *NF* 10 mg Oral DAILY ALLERGIC RHINITIS 18. CAMPTOSAR Resume this medication as directed. 19. RETURN TO WORK NOTE You may return to work without restrictions effective ___. Please excuse her absence from work since ___. 20. F/U APPT WORK NOTICE Ms. ___ will return to clinic during the week of ___ for her post-hospitalization follow-up appointment. Date is to be determined. Please excuse her absence from work. 21. Loperamide 2 mg PO QID:PRN diarrhea 22. magnesium oxide-Mg AA chelate *NF* 399 mg Oral TID Three 133mg tablets (399mg total)taken three times per day. 23. Cephalexin 500 mg PO Q6H Duration: 5 Days Discharge Disposition: Home Discharge Diagnosis: Left 2 mm ureterovesical junction stone. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Cough. TECHNIQUE: PA and lateral views of the chest. COMPARISON: Chest radiograph ___ and CT torso ___. FINDINGS: Left-sided Port-A-Cath tip terminates within the proximal right atrium, unchanged. Lung volumes are low. Mild enlargement of cardiac silhouette is unchanged. The aorta remains mildly tortuous. There is crowding of the bronchovascular structures, but no overt pulmonary edema is visualized. Known nodules within both lower lobes are better depicted on the prior CT. There is minimal streaky atelectasis in both lung bases. No focal consolidation, pleural effusion or pneumothorax is present. Cholecystectomy clips are demonstrated in the right upper quadrant of the abdomen. There are no acute osseous abnormalities. IMPRESSION: Mild bibasilar atelectasis. Known bilateral lower lobe pulmonary nodules are better depicted on the prior CT. Radiology Report INDICATION: History of a 2-mm left ureterovesicular stone. Left-sided stent placement. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: Five spot fluoroscopic images were obtained without a radiologist present. Images demonstrate the passage of a wire through the left ureter, and a subsequent successful placement of a left-sided stent. Please refer to the intraoperative report for further details. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: ?PNEUMONIA Diagnosed with CALCULUS OF KIDNEY temperature: 98.4 heartrate: 85.0 resprate: 20.0 o2sat: 98.0 sbp: 130.0 dbp: 73.0 level of pain: 10 level of acuity: 3.0

-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent--which is attached to a string and may be visible at your urethra. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -You will be given a course of antibiotics as prophylaxis to reduce your risk of infection while ureteral stent is in place -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up or you have been otherwise explicitly advised. -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up -NAPROXEN may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -NAPROXEN should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports until the stent has been removed. Light household activity and work may be performed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Ertapenem / diltiazem / iv contrast Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with medical history of CAD ___ RCA stent ___, HFpEF ___ porcine MVR (___), anti-cardiolipin antibody and paroxysmal atrial fibrillation ___ MAZE and PVI on warfarin and flecainide, mild aortic stenosis, broncho-alveolar carcinoma, seizures, CKD, and prior stroke, who presents with substernal chest pain radiating to the left that woke her up from sleep. Patient states she woke up at 3AM with chest discomfort. SSCP radiating to left shoulder. Mild nausea and diaphoresis. Pain worsened over the night prompting presentation to ED. No palpitations, cough or SOB. Chest pain was exertional and associated with lightheadedness with walking. She reports that she thinks she has had similar chest pain before. No recent fevers, chills. Endorses ___ numbness. Of note, Had a stroke years ago, has short term memory loss. Has been in intermittent atrial fibrillation since MVR/Maze. Followed by ___ but transitioning to Dr. ___. ED COURSE In the ED intial vitals were: 97.6 126 141/85 16 98% RA. She was noted to be in AF with RVR. EKG: atrial fibrillation, without ischemic changes. Labs/studies notable for: H/H 9.1/___, platelets 131. Chemistries notable for BUN 61, Cr 2.5, (last Cr 2.5 in ___. INR 1.7, Trop <0.01 x2. Patient was given: ASA and morphine immediately. She then converted to NSR with improvement in symptoms. Pain decreased to a five. Vitals on transfer: 98.4 71 101/54 17 96% RA. On the floor... she denies chest pain, dyspnea, lightheadedness, dizziness. Endorses feeling lightheaded and short of breath during exercise stress test which was aborted due to hypotension/ tachyarrythmia and possible ECG changes. Past Medical History: 1. CAD RISK FACTORS: +hypertension, +dyslipidemia, -diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: CAD ___ RCA stent (___) ___ angina, but no occlusions on cath - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Atrial fibrillation on warfarin, ___ cardioversion and unsuccessful ablation ___, now in NSR on flecainide - mitral stenosis / mitral regurgitation, ___ porcine valve ___ years ago - HTN - HFpEF - + anti-cardiolipin antibody with prior DVT on lifelong warfarin goal INR 2.5-3.5 - hyperlipidemia - CKD - CVA ___: R facial droop/speech arrest, followed by a TIA - seizure disorder (temporal lobe; confusional episodes, stable on keppra) - asbestos exposure - bronchoalveolar carcinoma ___ Right VATS/RLL wedge resection on ___ with clean margins (has stable recurrence on follow-up imaging) - anemia - alopecia - gout - vein ligation and stripping x 2 Social History: ___ Family History: Mother with CAD, type 2 DM. Father with CAD. Physical Exam: ====================== ADMISSION PHYSICAL EXAM ====================== VS: 98.2 161/77 71 18 97%RA GENERAL: WDWN sitting up in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. ___ systolic murmur best heard at ___. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild bibasilar crackles ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric . . ====================== DISCHARGE PHYSICAL EXAM ====================== Weight on admission: 63.1kg Weight on discharge: 62.0kg Vitals: 97.7, 102/65, 64, 16, 100% RA Tele: Sinus, First degree AV block (PR prolongation not new). No alarms I/O's not recorded GENERAL: WDWN sitting up in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. ___ systolic murmur best heard at ___. No thrills, lifts. LUNGS: CTAB no w/r/r ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS: ============== ___ 06:05AM BLOOD WBC-6.0 RBC-2.98* Hgb-9.1* Hct-28.0* MCV-94 MCH-30.5 MCHC-32.5 RDW-15.6* RDWSD-53.1* Plt ___ ___ 06:05AM BLOOD Neuts-73.7* Lymphs-14.7* Monos-9.3 Eos-1.5 Baso-0.5 Im ___ AbsNeut-4.41 AbsLymp-0.88* AbsMono-0.56 AbsEos-0.09 AbsBaso-0.03 ___ 06:05AM BLOOD ___ PTT-43.2* ___ ___ 06:05AM BLOOD Glucose-110* UreaN-61* Creat-2.5* Na-138 K-3.9 Cl-102 HCO3-23 AnGap-17 ___ 12:07PM BLOOD cTropnT-<0.01 ___ 06:05AM BLOOD cTropnT-<0.01 IMAGING/STUDIES: ================= CXR ___ 1. No definite acute cardiopulmonary process. 2. Grossly stable bibasilar interstitial markings and calcified pleural plaques. ETT ___ ___ yo woman with HL and HTN, h/o CAD and ___ stent of RCA in ___, HFpEF, h/o atrial tachycardia, flutter and fibrillation ___ MAZE in ___, PVI and CTI ablation in ___ and now on flecainide was referred to evaluate an atypical chest discomfort after presenting to the ED in PAT/PAF at ~ 125 bpm. The patient completed 7 minutes of a Gervino protocol representing a fair exercise tolerance; ~ ___ METS. Although the patient was near fatigue, the exercise test was stopped due to increasing atrial irritability accompanied with shortness of breath. The patient denied any chest, back, neck or arm discomforts during the procedure. No lightheadedness or palpitations were reported. While in the atrial tachycardia, 0.5-1 mm horizontal ST segment depression was noted in leads I, inferiorly and in V6. In addition, 0.5-1 mm ST segment elevation was noted in aVR. At 13 minutes of recovery, and following the administration of 2.5 mg Lopressor IV, sinus rhythm was noted with resolution of ST segment changes. The rhythm was sinus with frequent nonsustained runs of PAT noted in exercise and throughout recovery; rates ~ 115-120 bpm. Rare isolated VPBs. The blood pressure response to exercise was flat. IMPRESSION: Test stopped due to increasing atrial irritability accompanied by increasing shortness of breath. ST segment changes noted in the setting of the tachyarrhythmia; see above. Blunted blood pressure response to exercise. Fair exercise tolerance. Nuclear Perfusion ___: Normal myocardial perfusion study. No significant change from myocardial perfusion study ___. Stress ___: IMPRESSION: Frequent atrial irritability with frequent nonsustained runs of PAT noted at rest and throughout the procedure; similar rhythm noted on floor. No anginal symptoms or ischemic ST segment changes. Appropriate hemodynamic response to the Persantine infusion. Nuclear report sent separately. Medications on Admission: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Flecainide Acetate 50 mg PO Q12H 4. LeVETiracetam 750 mg PO BID 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO QPM 7. Warfarin 5 mg PO DAILY16 8. Calcium Carbonate 500 mg PO DAILY 9. Furosemide 40 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. LeVETiracetam 750 mg PO BID 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Rosuvastatin Calcium 40 mg PO QPM 8. Acetaminophen ___ mg PO Q6H:PRN pain/fever 9. Amiodarone 200 mg PO BID RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 10. Warfarin 7.5 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Primary: Unstable angina Anticardiolipin antibody syndrome Secondary: Paroxysmal atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with chest pain, evaluate for widened mediastinum or pneumothorax. TECHNIQUE: Single upright AP chest radiograph COMPARISON: Prior chest radiographs dated ___ and chest CT dated ___. . FINDINGS: Bilateral calcified pleural plaques are unchanged compared with multiple prior studies. Bibasilar interstitial markings are also unchanged or slightly decreased consistent with chronic interstitial lung disease. There is no pleural effusion, pneumothorax, or focal consolidation. The cardiomediastinal silhouette is stable. Chain sutures in the right mid lung are related to prior right lower lobe wedge resection. IMPRESSION: 1. No definite acute cardiopulmonary process. 2. Grossly stable bibasilar interstitial markings and calcified pleural plaques. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain, Nausea, L Shoulder pain Diagnosed with Other chest pain temperature: 97.6 heartrate: 126.0 resprate: 16.0 o2sat: 98.0 sbp: 141.0 dbp: 85.0 level of pain: 6 level of acuity: 2.0

Dear Ms. ___, You were recently admitted because you were experiencing chest pressure and were unable to complete a stress test in the emergency department because of an abnormal heart rhythm and symptoms. You had a different type of stress test in the hospital which was normal. You stayed for a few days afterward in order to have your Coumadin restarted safely. You were started on a new medicine called amiodarone. You are now ready to continue your recovery at home. Your medications were changed to help control your heart rhythm a bit better. ==================== MEDICATION CHANGES ==================== -STOPPED flecainide -STARTED amiodarone 200mg BID to control your atrial fibrillation -DECREASED aspirin to 81mg daily to decrease the chance of stomach bleeding You will need to wear a heart monitor for 30 days to better diagnose your heart rhythms. We wish you a speedy recovery, 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: SOB and chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ yo M with recently diagnosed neuroendocrine tumor of the lung, stage IV with mets to skin and brain who is admitted with increasing shortness of breath and chest pain. Describes the chest pain as a constant dull ache in his chest since last night at 10 pm. He took his morphine ___ at home which relieved the pain enough for him to sleep but it recurred this am so he called the ambulance. He says that the pain is not worse with activity or eating, although he has not been having much of an appetite and has lost weight. He does have paroxsymal nocturnal dyspnea and orthopnea. His EKG shows diffuse ST elevations, not in a vascular territory and his troponins are negative x 1. In the ED, his blood pressure was in the ___ systolic and they performed a CTA chest to eval for PE. There was no PE, no evidence of pneumonia, but progression of the cancer with encasement of pulmonary arteries, pulmonary veins, SVC, and left atrium. He had started chemo ___ with carboplatin/etoposide every 3 weeks and the oncology team does not think there is anything else to do for him since he already got the chemo. He was scheduled to get XRT to his whole brain for mets, but this has not happened yet. On arrival to the MICU, he is uncomfortable but saturating well. Past Medical History: Past Medical History: - metastatic neuroendocrine tumor of lung, stage IV, metastatic to brain and skin, started chemo ___ - alcoholic hepatitis with admission ___ with intoxication - anemia - GI bleed, gastritis, most recent endoscopy in ___ - HLD - right tibial ORIF ___ - chronic bilateral leg pain s/p accident and surgeries in ___ - multiple falls - depression Oncologic history: - ___: CXR with mediastinal LAD when admitted with alcohol intoxication. - ___: new liver lesions on RUQ ultrasound. - ___: admitted for tender head and neck nodes which initially appeared in early ___ on the chin, then submandibular and pre-auricular bilaterally with large one of anterior neck. He had night sweats and a 45 lb weight loss in ___. In mid ___, developed severe headaches and falls. LP this admission with negative cytology. Chest CT showed massive mediastinal LAD with 17cm RLL lung mass and LUL pulmonary nodules. Neck CT identified multiple subcutaneous nodules with central necrosis and large nodule abutting right jugular vein and invading neighboring structures. Brain MRI with 1cm lesion from falx and 7mm cerebellar lesion. - ___: right cervical lymph node biopsy with metastatic large cell neuroendocrine carcinoma c/w lung primary. - ___: Initiated treatment w ___ Social History: ___ Family History: no h/o cancer, mother and father passed away with DM Physical Exam: Vitals: T: 97.9, BP: 114/57, P: 80, R: 18, O2: 100% 2LNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, vascular mass on the left jaw bone Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: cachectic, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength in all extremities, grossly normal sensation, gait deferred, finger-to-nose intact Pertinent Results: Admission labs: ___ 05:33AM BLOOD WBC-9.7 RBC-3.26* Hgb-10.2* Hct-30.6* MCV-94 MCH-31.2 MCHC-33.2 RDW-13.5 Plt ___ ___ 05:33AM BLOOD Glucose-119* UreaN-12 Creat-0.4* Na-130* K-4.3 Cl-97 HCO3-22 AnGap-15 ___ 05:33AM BLOOD ___ BCx x 2 - pending Imaging: CXR ___ Right lower lobe opacity is likely a combination of tumor infiltration, atelectasis, and infection cannot be rule out. This area will be further evaluated on the subsequent CT angiogram. CTA Chest ___: 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Large infiltrative right hilar lung mass with extension into the mediastinum, much progressed from the prior study. 3. The mass causes compression of the right pulmonary artery, obliteration of the right pulmonary veins, narrowing of the right mainstem and lobar bronchial branches, and likely endobronchial invasion at these locations. 4. Diffuse infiltration of the right lower lobe with probable malignant effusion. 5. Extensive mediastinal and bilateral axillary lymph node metastases. 6. Lytic metastases of the right fifth and sixth anterior ribs. DISCHARGE LABS ___ 01:34AM BLOOD WBC-6.8 RBC-3.25* Hgb-10.2* Hct-30.4* MCV-94 MCH-31.5 MCHC-33.7 RDW-13.6 Plt ___ ___ 03:33PM BLOOD Glucose-97 UreaN-10 Creat-0.4* Na-129* K-3.5 Cl-100 HCO3-21* AnGap-12 ___ 01:34AM BLOOD CK-MB-22* MB Indx-25.9* cTropnT-<0.01 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Multivitamins 1 TAB PO DAILY 2. Pantoprazole 40 mg PO Q12H 3. traZODONE 25 mg PO HS:PRN insomnia 4. BusPIRone 20 mg PO BID 5. Citalopram 20 mg PO DAILY 6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 7. Acetaminophen 1000 mg PO BID 8. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough 9. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain 10. Ondansetron 8 mg PO Q8H:PRN nausea 11. Prochlorperazine ___ mg PO Q6H:PRN nausea Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H pain 2. BusPIRone 20 mg PO BID RX *buspirone 10 mg 2 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 3. Citalopram 20 mg PO DAILY RX *citalopram 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Morphine Sulfate ___ 7.5 to 15 mg PO Q2H:PRN Pain, Dyspnea RX *morphine 15 mg ___ tablet(s) by mouth q2h:PRN Disp #*84 Tablet Refills:*0 5. Ondansetron 8 mg PO Q8H:PRN nausea RX *ondansetron 8 mg 1 tablet(s) by mouth q8h:PRN Disp #*21 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 7. traZODONE 25 mg PO HS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth qHS:PRN Disp #*14 Tablet Refills:*0 8. Guaifenesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL ___ mL by mouth q6h:PRN Disp #*1 Unit Refills:*0 9. Multivitamins 1 TAB PO DAILY 10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 11. Prochlorperazine ___ mg PO Q6H:PRN nausea RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth q6h: PRN Disp #*28 Tablet Refills:*0 12. Nicotine Patch 21 mg TD DAILY 13. Morphine SR (MS ___ 15 mg PO Q12H RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 14. Filgrastim 300 mcg SC Q24H Duration: 5 Days 15. Lorazepam 0.5 mg PO Q4H:PRN anxiety RX *lorazepam 0.5 mg 1 tablet(s) by mouth q4h:PRN Disp #*42 Tablet Refills:*0 16. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth qHS:PRN Disp #*1 Unit Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: metastatic large cell neuroendocrine carcinoma of the lung Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: ___ man with a history of lung cancer presenting with chest pain. COMPARISONS: Comparison is made with a chest radiograph dated ___, for ___, medical record number ___, clip number ___. FINDINGS: There is a hazy, heterogeneous opacity in the right lower lobe which may represent infection, tumor infiltration, atelectasis, or a combination of all three. Widening of the mediastinum is caused by the patient's known malignancy. The left lung and upper right lung are mostly clear. There is no pneumothorax. A right pleural effusion is undoubtedly present. IMPRESSION: Right lower lobe opacity is likely a combination of tumor infiltration, atelectasis, and infection cannot be rule out. This area will be further evaluated on the subsequent CT angiogram. Radiology Report HISTORY: ___ man with lung cancer presenting with chest pain and shortness of breath. Evaluate for pulmonary embolism. COMPARISONS: Chest CT from ___. TECHNIQUE: MDCT-acquired axial images of the chest were obtained in the early arterial phase during rapid injection of 100 mL of Omnipaque intravenous contrast material. Coronal and sagittal reformats as well as oblique maximal intensity projection images provided and reviewed. DLP: 472.14 mGy-cm. FINDINGS: There are no pulmonary arterial filling defects to suggest presence of pulmonary embolism. Thoracic aorta is of normal caliber without dissection. There is a large heterogeneously enhancing mass originating in the right lower lung and infiltrating throughout the upper and lower mediastinum. There are areas of low density, suggestive of necrosis. The mass partially compresses the right main pulmonary artery and its branches. The superior vena cava is partially infiltrated and compressed. The posterior branches of the right pulmonary vein are obliterated. The mass causes compression of the left atrium. There is narrowing of the right main stem bronchus as well as the lobar branches as they traverse through the mass. There are soft tissue protuberances into the lobar branches of the right bronchus concerning for endobronchial invasion (2:60). There is more diffuse tumor infiltration into the right lower lobe parenchyma as well as an accompanying moderate right pleural effusion, likely malignant given the proximity of the tumor. There is a component of atelectasis in the right lower lobe as well. Likely much of the mass is also comprised of malignant lymph nodes. There is lymph node metastasis to the left axillary station with the largest measuring 2.4 x 2.0 cm (2:34). The largest lymph node in the right axilla measures 1.5 x 1.6 cm (2:16). Limited evaluation of the upper abdomen reveals pathologically enlarged paraesophageal lymph node at the hiatus measuring 1.8 x 1.4 cm (2:99). There is a small hiatal hernia. There are metastases to the right anterior fifth and sixth ribs with soft tissue expansion and lytic destruction (2:68, 602B:13). There are no concerning lesions in the spine. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Large infiltrative right hilar lung mass with extension into the mediastinum, much progressed from the prior study. 3. The mass causes compression of the right pulmonary artery, obliteration of the right pulmonary veins, narrowing of the right mainstem and lobar bronchial branches, and likely endobronchial invasion at these locations. 4. Diffuse infiltration of the right lower lobe with probable malignant effusion. 5. Extensive mediastinal and bilateral axillary lymph node metastases. 6. Lytic metastases of the right fifth and sixth anterior ribs. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: R/O STEMI Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH, SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES 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 taking care of you during your hospitalization at ___. You were admitted to the hospital with chest pain and shortness of breath. Imaging studies showed growth of the cancer in your lungs and the area around your heart. The cancer is causing your pain and trouble breathing, and is compressing your airways and some of the blood vessels around your heart. You recently got chemotherapy, which may help with your symptoms, but your disease is not curable. You told us that your goal is to go home and spend time with your family, and we are sending you home with hospice services.

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Lisinopril Attending: ___. Chief Complaint: Chief Complaint: dyspnea . Reason for MICU transfer: need for NIPPV Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ with h/o COPD/asthma, not on home O2, HTN, who p/w COPD/asthma exacerbation. For the last 2 days, she has had symptoms of a URI including subjective fever and a cough. Her grandchildren have recently been sick. She was seen at ___ today and given a Z-pack and 60mg prednisone. A CXR showed mild hyperinflation of the lungs, without consolidation. These interventions did not improve her symptoms and she presented to the ED. . PFTs per Atrius records last done ___, show FEV1 65% predicted, FVC 83% predicted, FEV1/FVC 64% (Gold stage II COPD). . In the ED, initial vitals 97.7, 96, 157/91, 18, 100% on 6L O2. Labs notable for hct 55, normal d-dimer, VBG 7.30/51/86. ___ ___ showed no infiltrate, hyperinflated lungs. She was given solumedrol 125mg IV, Duonebs x2, magnesium, and Ativan 2mg IV x1. After Ativan she appeared tired, so NIPPV was started ___ FiO2 40%. Vitals prior to transfer: 98, 132/79, 24, 98% non invasive. . On arrival to the MICU, pt on NIPPV and transitioned to NRB. Pt reports breathing more difficult on a NRB. She reports symptoms started 3 days ago after spending time with her sick grandchildren 4 days ago. She reports dry cough, myalgias - mostly back pain. She reports some pain below L breast in transport (less so than back pain) which she thinks is from coughing so much. She reports feeling hot and cold at home but did not measure temp; no rigors. She reports rhinorrhea and tickle in her throat as well. She reports she has not been hospitalized for COPD/asthma in the past. She did NOT get her flu shot this year. . Review of systems: (+) Per HPI. Otherwise negative. . Past Medical History: - COPD/asthma - HTN - depression - former smoker (quit ___ Social History: ___ Family History: + colon cancer Physical Exam: ADMISSION EXAM ============== Vitals: 97.9, ___, 29, 100% on ___ General- middle aged black woman, sitting up in moderate respiratory distress Neck- supple CV- regular, tachy at 100s, no appreciable murmurs Lungs- poor air entry diffusely with diffuse expiratory wheezes, accessory muscle use, speaks in short sentences Abdomen- soft, non-tender, non-distended GU- +foley Ext- warm, well perfused, no ___ edema DISCHARGE EXAM ============== VS: AVSS Gen: NAD, comfortable HEENT: OP clear, no lesions, MMM CV: RRR, no murmur Lungs: good air movement, no accessory muscle use, no crackles, some faint expiratory wheezing diffusely Abd: soft, NT, ND, NABS Ext: WWP, no edema GU: No Foley . Pertinent Results: ADMISSION LABS ============== ___ 03:43AM BLOOD WBC-10.0 RBC-6.03* Hgb-17.3* Hct-54.8* MCV-91 MCH-28.7 MCHC-31.6 RDW-13.0 Plt ___ ___ 03:43AM BLOOD Neuts-80.3* Lymphs-9.3* Monos-9.4 Eos-0.4 Baso-0.6 ___ 04:18AM BLOOD ___ PTT-33.2 ___ ___ 03:43AM BLOOD Glucose-126* UreaN-7 Creat-0.6 Na-135 K-4.1 Cl-100 HCO3-24 AnGap-15 ___ 03:43AM BLOOD ALT-21 AST-22 CK(CPK)-178 AlkPhos-67 TotBili-0.1 ___ 03:43AM BLOOD CK-MB-5 cTropnT-<0.01 ___ 02:59AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.3 ___ 03:43AM BLOOD D-Dimer-495 ___ 04:51AM BLOOD ___ pO2-86 pCO2-51* pH-7.30* calTCO2-26 Base XS--1 ___ 11:30AM BLOOD Lactate-0.9 ___ 04:51AM BLOOD O2 Sat-95 . DISCHARGE LABS =========== ___ 07:20AM BLOOD WBC-12.3* RBC-5.54* Hgb-16.0 Hct-49.4* MCV-89 MCH-28.9 MCHC-32.4 RDW-13.1 Plt ___ ___ 07:20AM BLOOD Glucose-81 UreaN-10 Creat-0.5 Na-138 K-3.1* Cl-97 HCO3-32 AnGap-12 ___ 07:20AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1 . PERTINENT LABS ========== ___ Erythropoietin < 1 (Low) ___ Alpha-1-antitrypsin 153 (WNL) . MICROBIOLOGY =========== ___ MRSA screen - NEGATIVE ___ DFA for influenza - CANCELLED ___ Rapid respiratory viral screen - POSITIVE for INFLUENZA A ___ Sputum culture - POOR SAMPLE ___ C. diff - NEGATIVE . IMAGING STUDIES =============== ___ CHEST (PA & LAT) FINDINGS: No focal consolidation, pleural effusion, pneumothorax, or pulmonary edema is detected. The lungs are hyperinflated, with worsening of diaphragmatic flattening bordering on inversion. Heart and mediastinal contours are within normal limits. IMPRESSION: Increased lung hyperinflation. . ___ PCXR FRONTAL VIEWS OF THE CHEST: The lungs are clear but remain hyperinflated. There is no pleural effusion, pneumothorax or focal airspace consolidation. The heart size is normal. The mediastinal and hilar structures are unremarkable. . Radiology Report HISTORY: ___ female with acute dyspnea. COMPARISON: ___. TECHNIQUE: Frontal and lateral chest radiographs were obtained. FINDINGS: No focal consolidation, pleural effusion, pneumothorax, or pulmonary edema is detected. The lungs are hyperinflated, with worsening of diaphragmatic flattening bordering on inversion. Heart and mediastinal contours are within normal limits. IMPRESSION: Increased lung hyperinflation. Reported to ___ by ___ by phone at 7:36 a.m. on ___ after attending radiologist review. Radiology Report HISTORY: Increased sputum, evaluate for pneumonia. COMPARISON: Chest radiographs ___ and ___. FRONTAL VIEWS OF THE CHEST: The lungs are clear but remain hyperinflated. There is no pleural effusion, pneumothorax or focal airspace consolidation. The heart size is normal. The mediastinal and hilar structures are unremarkable. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea, Asthma exacerbation Diagnosed with RESPIRATORY ABNORM NEC temperature: 97.7 heartrate: 96.0 resprate: 18.0 o2sat: 100.0 sbp: 157.0 dbp: 91.0 level of pain: 0 level of acuity: 3.0

You were admitted to the hospital with shortness of breath. You were found to have the flu (influenza). This infection likely also triggered a COPD / emphysema flare. Because of the difficulty in breathing, you were briefly admitted to the ICU for special breathing equipment. You will need to complete a course of antibiotics for flu. You are also on a short prednisone burst for mild COPD / emphysema flare. . Please take your medications as listed. . Please follow-up with your physicians as listed. .

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Compazine Attending: ___ Chief Complaint: chest tightness Major Surgical or Invasive Procedure: Cardiac cath ___ History of Present Illness: ___ with RCA stenosis on medical management, hypothyroidism, and bipolar disorder presenting with chest tightness and dizziness. Has been experiencing intermittent chest tightness of the right side for months for which she is followed by ___ cardiology. She developed ___ chest tightness ___ that has been persistent. Complicated by further dizziness and lightheadedness while shopping today, as if she "was about to pass out". Her symptoms improved with rest and SL nitro, but returned within minutes. SL nitro was able to relieve repeat symptoms. Came to ___ ED for evaluation given concern. Endorses concomitant palpitations, but no SOB, pleurisy, abdominal pain, fevers, or chills. In the ED initial vitals were: 98.2F, 72, 119/63, 20, 96% on RA, ___ pain Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD 3. OTHER PAST MEDICAL HISTORY - Osteopenia - Hypothyroidism - bipolar disorder - Positive PPD in ___ s/p 4 months of rifampin - TAH/BSO (___) - L. neck mass Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: 24 HR Data (last updated ___ @ ___) Temp: 97.7 (Tm 97.7), BP: 99/60, HR: 65, RR: 18, O2 sat: 93%, O2 delivery: RA, Wt: 132.05 lb/59.9 kg GENERAL: Older appearing woman sitting in NAD. Pleasant and cooperative. HEENT: PERRL, non-erythematous oropharynx. NECK: No JVD CV: RRR, SEM best heard at ___ PULM: CTAB in anterior fields, mild mid-inspiratory crackles ___ at the bases with mild improvement with cough. Abdomen: Soft, NTND EXT: No ___ edema NEURO: AAOx3 DISCHARGE PHYSICAL EXAM: Afebrile, BP 90-100s/60s, HR 60-70s, O2 96 on RA GENERAL: Pleasant and cooperative. In no acute distress. HEENT: PERRL, non-erythematous oropharynx. Dry mucous membranes. NECK: No JVD CV: RRR, SEM best heard at ___ PULM: CTAB in anterior fields, mild mid-inspiratory crackles ___ at the bases with mild improvement with cough. Abdomen: Soft, NTND EXT: No ___ edema Pertinent Results: ADMISSION LABS: ___ 01:10PM BLOOD WBC-7.0 RBC-4.10 Hgb-12.3 Hct-37.8 MCV-92 MCH-30.0 MCHC-32.5 RDW-13.3 RDWSD-45.2 Plt ___ ___ 01:10PM BLOOD Neuts-52.4 ___ Monos-11.2 Eos-4.9 Baso-0.4 Im ___ AbsNeut-3.66 AbsLymp-2.17 AbsMono-0.78 AbsEos-0.34 AbsBaso-0.03 ___ 01:10PM BLOOD Glucose-93 UreaN-23* Creat-0.8 Na-132* K-9.6* Cl-102 HCO3-21* AnGap-9* ___ 06:04PM BLOOD CK(CPK)-127 ___ 01:10PM BLOOD cTropnT-<0.01 ___ 06:04PM BLOOD CK-MB-2 ___ 06:04PM BLOOD cTropnT-<0.01 ___ 06:27AM BLOOD CK-MB-2 cTropnT-<0.01 DISCHARGE LABS ___:27AM BLOOD WBC-5.2 RBC-4.34 Hgb-12.9 Hct-38.7 MCV-89 MCH-29.7 MCHC-33.3 RDW-13.0 RDWSD-42.7 Plt ___ ___ 06:27AM BLOOD Glucose-89 UreaN-17 Creat-0.6 Na-138 K-4.3 Cl-105 HCO3-23 AnGap-10 ___ 06:27AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1 REPORTS: ___ CHEST XRAY: NO ACUTE PROCESS ___ CARDIAC CATH: The left main, left anterior descending, circumflex and right coronary artery have no angiographically significant coronary abnormalities. Complications: There were no clinically significant complications. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Divalproex (EXTended Release) 500 mg PO DAILY 2. QUEtiapine Fumarate 200 mg PO QHS 3. Vitamin D 1000 UNIT PO DAILY 4. Alendronate Sodium 70 mg PO QSUN 5. Atorvastatin 40 mg PO QPM 6. Citalopram 30 mg PO DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Naproxen 500 mg PO Q12H 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. Aspirin 81 mg PO DAILY 14. ClonazePAM 0.5 mg PO Q8H:PRN anxiety 15. amLODIPine 5 mg PO DAILY Discharge Medications: 1. amLODIPine 2.5 mg PO DAILY RX *amlodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Alendronate Sodium 70 mg PO QSUN 3. Atorvastatin 40 mg PO QPM 4. Citalopram 30 mg PO DAILY 5. ClonazePAM 0.5 mg PO Q8H:PRN anxiety 6. Divalproex (EXTended Release) 500 mg PO DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Naproxen 500 mg PO Q12H 11. QUEtiapine Fumarate 200 mg PO QHS 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Chest tightness, ruled out cardiac etiology Secondary Diagnoses: Hypothyroidism Bipolar disease Depression Osteopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with chest pain// An etiologies for CP? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Minimal basilar atelectasis is seen. There is no focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Anterior wedging of a vertebral body at the thoracolumbar junction is again seen, similar to prior. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain, Dizziness Diagnosed with Unstable angina, Dizziness and giddiness, Athscl heart disease of native coronary artery w/o ang pctrs temperature: 98.2 heartrate: 72.0 resprate: 20.0 o2sat: 96.0 sbp: 119.0 dbp: 63.0 level of pain: 5 level of acuity: 2.0

Dear Ms ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you were having chest pain and dizziness. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You had a cardiac catheterization to look for any disease in your heart vessels. You had no disease in the arteries that feed your heart. - You were given some fluids through the IV. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Your primary care doctor ___ adjust your blood pressure medications in the outpatient setting. - Seek medical attention if you have new or concerning symptoms or you develop any new chest pain, swelling in your legs, abdominal distention, or shortness of breath at night. We wish you the best! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Diltiazem / Lisinopril / Verapamil Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Coronary Angiography (___) - Placement of BMS x1 to LAD History of Present Illness: Mr. ___ is a ___ with hx CAD (single vessel coronary artery disease, LAD w/ 40% stenosis after the diagonal, proximal D1 w/ 90% stenosis; s/p Cath in ___ (first PCI with BMS to D1 complicated by acute closure requiring 2 additional BMS stents), HTN, frequent GI bleeding who prevents following acute onset CP, SOB, and elevated blood pressures. Pt. has been in her usual state of health until the last few weeks where she has been noting increasing DOE. Evening prior to admission, pt. developed sharp left-sided non-pleuritic chest pain. Pain radiates to her jaw and left arm. No recent fevers, chills, cough, or abdominal pain. Also denies any lightheadedness, dizziness, or new ___ swelling. Pt. took her blood pressures on day of admission and noted them to be extremely elevated to 240/110. Patient had pharmacol MIBI stress test 2 days ago at ___ that was negative. Of note, pt's previous ischemic pain in ___ consistent with mid scapular back pain for months. Following chest pain and positive stress test, pt. had cath which showed 40% LAD stenosis, 90% D1 stenosis. She received BMS to D1 which was c/b acute D1 closure requring emergent recatheterization and 2 additional BMS. Pt's post intervention course over the next several years was complicated by several GI bleeding events in the setting of ongoing anticoagulation on plavix (plavix later discontinued). Pt. also unable to take many typical cardiac medications given intolerances to beta blockers (bradycardia/ ? complete heart block), statins (muscle pain), ACEi (cough), Plavix (GIB), and some type of intolerance to ___. In the ED, initial VS were 98.0, 250/97 (similar to pressures she had been reading at home), 100, 18, 100% on RA. Pt. had negative guaiac. Labs were notable for trop elevation 0.07 to 0.15. Pt. was thought to be low-probability for PE, therefore a d-dimer was sent which returned positive. CTA was then done which was negative for PE. Pt. was given heparin gtt and full dose aspirin. Pt. was taken directly from the ED to the cath lab where pt. was noted to have 90% mid LAD lesion which was successfully corssed with BMS stent. Pt. was started on ticagrelor. Post-cath, pt. c/o pleuritic substernal chest pain radiating to the back. Exam revealed reproducible chest pain consistent with musculoskeletal injury. Pain improved with fentanyl bolus. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, orthopnea, ankle edema, palpitations, syncope or presyncope. Pt. does endorse dyspnea on exertion, paroxysmal nocturnal dyspnea. Past Medical History: CAD (single vessel coronary artery disease, LAD w/ 40% stenosis after the diagonal, proximal D1 w/ 90% stenosis; s/p Cath in ___ (first PCI with BMS to D1 complicated by acute closure requiring 2 additional BMS stents; pt. previously on plavix but d/c'ed given GI bleeds) Hypertension EP study ___ d/t bradycardia GERD H Pylori ___ Lower GI bleed r/t diverticulitis Hx. of Polyps Mild obstructive sleep apnea (dx/ by sleep study ___ Hypothyroid Hx. of Pneumonia Pernicious anemia Osteoporosis Chronic headaches Depression Hx. of intermittent blurry vision-unclear etiology Eye surgery for growth Social History: ___ Family History: Father died of an MI at age ___. Mother died at age ___. Brother suffered a stroke Physical Exam: ADMISSION PHYSICAL EXAMINATION: =================================== VS: 98.1, 68, 150/77,, 18, 100% on RA General: Lying flat, awake/alert, NAD HEENT: NCAT, EOMI, oropharynx clear Neck: Supple, no JVD CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks; tenderness to palpation on the costochondro joints left of the sternum Lungs: Anterior fields CTAB Abdomen: Soft, NT, ND, +BS Ext: WWP, ___ adiposity but no ___ edema Neuro: ___, SILT, A/O x3 Pulses: RP and DP 2+ bilaterally DISCHARGE PHYSICAL EXAMINATION: =================================== PHYSICAL EXAMINATION: VS: 98.4, 74, 140/75, 22, 100% on RA General: NAD HEENT: NCAT, EOMI, oropharynx clear Neck: Supple, no JVD CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks Lungs: CTAB, no wheezes, rales, or rhonchi Abdomen: Soft, NT, ND, +BS Ext: WWP, no ___ edema Neuro: ___, SILT, A/O x3 Pulses: RP and DP 2+ bilaterally Pertinent Results: ADMISSION LABS ============== ___ 03:35AM BLOOD WBC-8.6 RBC-4.86 Hgb-14.0 Hct-41.5 MCV-85 MCH-28.8 MCHC-33.7 RDW-12.9 Plt ___ ___ 03:35AM BLOOD Neuts-58.0 ___ Monos-5.6 Eos-2.3 Baso-0.5 ___ 03:35AM BLOOD Glucose-122* UreaN-18 Creat-0.8 Na-138 K-6.4* Cl-101 HCO3-24 AnGap-19 NOTABLE LABS =============== ___ 03:35AM BLOOD D-Dimer-560* ___ 03:35AM BLOOD cTropnT-0.07* ___ 11:15AM BLOOD cTropnT-0.15* ___ 09:33PM BLOOD CK-MB-6 cTropnT-0.23* ___ 06:20AM BLOOD CK-MB-5 cTropnT-0.22* proBNP-1790* DISCHARGE LABS ============== ___ 06:20AM BLOOD WBC-8.8 RBC-4.53 Hgb-12.8 Hct-39.3 MCV-87 MCH-28.2 MCHC-32.6 RDW-13.4 Plt ___ ___ 06:20AM BLOOD Glucose-100 UreaN-15 Creat-0.6 Na-141 K-3.9 Cl-107 HCO3-23 AnGap-15 STUDIES =========== CXR (___): IMPRESSION: Normal chest radiograph. CTA CHEST (___): IMPRESSION: 1. No acute process. Specifically, there is no pulmonary embolus or aortic pathology. 2. Minimal bibasilar bronchiectasis evident. RIGHT FEMORAL VASCULAR ULTRASOUND (___): Prelim Normal CATH (___): COMMENTS: Selective coronary angiograpy of this right dominant system revealed: 1. LMCA - mild disease 2. LAD - 99% mid LAD lesion patent prior diagona 3. Lcx - mild disease 4. RCA - no significant disease Successful ___ stenting of the mLAD. Angioseal closure of the RFA access site. The patient left the lab free of angina and in stable condition. FINAL DIAGNOSIS: 1. Single vessel ___ arteries arteries, s/p bare-metal stenting. 2. Normal ventricular function. 3. Aspirin and Brillinta daily 4. Wean off nitroglycerin to imdur for blood pressure control Radiology Report INDICATION: Chest pain, evaluate for cardiopulmonary process. COMPARISON: Comparison is made to chest radiograph performed ___. FINDINGS: Frontal and lateral chest radiographs demonstrate unremarkable cardiomediastinal and hilar contours. Lungs are clear. No pleural effusion or pneumothorax is present. IMPRESSION: Normal chest radiograph. Radiology Report INDICATION: Chest pain, elevated D-dimer, evaluate for pulmonary embolism. COMPARISON: Comparison is made to CT chest performed ___. TECHNIQUE: Intravenous contrast was administered and arterial phase imaging was acquired. Coronal, sagittal and oblique reformats were provided. FINDINGS: CTA CHEST: The pulmonary vasculature is well opacified and without filling defect to suggest embolus. The aorta contains minimal atherosclerotic calcifications but is otherwise unremarkable. Dense atherosclerotic calcifications are noted within the left anterior descending artery without aneurysm. Heart size is normal and with a small physiologic pleural effusion. CT CHEST: There is no supraclavicular, axillary, mediastinal or hilar lymphadenopathy. Airways are patent to the subsegmental level with mild bronchiectasis and bronchial wall thickening in the lower lung bases. Evaluation of the pulmonary parenchyma is limited due to expiratory phase imaging and motion. Within this limitation, no opacification concerning for pneumonia is identified. No solid pulmonary nodules evident. No pleural effusion or pneumothorax identified. Limited assessment of the upper abdomen demonstrates a small hiatal hernia. No fracture is identified. No suspicious lytic or blastic lesions present. IMPRESSION: 1. No acute process. Specifically, there is no pulmonary embolus or aortic pathology. 2. Minimal bibasilar bronchiectasis evident. Radiology Report INDICATION: Status post catheterization via right femoral artery with bruit. Assess for pseudoaneurysm. COMPARISON: No prior study available for comparison. FINDINGS: No pseudoaneurysm, dissection, stenosis, femoral venous thrombosis, superficial soft tissue hematoma or edema identified. IMPRESSION: Normal examination. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: Chest pain Diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC temperature: 98.0 heartrate: 100.0 resprate: 18.0 o2sat: 95.0 sbp: 250.0 dbp: 97.0 level of pain: 6 level of acuity: 2.0

Ms. ___, It was a pleasure to meet and care for you during your hospitalization at ___. You were admitted with chest pain and shortness of breath. Lab tests showed evidence of a heart attack. Because of your risk of previous coronary artery disease, you had a catheterization which showed a large obstruction in one of the major heart vessels. A stent was placed. You should continue ticagrelor (a blood thinner) for the next 1 week (end date ___. Once you finish your ticagrelor, please start plavix immediately on ___. You must continue this for at least 4 additional weeks. Please discuss with your cardiologist exactly how long you should be on plavix. You much continue to take aspirin forever. We wish you a speedy recovery. All the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with h/o recurrent pancreatitis of unknown etiology c/b pancreatic pseudocyst formation and rupture who now presents with abdominal pain. The patient reports that her pain began 2 days prior to admission while placing A/C units in the window. She noticed ___ back pain as if someone put a fist through her back. She thought is was muscular in etiology, but when she got home from her daughters, she developed nausea and mid/epigastric abdominal pain consistent with her pancreatitis flares. SHe went to bed that night and the next morning tried to eat some toast with some tea and her pain became ___ and she had increased nausea without vomiting. She took some tylenol and advil without benefit and she made herself NPO. On the morning of admission, she tried to work from home hoping the pain would improve, but it was persistent so she came to the ED for further evaluation. She also reports some mild loose BM the day of admission. Not watery or bloody, just loose. In addition over the last few days, she has had increased vaginal itching and whitish discharge. In the ED, initial vs were: 97.3 71 162/87 16 98% RA. Labs were remarkable for lipase 362, Hgb 16, UA w/ large leuk (12 WBC) few bacteria. Patient was given ceftriaxone 1gm for possible UTI and morphine 5mg x3 for pain control. Also given zofran 4mg IV x2 and metoclopramide 10mg IV x1 for nausea. CT abdomen/pelvis was performed which showed Stranding along the second and third portions of the duodenum may be duodenitis, however, given elevated lipase inflammation may be secondary to pancreatitis. Patient was given 2L NS. Vitals on Transfer: 98.2 70 128/70 16 97% On the floor, patient pain is better controlled, but with nausea and vomiting. 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 constipation. Denies arthralgias or myalgias. Past Medical History: Exploratory laparotomy (___) External drainage of pancreatic pseudocyst (___) ? Gallstone pancreatitis in ___ although recurrent episodes after cholecystectomy and no evidence of stones on imaging. Chronic pancreatitis of the tail of the pancreas evident on imaging Obesity Splenic vein thrombus Laparoscopy ccy (___) C-section x2 (remote past) Diabetes Mellitus Social History: ___ Family History: Notable for PBC and Sjogren's in mother. Sister with multiple sclerosis Father with CAD and DM Physical Exam: admission Vitals: T: 97.7 BP: 127/78 P: 77 R: 12 O2: 94% RA, FSG: 282 General: Alert, oriented, in moderate distress ___ nasuea HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, distant heart sounds, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender in epigastric area with no gaurding with mid/deep palpation, non-distended, bowel sounds present, Organomegaly difficult to assess given body habitus Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, varicosities of the lower extremity Neuro: CN II-XII intact, strenght and sensation intact on extremities, gait deferred . discharge VS: 97.4 74 106/59 18 96%RA I/O: NPO 150 IVF | 550 UOP BMx1 General: Alert, oriented, in moderate distress ___ nasuea HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, distant heart sounds, no m/r/g Abdomen: soft, minimally tender in epigastric area with no gaurding with mid/deep palpation, non-distended, bowel sounds present Ext: Warm, well perfused Neuro: A&Ox3 Pertinent Results: admission ___ 03:11PM BLOOD WBC-10.6# RBC-5.38 Hgb-16.3* Hct-46.8 MCV-87 MCH-30.3 MCHC-34.7 RDW-13.5 Plt ___ ___ 03:11PM BLOOD Glucose-174* UreaN-11 Creat-0.8 Na-140 K-4.1 Cl-101 HCO3-28 AnGap-15 ___ 03:11PM BLOOD ALT-33 AST-26 AlkPhos-110* TotBili-1.2 ___ 03:11PM BLOOD Albumin-4.8 ___ 07:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1 . STUDIES: CT ABD/PELVIS ___ 1. Stranding along the second and third portions of the duodenum may be duodenitis, however, given elevated lipase inflammation may be secondary to pancreatitis. 2. Chronic splenic vein thrombosis. 3. Splenomegaly. . discharge ___ 07:20AM BLOOD WBC-5.5 RBC-4.09* Hgb-12.7 Hct-36.4 MCV-89 MCH-31.0 MCHC-34.8 RDW-13.4 Plt ___ ___ 07:20AM BLOOD Glucose-133* UreaN-8 Creat-0.7 Na-141 K-4.0 Cl-108 HCO3-24 AnGap-13 ___ 07:20AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8 Radiology Report INDICATION: History of pancreatitis complicated by pancreatic pseudocyst with severe epigastric abdominal pain. Evaluate for acute pancreatic pathology. COMPARISON: MR abdomen ___. CT abdomen and pelvis ___. MRCP ___. TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen and pelvis after administration of 150 mL of Omnipaque IV contrast. Multiplanar axial, coronal, and sagittal images were generated. TOTAL BODY DLP: 991.98 mGy-cm. FINDINGS: The lung bases are clear. The heart is not enlarged and there is no pericardial effusion. CT ABDOMEN: There is fatty infiltration of the liver without focal lesions or intrahepatic biliary duct dilation. The gallbladder has been surgically removed. The spleen measures 14.3 cm. The portal vein is patent; however, there is chronic splenic vein thrombosis. The adrenal glands are unremarkable. The kidneys excrete contrast promptly and symmetrically. There is no hydronephrosis. Stranding along the second and third portions of the duodenum may be related to duodenitis, however, given elevated lipase, inflammation may be secondary to acute pancreatitis. The pancreas is somewhat atrophic. No drainable fluid collection is seen. The colon and appendix are within normal limits. The intra-abdominal vasculature is unremarkable. There is no retroperitoneal or mesenteric lymph node enlargement by CT size criteria. There is no ascites, free air, or abdominal wall hernias. PELVIC CT: The urinary bladder and terminal ureters are normal. There is no pelvic wall or inguinal lymph node enlargement. There is no pelvic free fluid. OSSEOUS STRUCTURES: There are no focal lytic or blastic lesions suspicious for malignancy. IMPRESSION: 1. Stranding along the second and third portions of the duodenum may be duodenitis, however, given elevated lipase, inflammation may be secondary to pancreatitis. 2. Splenomegaly and chronic splenic vein thrombosis. 3. Hepatic steatosis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: EPIGASTRIC PAIN Diagnosed with ACUTE PANCREATITIS temperature: 97.3 heartrate: 71.0 resprate: 16.0 o2sat: 98.0 sbp: 162.0 dbp: 87.0 level of pain: 10 level of acuity: 2.0

Ms. ___: It was a pleasure to take care of you. You were admitted to ___ because of belly and back pain likely to be due to a flare of pancreatitis. We treated you with intravenous fluids and pain medications. As you are tolerating oral intake, we are able to discharge you today. Please follow up with your doctors as below. Please review your medication list closely.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilaudid Attending: ___. Chief Complaint: vomiting, R abd pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ year old male with HIV (on ART, last CD4 1200) presenting with acute onset vomiting and right sided abdominal pain that woke him up from sleep on the day of admission at 12AM ___. The patient endorses copious yellow vomiting. He has also been experiencing diarrhea. He experiences nausea, vomiting and abdominal pain on a nearly daily basis (4 out of 7 days of the week). He takes Zofran for nausea and oxycodone for pain. He also takes and herbal supplement buscapina for nausea. His symptoms acutely worsened over the last 24 hours. He denies fevers or sick contacts. Of note, he is s/p cholecystectomy and appendectomy. No history of kidney stones. He denies recent travel. He own 2 dogs, 1 cat and 1 parakeet. Regarding his GI history the patient has known NAFLD. He has a history of acute hepatitis (secondary acetaminophen/viral illness), pancreatitis and chronic RUQ abd pain/n/v/d. He smokes marijuana daily for nausea. He is s/p cholecystectomy and appendectomy. An EGD in ___ showed mild mucosal abnormalities in the stomach and duodenum, biospies were normal. He underwent a liver biopsy in ___ which showed evidence of toxic metabolic injury and stage I fibrosis. tTg negative, quant gold negative (___) and ___ negative in the past. In the ED intial vitals were: 96.6 68 136/79 18 95% RA - Labs were significant for: WBC 15 (75%N), Hct 45, plt 429 - Patient was given: Zofran, IVFs, morphine - CTU: no acute abdominal process - RUQ: unremarkable - Admit for abdominal pain - Vitals prior to transfer were: 97.9 68 113/75 14 97% RA On the floor, pt reports continued abdominal pain in the RUQ, which has not improved. Nausea which is somewhat improved. Review of Systems: (+) per HPI Past Medical History: NAFLD HIV on HAART Seizures Type II diabetes CAD s/p MI Migraine Anxiety History of acute hepatitis/pancreatitis Colonoscopy and EGD in ___ for HIV surveillence PAST SURGICAL HISTORY: S/p cholecystectomy S/p appendectomy Social History: ___ Family History: Father: deceased, ___ Mother: healthy Sister: S/p hysterectomy No children Uncle dx with colon and lung cancer Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 97 118/60 62 16 98% RA General- middle aged male in moderate amount of pain, occasional grunting HEENT- b/l periorbital edema, PERRL conjunctiva normal, anicteria sclerae Neck- supple, no LAD Lungs- CTA bilaterally CV- RRR, S1/S2 normal, no MRG Abdomen- +BS, soft, diffusely tender, no rebound or rigidity, voluntary guarding GU- no performed Ext- WWP, trace lower extremity edema Neuro- CNII-XII intact, ___ upper and lower extremity strength DISCHARGE PHYSICAL EXAM: Vitals- Tm 98.1, 68, 103/61, 96 on RA General- middle aged male lying in bed in NAD but appears fatigued HEENT- no periorbital edema, PERRL conjunctiva normal, anicteria sclerae Neck- supple, no LAD Lungs- CTA bilaterally CV- RRR, S1/S2 normal, no MRG Abdomen- +BS, soft, nontender, no rebound or rigidity, voluntary guarding GU- no performed Ext- WWP, no lower extremity edema Neuro- CNII-XII intact, ___ upper and lower extremity strength Pertinent Results: ========================== LABS ON ADMISSION ========================== ___ 04:40PM BLOOD WBC-15.0*# RBC-4.59* Hgb-14.6 Hct-45.0 MCV-98 MCH-31.8 MCHC-32.5 RDW-14.3 Plt ___ ___ 04:40PM BLOOD Neuts-75.3* ___ Monos-3.5 Eos-0.2 Baso-0.6 ___ 04:40PM BLOOD Glucose-126* UreaN-13 Creat-0.9 Na-139 K-4.1 Cl-104 HCO3-20* AnGap-19 ___ 04:40PM BLOOD Albumin-4.3 ___ 04:40PM BLOOD ALT-37 AST-39 AlkPhos-122 TotBili-0.4 ___ 04:40PM BLOOD Lipase-13 ___ 04:47PM BLOOD Lactate-2.9* ___ 10:23PM BLOOD Lactate-1.4 ___ 04:40PM BLOOD cTropnT-<0.01 ========================== LABS ON DISCHARGE ========================== ___ 06:50AM BLOOD WBC-6.6 RBC-4.11* Hgb-13.2* Hct-41.4 MCV-101* MCH-32.2* MCHC-32.0 RDW-14.5 Plt ___ ___ 06:50AM BLOOD ___ PTT-31.3 ___ ___ 06:50AM BLOOD Glucose-134* UreaN-14 Creat-0.8 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 ___ 06:50AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0 ___ 06:50AM BLOOD ALT-136* AST-63* AlkPhos-170* TotBili-0.6 ========================== OTHER RESULTS ========================== ___ 04:40PM BLOOD ALT-37 AST-39 AlkPhos-122 TotBili-0.4 ___ 06:00AM BLOOD ALT-88* AST-140* AlkPhos-104 TotBili-0.7 ___ 06:00AM BLOOD ALT-102* AST-140* AlkPhos-130 TotBili-0.4 ___ 06:00AM BLOOD ALT-157* AST-211* AlkPhos-150* TotBili-1.0 ___ 06:10AM BLOOD ALT-213* AST-159* AlkPhos-159* TotBili-0.8 ___ 06:40AM BLOOD ALT-193* AST-124* AlkPhos-180* TotBili-1.0 ___ 06:50AM BLOOD ALT-136* AST-63* AlkPhos-170* TotBili-0.6 ___ 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE ___ 06:00AM BLOOD HCV Ab-NEGATIVE ___ 06:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 02:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG ___ MRCP - IMPRESSION: 1. No obstructive biliary stones are noted. The patient is status post cholecystectomy with the common bile duct measuring up to 8 mm which is within normal limits post-cholecystectomy. 2. Fat replacement throughout the pancreas and more than expected for the patient's age. Mild fibrosis of the pancreatic parenchyma which raises the concern for a form of chronic pancreatitis. 3. No fat deposition within the liver. No cirrhotic changes noted within the liver. No splenomegaly. CXR ___ IMPRESSION: No pneumonia. CXR ___ FINDINGS: Lungs are clear. Cardiac silhouette is normal in size. Mediastinal contours unremarkable. There is no pleural effusion, pneumothorax or pulmonary edema. There is no free air. IMPRESSION: No evidence of acute cardiopulmonary process. RUQ U/S ___ FINDINGS: The liver is of normal echogenicity without any focal lesions or intra or extrahepatic biliary dilatation. The common bile duct measures 6 mm. The main portal vein is patent with normal hepatopetal flow. The patient is status post cholecystectomy. The head of the pancreas is unremarkable however the tail and body are obscured by bowel gas. Limited views of the right kidney are unremarkable and demonstrate no hydronephrosis. The spleen is normal in size measuring 12.4 cm. IMPRESSION: Unremarkable right upper quadrant ultrasound. No evidence of biliary dilatation. CTU ___ FINDINGS: Lung bases demonstrate minimal dependent atelectasis and scarring. There are stable sub 4 mm bibasilar lower lobe nodules. Cardiac apex unremarkable. The liver is hypodense compatible with hepatic steatosis. Patient status post cholecystectomy. Noncontrast appearance of the spleen, pancreas, adrenal glands, bilateral kidneys, small bowel are all within normal limits. There is scattered diverticulosis without any evidence of acute diverticulitis of the large bowel. The appendix is not seen. The bladder, rectum, prostate are all within normal limits. There are bilateral fat containing inguinal and umbilical hernias. There is no lymphadenopathy in the pelvis. No suspicious osseous lesions are present. Old left rib fracures noted. IMPRESSION: 1. No evidence of acute intra-abdominal process 2. Fatty liver, diverticulosis, bilateral fat containing inguinal hernias. EKG ___ NSR, no acute ST/T wave changes Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ALPRAZolam 1.5 mg PO TID 2. benazepril 10 mg oral daily 3. BusPIRone 15 mg PO BID 4. Divalproex (EXTended Release) 500 mg PO DAILY 5. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral daily 6. Gabapentin 400 mg PO TID 7. NIFEdipine CR 30 mg PO DAILY 8. Ondansetron 4 mg PO DAILY:PRN nausea 9. OxycoDONE (Immediate Release) ___ mg PO DAILY:PRN headache 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. ALPRAZolam 1.5 mg PO TID RX *alprazolam 0.5 mg 3 tablet(s) by mouth three times daily Disp #*42 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*14 Tablet Refills:*0 3. BusPIRone 15 mg PO BID 4. Divalproex (EXTended Release) 500 mg PO DAILY 5. Gabapentin 400 mg PO TID RX *gabapentin 400 mg 1 capsule(s) by mouth three times per day Disp #*42 Capsule Refills:*0 6. NIFEdipine CR 30 mg PO DAILY 7. Docusate Sodium 100 mg PO BID Do not take if stools are loose. RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Capsule Refills:*0 8. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral daily 9. benazepril 10 mg ORAL DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 4 mg PO DAILY:PRN nausea RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8 hours Disp #*42 Tablet Refills:*0 12. OxycoDONE (Immediate Release) ___ mg PO DAILY:PRN headache RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*28 Tablet Refills:*0 13. Polyethylene Glycol 17 g PO DAILY Do not take if stools are loose. RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth daily Disp #*1 Box Refills:*0 14. Senna 8.6 mg PO BID Do not take if stools are loose. RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet Refills:*0 15. Outpatient Lab Work LFT (AST, ALT, AlkPhos, TBili) ___ FAX TO: ___. ___: ___ Fax: ___ Discharge Disposition: Home Discharge Diagnosis: Diagnosis: Nausea/Vomiting Secondary diagnoses: HIV on ART NAFLD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Tenderness to palpation. Question free air. COMPARISON: ___. FINDINGS: Lungs are clear. Cardiac silhouette is normal in size. Mediastinal contours unremarkable. There is no pleural effusion, pneumothorax or pulmonary edema. There is no free air. IMPRESSION: No evidence of acute cardiopulmonary process. Radiology Report HISTORY: History of right upper quadrant pain and tenderness. Status post cholecystectomy. COMPARISON: CT abdomen from ___. FINDINGS: The liver is of normal echogenicity without any focal lesions or intra or extrahepatic biliary dilatation. The common bile duct measures 6 mm. The main portal vein is patent with normal hepatopetal flow. The patient is status post cholecystectomy. The head of the pancreas is unremarkable however the tail and body are obscured by bowel gas. Limited views of the right kidney are unremarkable and demonstrate no hydronephrosis. The spleen is normal in size measuring 12.4 cm. IMPRESSION: Unremarkable right upper quadrant ultrasound. No evidence of biliary dilatation. Radiology Report HISTORY: Right upper quadrant pain. COMPARISON: ___. Technique: CT of the abdomen and pelvis without IV or oral contrast. FINDINGS: Lung bases demonstrate minimal dependent atelectasis and scarring. There are stable sub 4 mm bibasilar lower lobe nodules. Cardiac apex unremarkable. The liver is hypodense compatible with hepatic steatosis. Patient status post cholecystectomy. Noncontrast appearance of the spleen, pancreas, adrenal glands, bilateral kidneys, small bowel are all within normal limits. There is scattered diverticulosis without any evidence of acute diverticulitis of the large bowel. The appendix is not seen. The bladder, rectum, prostate are all within normal limits. There are bilateral fat containing inguinal and umbilical hernias. There is no lymphadenopathy in the pelvis. No suspicious osseous lesions are present. Old left rib fracures noted. IMPRESSION: 1. No evidence of acute intra-abdominal process 2. Fatty liver, diverticulosis, bilateral fat containing inguinal hernias. Radiology Report HISTORY: ___ man with cough, coarse breath sounds, leukocytosis. Evaluate for pneumonia. COMPARISON: Multiple prior radiographs of the chest dated ___ and ___. FINDINGS: Frontal and lateral radiographs of the chest demonstrate hyperexpanded and clear lungs. The cardiomediastinal and hilar contours are unremarkable. There is no pneumothorax, pleural effusion, or consolidation. IMPRESSION: No pneumonia. Radiology Report HISTORY: History of increasing abdominal pain. Evaluate for obstruction. COMPARISON: CT from ___. FINDINGS: Upright and supine frontal abdominal radiographs show an unremarkable bowel gas pattern without evidence of obstruction or bowel dilation. Moderate amount of stool is noted in the right colon, and there is no evidence of pneumatosis or intraperitoneal free air. Cholecystectomy surgical clips are seen within the right upper quadrant. The bony structures are unremarkable. Atelectasis or scarring is seen in the left lung base. IMPRESSION: Unremarkable bowel gas pattern without evidence of obstruction. Moderate amount of stool in the right colon. Radiology Report HISTORY: Non-alcoholic fatty liver disease status post cholecystectomy, now with abnormal LFTs and right upper quadrant pain, concern for biliary pathology. COMPARISON: This examination is compared to prior CT abdomen and pelvis from ___ and prior CTU from ___. TECHNIQUE: Multisequential, multiplanar MRI of the abdomen was performed pre and post the uneventful administration of 8 mL of Gadavist intravenous contrast. In addition, the patient was administered 1 cc of Gadavist mixed with 50 cc of water P.O. prior to the examination. FINDINGS: There is no fat deposition within the liver. There is no nodularity of the liver to suggest cirrhosis. There is no splenomegaly and no intra-abdominal varices are noted. The spleen appears unremarkable. There is a 15 mm accessory spleen noted. In segment VIII of the liver, there is a subcentimetric area of hyperenhancement on arterial images without corresponding abnormality on other sequences, most likely representing a perfusion anomaly. There are no suspicious liver lesions. There is fat interdigitation seen throughout the pancreas which is slightly more than expected for the patient's age. In addition, there is lower signal intensity diffusely throughout the pancreatic parenchyma on the arterial phase, which may be related to pancreatic fibrosis and raises concern for a form of chronic pancreatitis. There is no pancreatic duct dilatation. There has been prior cholecystectomy noted. The common bile duct measures up to 8 mm which is within normal limits in patient with prior cholecystectomy. Areas of hypointense signal noted within the common bile duct are related to artifact. There are no obstructive stones visualized. There is no intrahepatic bile duct dilatation. The adrenal glands, spleen and kidneys appear unremarkable. Incidental note is made of an accessory left hepatic artery, which appears dominant. There is no upper intra-abdominal lymphadenopathy. The bone marrow signal intensity is within normal limits. IMPRESSION: 1. No obstructive biliary stones are noted. The patient is status post cholecystectomy with the common bile duct measuring up to 8 mm which is within normal limits post-cholecystectomy. 2. Fat replacement throughout the pancreas and more than expected for the patient's age. Mild fibrosis of the pancreatic parenchyma which raises the concern for a form of chronic pancreatitis. 3. No fat deposition within the liver. No cirrhotic changes noted within the liver. No splenomegaly. Findings were discussed with Dr. ___ at 11:15 a.m. on ___, two hours after discovery of the findings. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: RUQ abdominal pain, Vomiting Diagnosed with ABDOMINAL PAIN RUQ, VOMITING, ASYMPTOMATIC HIV INFECTION temperature: 96.6 heartrate: 68.0 resprate: 18.0 o2sat: 95.0 sbp: 136.0 dbp: 79.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you during your stay at ___ ___. You were admitted for abdominal pain, nausea and diarrhea. You underwent several diagnostic imaging procedures, none of which pointed to any obvious cause for your symptoms. You may have had a viral illness that led to your symptoms. Chronic marijuana use can also lead to a vomiting syndrome similar to yours; we would recommend decreasing or stopping your use of marijuana. You were treated with anti-nausea medications and pain medications, and your symptoms improved. By discharge you were able to eat comfortably and were having normal bowel movements. You were sent home to follow up with your PCP and gastroenterologist for further evaluation and treatment. We wish you the very best in your recovery! -___ medical team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: sore throat Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ without significant past medical history who is admitted with several months of fever and sore throat found to be neutropenic and thrombocytopenic. Patient first developed sore throat and fever in ___, and he was treated for Strep throat with penicillin. Since that episode, he reports several intermittent bouts of recurrent strep throat, fevers, and malaise that would last for several days at a time before improving. He notes two such episodes in ___, last being two weeks ago which improved with Tylenol and Sudafed. Yesterday morning, patient again awoke with a markedly sore throat. He also noted rigors/sweats, headache, sore back, and orthostasis. He stayed in bed all day, and presented to ___ this morning. There, he was found to have pancytopenia, with WBC 0.5 (0 neutrophils), Plt 22. He was given Toradol, PCN, decadron, and 2L of fluid. He was transferred to ___ for further evaluation. In the ED, initial VS were t 96.7 HR 90 BP 113/65 RR 18 O2 100%RA. Labs were notable for WBC 0.3 (20%N, 75%L), HCT 35.7, PLT 15, Uric acid 3.1, Na 135, K 3.9, Cr .0.8, lactate 1.6, ALT 12, AST 9, ALP 51, LDH 209, TBili 0.5, Alb 3.9, Fibrinogen 670, INR 1.2. CT neck with contrast showed enlargement of the left palantine tonsil without abscess. CXR showed no acute process. Bone marrow biopsy was performed and patient was given 2g cefepime, 1mg po Ativan, 1L NS, 1g IV vancomycin, 4mg IV morphine, and APAP prior to transfer to ___ for further management. VS prior to transfer were T 102.2, HR 102, BP 134/84, RR 18, O2 100%RA. On arrival to the floor, patient reports significant anxiety. He notes sore throat and odynophagia as above. He denies any bleeding or significant bruising. No new rashes or joint pains. No nausea, vomiting, or abdominal pain. He has been constipated for a few days. No new joint pains or swelling. No travel outside of ___, and no significant outdoor activity or bug bites. He drinks ___ days per week, ___ beers. A few times a month he will binge drink up to 5 beers. Reports much heavier alcohol use several years ago. He smokes marijuana about 2x per week, no other current illicit drugs. However, he does have a history of daily IV heroin use, reports being clean ___ years. He was incarcerated for almost ___ years, and was released in ___. Sexually active with one female partner; doesn't use condoms. About ___ female partners in the last year. Per report, he also had a WBC at OSH of 1.7 in ___. Past Medical History: History of IVDU Social History: ___ Family History: Paternal grandfather with stroke in ___, parents alive and in good health. denies family history of malignancy or hematologic disorder. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 100.8 112-120/60-68 ___ RA GENERAL: Pleasant well appearing young male in no acute distress HEENT: PERRL. EOMI. Enlarged L tonsil with exudates/tonsiliths. Cervical lymphadenopathy b/l. No supraclavicular, axillary CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes DISCHARGE PHYSICAL EXAM ======================= VS: 98.6 (98.0-98.3) 126/76 (110-126/50-80) 83 (78-102) 20 96-99% RA I/O: 1680/BRP GENERAL: Pleasant well appearing young male in no acute distress HEENT: Enlarged L tonsil (reduced in size on ___, nonerythematous or exudative, but 1 petechaie on L soft palate and also petechaie on L buccal mucosa (resolved on ___. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: No increase work of breathing, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema NEURO: Alert, oriented, CN II-XII intact SKIN: No significant rashes Pertinent Results: ADMISSION LABS ======================== ___ 01:15PM PLT SMR-RARE PLT COUNT-15* ___ 01:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ ___ 01:15PM NEUTS-20* BANDS-2 LYMPHS-75* MONOS-0 EOS-0 BASOS-0 ATYPS-3* ___ MYELOS-0 AbsNeut-0.07* AbsLymp-0.23* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 01:15PM WBC-0.3* RBC-4.14* HGB-12.2* HCT-35.7* MCV-86 MCH-29.5 MCHC-34.2 RDW-11.4 RDWSD-34.9* ___ 01:15PM HAPTOGLOB-300* ___ 01:15PM ALBUMIN-3.9 URIC ACID-3.1* ___ 01:15PM ALT(SGPT)-12 AST(SGOT)-9 LD(LDH)-209 ALK PHOS-51 TOT BILI-0.5 ___ 01:15PM GLUCOSE-157* UREA N-9 CREAT-0.8 SODIUM-135 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-20* ANION GAP-15 ___ 01:30PM LACTATE-1.6 ___ 04:02PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 RENAL EPI-<1 ___ 04:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN->12 PH-7.0 LEUK-NEG ___ 04:02PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 09:22PM ___ ___ 04:29PM ___ PTT-24.1* ___ ___ 09:22PM HBsAg-Negative HBs Ab-Negative HBc Ab-Negative ___ 09:22PM HIV Ab-Negative; HIV, CMV, EBV, parvovirus B19 VLs all negative MICROBIOLOGY ======================== Blood cx x2 (___): No growth (final) Urine cx (___): No growth (final) Urine cx (___): No growth (final) IMAGING ======================== CHEST (PA & LAT) (___): IMPRESSION: No acute cardiopulmonary process. CT NECK W/CONTRAST (___): IMPRESSION: 1. Asymmetric enlargement of the left palatine tonsil without peritonsillar abscess. 2. Bilateral cervical adenopathy. CT Torso (___): IMPRESSION: 1. No worrisome lymphadenopathy in the abdomen or pelvis. 2. Mild splenomegaly. 3. Moderate colonic fecal loading. 4. Please see the separately submitted report of the same day CT Chest for findings above the diaphragm. CARDIAC STUDIES ======================== TTE (___): IMPRESSION: The left atrium and right atrium are normal in cavity size. 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%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis or pathologic flow. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. PATHOLOGY ======================== Bone Marrow Biopsy (___) PATHOLOGY: MARKEDLY HYPOCELLULAR BONE MARROW WITH RARE ERYTHROPOIETIC ISLANDS AND SPARSE LYMPHOID INFILTRATE, PLASMA CELLS AND STROMAL CELLS, CONSISTENT WITH MARROW APLASIA. SEE NOTE. NOTE: In the abscence of an obvious toxic exposure, such as medications, chemicals or infections, the findings are consistent with aplastic anemia. CYTOGENETICS REPORT: FISH: NO EVIDENCE of REARRANGEMENT of RUNX1 or ETV6. No evidence of interphase bone marrow cells with rearrangement of the ETV6 gene or the RUNX1 gene. Uncultured cells for fluorescence in situ hybridization (FISH) analysis with the ___ Molecular ETV6(TEL)/RUNX1(AML1) dual color probe set: SpectrumOrange directly labeled probe for the RUNX1 gene on ___ and SpectrumGreen directly labeled probe for exons 1A-4 on the telomeric 5' end of the ETV6 gene. This probe combination detects the ETV6/RUNX1 gene rearrangement seen in pediatric B-lymphoblastic leukemia. It also detects other rearrangements of ETV6 and RUNX1 as well as copy number abnormalities of these gene regions. FINDINGS: A total of 200 interphase nuclei were examined with the ETV6(TEL)/RUNX1(AML1) dual color probe set and fluorescence microscopy. 200 cells (100%) had 2 red signals and 2 green signals. 0 cells (0%) had 3 red signals and 2 green signals. 0 cells (0%) had 2 red signals and 3 green signals. Normal cut-off values for this probe set include: 84% for a normal 2 red and 2 green signal pattern, 1% for a 3 red and 2 green signal pattern, and 1% for a 2 red and 3 green signal pattern. nuc ish(ETV6,RUNX1)x2[200] FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: Kappa, Lambd, and CD antigens 2,3,4,5,7,8,10,11c,13,14,16,19,20,24,33,34,38,45,56,64, and 117. RESULTS: 10-color analysis with linear side scatter vs. CD45 gating is used to evaluate lymphocytes, blasts and plasma cells. 75% of total acquired events are evaluable non-debris events. The viability of the analyzed non-debris events, done by 7-AAD is 92%. CD45-bright, low side gated lymphocytes comprise 86% of total analyzed events B cells comprise 14% of lymphoid gated events, are polyclonal, and do not express aberrant antigens. T cells comprise 64% of lymphoid gated events, and express mature lineage antigens CD3, CD5, CD2; a minor subset (3%) have dim, variable loss of CD7 (nonspecific finding). T cells have a helper cytotoxic ratio of 0.7. There is an expanded population of double-negative (CD4-, CD8-) cells comprising 6% of CD3(+) T cells. CD56(+), CD3(-) natural killer cells are 22% of gated lymphocytes. These co-express CD2 and CD7. No abnormal events are identified in the "blast gate." Blast cells comprise <1% of total analyzed events. INTERPRETATION Nonspecific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia or lymphoma are not seen in specimen. Correlation with clinical, morphologic (see separate pathology report ___ and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. Peripheral blood (___): FLOW CYTOMETRY REPORT- Peripheral blood FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: CD antigens 14,15,24,45,59, 235a, FLAER. RESULTS: A high sensitivity paroxysmal nocturnal hemoglobinuria panel is performed. INTERPRETATION Flow cytometric quantitation of glycosylphosphatidylinositol (GPI) using fluorescent Aerolysin (FLAER) and CD24 or CD14 on granulocytes and monocytes, respectively, and quantitation of the GPI-anchored antigens CD59 on erythrocytes did not demonstrate the presence of a PNH clone. There is no phenotypic support for a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). These results should be correlated with all available clinically and laboratory data. PERTINENT & DISCHARGE LABS ======================== ___ 04:37PM BLOOD IgG-618* IgA-<5* IgM-147 ___ 06:25AM BLOOD PEP-NO SPECIFI IgG-571* IgA-<5* IgM-135 IFE-NO MONOCLO ___ 12:00AM BLOOD WBC-3.8* RBC-3.04* Hgb-8.8* Hct-26.1* MCV-86 MCH-28.9 MCHC-33.7 RDW-12.2 RDWSD-37.4 Plt Ct-20* ___ 12:00AM BLOOD Neuts-29.3* Lymphs-56.8* Monos-12.0 Eos-0.0* Baso-0.0 NRBC-1.1* Im ___ AbsNeut-1.10* AbsLymp-2.13 AbsMono-0.45 AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL Tear Dr-OCCASIONAL ___ 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-20* ___ 12:00AM BLOOD Glucose-128* UreaN-35* Creat-0.8 Na-138 K-4.2 Cl-99 HCO3-30 AnGap-13 ___ 12:00AM BLOOD ALT-50* AST-11 LD(LDH)-228 AlkPhos-33* TotBili-0.3 ___ 12:00AM BLOOD Albumin-3.1* Calcium-8.6 Phos-4.9* Mg-1.7 ___ 08:57AM BLOOD Cyclspr-357 PENDING LABS ======================== ___ 16:40: anti-IgA pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Acyclovir 400 mg PO Q12H RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills:*0 3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN indigestion RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 1 cup by mouth twice a day Refills:*0 4. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H For aplastic anemia, ICD10 D61.9. RX *cyclosporine modified [Neoral] 100 mg 2 capsule(s) by mouth every twelve (12) hours Disp #*56 Capsule Refills:*0 5. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H For aplastic anemia. ICD10 D61.9. RX *cyclosporine modified [Neoral] 25 mg 2 capsule(s) by mouth every twelve (12) hours Disp #*56 Capsule Refills:*0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 7. PredniSONE 10 mg PO DAILY Duration: 7 Doses Start: After 20 mg DAILY tapered dose This is dose # 3 of 3 tapered doses RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 8. PredniSONE 40 mg PO DAILY Duration: 5 Doses Start: Tomorrow - ___, First Dose: First Routine Administration Time This is dose # 1 of 3 tapered doses RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*20 Tablet Refills:*0 9. PredniSONE 20 mg PO DAILY Duration: 7 Doses Start: After 40 mg DAILY tapered dose This is dose # 2 of 3 tapered doses RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 10. QUEtiapine Fumarate 12.5 mg PO BID:PRN anxiety, nausea RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 11. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*28 Tablet Refills:*0 12. Simethicone 40-80 mg PO QID:PRN Flatulence/Bloating RX *simethicone [Gas Relief] 80 mg 1 tab by mouth four times a day Disp #*56 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= Aplastic Anemia Tonsillitis Neutropenic fever IgA Deficiency Transaminitis Steroid-induced hyperglycemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with likely acute leukemia, weakness. Evaluate for mass or pneumonia. TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: NECK CT WITH CONTRAST INDICATION: ___ male with left-sided necrotizing tonsil. TECHNIQUE: Contiguous axial images obtained through the neck after the administration of intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Total DLP (Body) = 432 mGy-cm. COMPARISON: None. FINDINGS: The parotid glands and submandibular glands are unremarkable. There is a 3 mm nodule in the left thyroid lobe. There is bilateral cervical adenopathy, specifically involving level 2 bilaterally. On the left a level 2 lymph node measures 2.0 x 1.4 cm. On the right, a level-II lymph node measure up to 1.5 x1.3 cm. Other scattered smaller not pathologically enlarged lymph nodes are identified at additional levels along the internal jugular chain bilaterally. There is asymmetric enlargement of the left palatini tonsil with respect to the right. There is no evidence of peritonsillar abscess. The aerodigestive tract appears normal. Included paranasal sinuses and mastoids are essentially clear besides mild mucosal thickening in the maxillary sinuses. . Vascular structures in the neck are grossly unremarkable. Included intracranial structures appear normal. No focal suspicious osseous lesion identified. IMPRESSION: Asymmetric enlargement of the left palatine tonsil without peritonsillar abscess. Bilateral cervical adenopathy. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with picc // s/p r 44cm dl picc ___ ___ Contact name: ___: ___ TECHNIQUE: Chest single view COMPARISON: ___ 14:46 FINDINGS: New right PICC line tip near cavoatrial junction. Lungs are clear. Normal heart size, pulmonary vascularity. IMPRESSION: New right PICC line Radiology Report INDICATION: ___ year old man with newly diagnosed aplastic anemia and IgA deficiency. // Please evaluate for any lymphadenopathy/lymphoma. Thanks TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 16.7 s, 0.2 cm; CTDIvol = 284.8 mGy (Body) DLP = 57.0 mGy-cm. 3) Spiral Acquisition 10.7 s, 69.4 cm; CTDIvol = 18.7 mGy (Body) DLP = 1,285.1 mGy-cm. Total DLP (Body) = 1,344 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal attenuation throughout, without evidence of focal lesions. The spleen is mildly enlarged measuring up to 14.4 cm (05:58). A 2 cm accessory spleen is incidentally noted (5:63). 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 with moderate colonic fecal loading. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. 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: An umbilical hernia containing fat is noted. IMPRESSION: 1. No worrisome lymphadenopathy in the abdomen or pelvis. 2. Mild splenomegaly. 3. Moderate colonic fecal loading. 4. Please see the separately submitted report of the same day CT Chest for findings above the diaphragm. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ male with newly diagnosed aplastic anemia and IgA deficiency, evaluate for lymphadenopathy or lymphoma. TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agent and reconstructed as contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 16.7 s, 0.2 cm; CTDIvol = 284.8 mGy (Body) DLP = 57.0 mGy-cm. 3) Spiral Acquisition 10.7 s, 69.4 cm; CTDIvol = 18.7 mGy (Body) DLP = 1,285.1 mGy-cm. Total DLP (Body) = 1,344 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: None FINDINGS: NECK, THORACIC INLET, AXILLAE: The visualized thyroid contains small hypodense thyroid nodules, not meeting ACR criteria for further evaluation. Supraclavicular and axillary lymph nodes are not enlarged. A left supraclavicular lymph node measures 6 mm in short axis (5:6). MEDIASTINUM: Mediastinal lymph nodes are not enlarged. HILA: Hilar lymph nodes are not enlarged. A right hilar lymph node measures up to 9 mm in short axis (6:117). HEART: The heart is not enlarged and there is no coronary arterial calcification. There is no pericardial effusion. VESSELS: Vascular configuration is conventional. Aortic caliber is normal. The main, right, and left pulmonary arteries are normal caliber. A right PICC terminates in the right atrium. PULMONARY PARENCHYMA: There is no evidence of infection or malignancy. There is no emphysema. AIRWAYS: The airways are patent to the subsegmental level bilaterally. PLEURA: There is no pleural effusion. CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion. Multilevel degenerative changes are absent. UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report for subdiaphragmatic findings. IMPRESSION: 1. No lymphadenopathy by CT criteria. A single borderline right hilar lymph node measures 9 mm in short axis, attention on follow-up imaging is recommended. 2. Please see separately submitted Abdomen and Pelvis CT report for subdiaphragmatic findings. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with recent PICC line placement with intermittent arrhythmia and episode of pleuritic chest discomfort // Please evaluate PICC line placement and any acute processes TECHNIQUE: Chest single view COMPARISON: ___ 16:42 FINDINGS: Right PICC line tip low SVC. Lungs are clear. Normal heart size, pulmonary vascularity. IMPRESSION: Right PICC line tip low SVC. Radiology Report INDICATION: ___ year old man with newly diagnosed aplastic anemia w/ PICC line. // Please re-evaluate placement of PICC line TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the right PICC line projects over the mid SVC, mildly retracted since the prior radiograph. No focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiomediastinal silhouette is within normal limits. IMPRESSION: Mild interval retraction of the right PICC line, the tip now projecting over the mid SVC. Clear lungs. Radiology Report INDICATION: ___ year old man with aplastic anemia on IV abx // Assess for PICC placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the right PICC line projects over the mid SVC. No pleural effusion or pneumothorax identified. New haziness along the contour of the right hemidiaphragm may reflect a new small effusion or atelectasis. IMPRESSION: The tip of the right PICC line projects over the mid SVC. New haziness along the contour of the right hemidiaphragm may reflect a small effusion or atelectasis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal labs Diagnosed with Other pancytopenia temperature: 96.7 heartrate: 90.0 resprate: 18.0 o2sat: 100.0 sbp: 113.0 dbp: 65.0 level of pain: 2 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you. Why you were admitted, - You were admitted because you had persistent sore throats and were found to have a condition called aplastic anemia. What we did for you, - We started you on immunosuppressive therapy with ATG and cyclosporine to treat your aplastic anemia - We gave you antibiotics for the infection of your tonsils, which resolved What you should do when you go home, - Please take all your medications as prescribed and go to the appointments that we have arranged

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with history of cryptogenic cirrhosis s/p liver transplant, CKD, and recurrent self-resolving febrile illnesses, here with fever. Patient and family report that he has been having fevers ~q6 weeks without clear source. Fever began again yesterday, tmax of 101.2. He complains of chills and diffuse myalgias, similar to previous episodes of fever. No focal symptoms. Reports he has leg pains which are chronic but make it difficult for him to walk. ROS positive for dysuria and urinary urgency, which started yesterday. No other focal symptoms. In the ED, initial vitals were 100.6 115 112/61 18 98% RA Labs notable for: negative UA; Cr 1.8 (at baseline), LFTs wnl CXR and RUQ u/s were unremarkable. Past Medical History: - Cholangitis c/b citrobacter bacteremia in ___ - Cryptogenic cirrhosis s/p transplant ___ - Hiatal hernia - GERD - Esophageal dismotility - Prostate cancer s/p prostatectomy and penile prosthesis - Depression - Chronic kidney disease with baseline creatinine 1.3-3.0 - History of pancreatic cyst (monitored with MRCP) - Hypertension - Hypertriglyceridemia Social History: ___ Family History: No family history of liver disease, diabetes, or premature CAD. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.3 120/57 104 20 97%RA General: NAD. Well-appearing. Very pleasant. Appears younger than stated age. HEENT: PERRL. EOMI. dry MMs Neck: JVP not elevated CV: RRR. ___ holosystolic murmur heard best at left sternal border Lungs: CTAB Abdomen: NT/ND. +BS. Diffusely audible abdominal bruit. Ext: No edema Neuro: A&Ox3. No focal deficits. No asterixis Skin: warm and well-perfused. DISCHARGE PHYSICAL EXAM: VS: 98.2 120/68 87 20 99% RA General: Walking around the room, in NAD HEENT: PERRL. EOMI, MMM Neck: JVP not elevated CV: RRR. ___ holosystolic murmur heard best at left sternal border Lungs: CTAB Abdomen: Non-distended, mildly tender in the RUQ, +BS. Ext: No edema Neuro: A&Ox3. No focal deficits. No asterixis Skin: warm and well-perfused. Pertinent Results: Admission Labs: ___ 06:59PM BLOOD WBC-11.8* RBC-3.37* Hgb-10.1* Hct-30.4* MCV-90 MCH-30.0 MCHC-33.3 RDW-14.1 Plt ___ ___ 06:59PM BLOOD Neuts-75.9* Lymphs-14.5* Monos-6.8 Eos-2.7 Baso-0.1 ___ 07:22PM BLOOD ___ PTT-29.3 ___ ___ 06:59PM BLOOD Glucose-130* UreaN-26* Creat-1.8* Na-137 K-4.6 Cl-100 HCO3-25 AnGap-17 ___ 06:59PM BLOOD ALT-22 AST-21 AlkPhos-156* TotBili-0.3 ___ 06:59PM BLOOD Lipase-26 ___ 06:59PM BLOOD Albumin-4.3 ___ 07:44PM BLOOD rapmycn-6.6 ___ 07:14PM BLOOD Lactate-1.4 Urine: ___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 08:30PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 Micro: ___ 6:59 pm BLOOD CULTURE R AC. Blood Culture, Routine (Pending): ___ 8:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. ___ 6:55 pm Immunology (CMV) CMV Viral Load (Pending): ___ 07:44PM BLOOD rapmycn-6.6 ___ 06:20AM BLOOD rapmycn-PND IMAGING: CXR ___: No acute cardiopulmonary process. RUQ U/S: ___: 1. Patent hepatic vasculature, similar to the prior exams. Evaluation of the right hepatic artery is somewhat limited due to patient cooperation, though it is patent with a normal waveform. 2. Normal echogenicity of the transplanted liver. 3. Pneumobilia again seen. No biliary duct dilation. 4. Limited evaluation of the common bile duct stents due to overlying bowel gas. Stents not seen CT Abd/Pelvis w/ contrast ___: 1. No evidence of posttransplant lymphoproliferative disease. 2. Transplanted liver, with pneumobilia within left lobe of the liver. Biliary stents in appropriate position. Mild intrahepatic biliary ductal dilatation of the left lobe of the liver. Even though there is no query biliary ductal enhancement or thickening, possibility of cholangitis is raised. Clinical correlation is recommended. 3. No lymphadenopathy. 4. Please refer to the CT chest from the same day for complete details on thoracic findings. CT Chest: ___: Subtle patchy areas of ground-glass changes along the peripheral aspects of upper and lower lobes of the lung are nonspecific, and may simply relate to atelectasis, however differential considerations would include prior scarring given the parenchymal changes on prior study from ___ and infectious/inflammatory etiologies including atypical organisms. Continued followup is recommended. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fish Oil (Omega 3) 1000 mg PO BID 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. mycophenolate sodium 360 mg Oral BID 5. Sirolimus 1.5 mg PO DAILY 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 8. Ursodiol 300 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Fish Oil (Omega 3) 1000 mg PO BID 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. mycophenolate sodium 360 mg Oral BID 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Sirolimus 1.5 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 9. Ursodiol 300 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Fever Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Fever. ___. TECHNIQUE: Frontal and lateral views of the chest. FINDINGS: Frontal and lateral views of the chest were obtained. There is elevation of the right hemidiaphragm with overlying atelectasis. No definite focal consolidation is seen. There is no pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes are unremarkable. Tubular structure is seen projecting over the upper abdomen on the lateral view. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Status post liver transplant, here with fever. Evaluate transplant. COMPARISONS: Liver ultrasound from ___. Liver ultrasound from ___. CT of the abdomen and pelvis from ___. TECHNIQUE: Grayscale, Doppler and spectral ultrasound images were acquired through the right upper quadrant. FINDINGS: The patient is status post a liver transplant. The transplant is normal in shape and contour. There is normal echogenicity. No focal hepatic lesions are identified. Again, there is pneumobilia, which is not unexpected in the presence of biliary stents. There is no biliary duct dilation. Due to overlying bowel gas, the hepatic hilum is not well evaluated and the stents in the common bile duct are not visualized. The gallbladder is surgically absent. The main hepatic artery, right hepatic artery and left hepatic artery are patent with normal arterial waveforms. Evaluation of the right hepatic artery and its resistive index is somewhat limited due to patient cooperation. The resistive indices in the main and left hepatic arteries are normal, measuring 0.52 and 0.42, respectively. These are not significantly changed from the prior exam. The main, right and left portal veins are patent. The right, middle and left hepatic veins are patent. The spleen is normal measuring 8.9 cm. The pancreas is not well evaluated due to overlying bowel gas. Limited views of the right kidney are normal without hydronephrosis. There is no ascites on this limited right upper quadrant ultrasound. IMPRESSION: 1. Patent hepatic vasculature, similar to the prior exams. Evaluation of the right hepatic artery is somewhat limited due to patient cooperation, though it is patent with a normal waveform. 2. Normal echogenicity of the transplanted liver. 3. Pneumobilia again seen. No biliary duct dilation. 4. Limited evaluation of the common bile duct stents due to overlying bowel gas. Stents not seen Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man s/p liver transplant presenting with recurrent fevers. Rule out post-transplant lymphoproliferative disease. TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with intravenous and oral contrast. Sagittal and coronal reformats were prepared. DLP: 849.99 mGy-cm COMPARISON: Prior abdominal ultrasound from ___, MRCP from ___ and CT abdomen pelvis from ___. FINDINGS: ABDOMEN: Please refer to the CT chest from the same day for complete details on thoracic findings. The transplanted liver demonstrates homogeneous enhancement. There is evidence of pneumobilia, predominate within the left lobe of the liver. Biliary stents are identified, in appropriate position. Mild intrahepatic biliary ductal dilatation is identified in the left lobe of the liver. Adrenal glands, spleen, pancreas are within normal limits. Both kidneys demonstrate symmetric enhancement and excretion of contrast. No focal renal lesions are identified. No hydronephrosis. No retroperitoneal or mesenteric lymphadenopathy. Visualized hepatic and portal veins are patent. Caliber of abdominal aorta is within normal limits. Mild atheromatous calcification is identified at the origin of celiac artery, SMA and renal arteries. No ascites. The stomach is unremarkable. Caliber of small bowel is within normal limits. No significant diverticulosis. PELVIS: Mildly distended urinary bladder is unremarkable. Patient is status post prostatectomy. Penile prosthesis is identified. No significant pelvic free fluid. No inguinal or pelvic lymphadenopathy. OSSEOUS STRUCTURES: No focal osteolytic or osteoblastic lesions are identified. Mild multilevel degenerative changes of the thoracic and lumbar spine are evident. IMPRESSION: 1. No evidence of posttransplant lymphoproliferative disease. 2. Transplanted liver, with pneumobilia within left lobe of the liver. Biliary stents in appropriate position. Mild intrahepatic biliary ductal dilatation of the left lobe of the liver. Even though there is no query biliary ductal enhancement or thickening, possibility of cholangitis is raised. Clinical correlation is recommended. 3. No lymphadenopathy. 4. Please refer to the CT chest from the same day for complete details on thoracic findings. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ man status post liver transplant presenting with recurrent fevers. Rule out posttransplant lymphoproliferative disease. TECHNIQUE: Axial CT images of the chest were obtained with intravenous contrast. Sagittal and coronal reformats were prepared. DLP: 849.99 mGy-cm COMPARISON: Chest radiograph from ___ and CT chest, abdomen and pelvis from ___. FINDINGS: No axillary, supraclavicular, mediastinal or hilar lymphadenopathy. Small subcentimeter mediastinal lymph nodes are identified. Cardiac size is within normal limits. No pericardial pleural effusions are identified. Caliber of pulmonary artery and thoracic aorta are within normal limits. No focal soft tissue abnormality. The subdiaphragmatic cyst structures are described in detail on the CT abdomen study from the same day. Subtle patchy areas of ground-glass changes are identified along the peripheral aspects of the upper and lower lobes (02:15, 18, 21, 27, 35, 41). No evidence of consolidation. No bronchiectasis. No obstructing tracheobronchial lesions. OSSEOUS STRUCTURES: No suspicious focal osseous lesions are identified. Mild degenerative changes of the thoracic and lumbar spine are evident. IMPRESSION: Subtle patchy areas of ground-glass changes along the peripheral aspects of upper and lower lobes of the lung are nonspecific, and may simply relate to atelectasis, however differential considerations would include prior scarring given the parenchymal changes on prior study from ___ and infectious/inflammatory etiologies including atypical organisms. Continued followup is recommended. Please refer to CT abdomen/pelvis from the same day for complete details on abdominal/pelvic findings. Gender: M Race: PORTUGUESE Arrive by WALK IN Chief complaint: Fever, TRANSPLANT Diagnosed with FEVER, UNSPECIFIED temperature: 100.6 heartrate: 115.0 resprate: 18.0 o2sat: 98.0 sbp: 112.0 dbp: 61.0 level of pain: 5 level of acuity: 2.0

Dear Mr. ___, You were admitted because you were having fevers at home. We performed studies to determine the cause of your fevers. All of the studies you have received in the hospital, including a CT scan of your chest and abdomen, has not revealed a source for your fevers. Fortunately, you only had a mild temperature when you came in, and did not have any fevers during your stay. We are very reassured by this. At this time we feel that you are safe for discharge home. It is very important for you to follow up with 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: Clozapine / Phenothiazines Attending: ___. Chief Complaint: some bleeding from trach Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/chronic trach ___ laryngeal cancer s/p exploration and tracheal tube change on ___ by ENT presents from nursing facility due to frank blood coming from the trachea tube. Pt reports sore throat and pain at the top of the lung. In ED Respiratory therapy evaluated inner cannula and found no concern. Clear mucus suctioned out of the tube, no blood seen. ENT evaluation found trauma to carina from repeated deep suctioning. Pt anxious and insistant on suctioning in the ED. However ENT recommended to avoid deep suctioning. Pt developed a fever up to ___ given vanc/cefepime. ativan given for anxiety. On arrival to the floor pt reports pain is unchanged. No fevers prior to ED visit. ROS: +as above, otherwise reviewed and negative Past Medical History: 1. Stage ___ Cancer s/p resection, chemotherapy and radiation 2. Schizophrenia. 3. Crohn's disease. 4. Coronary artery disease status post MI in her mid ___. 5. Hypertension. 6. Neurogenic bladder. 7. Hyperlipidemia. 8. Back pain. 9. COPD. Social History: ___ Family History: One sister. Father had heart disease. Cousin with breast cancer Physical Exam: Vitals: T:afeb BP:113/72 P:78 R:18 O2:96% on 50%trach mask PAIN: 6 General: nad Lungs: clear CV: rrr no m/r/g Abdomen: bowel sounds present, soft, nt/nd PEG tube site c/d/i Ext: no e/c/c Skin: no rash GU: Foley present, chronic Neuro: alert, follows commands Pertinent Results: ___ 10:18AM WBC-8.0 RBC-4.37# HGB-11.0* HCT-36.1 MCV-83 MCH-25.2* MCHC-30.5* RDW-15.0 ___ 10:18AM NEUTS-81.7* LYMPHS-12.2* MONOS-4.0 EOS-1.8 BASOS-0.2 ___ 10:18AM PLT COUNT-494* ___ 10:18AM GLUCOSE-147* UREA N-20 CREAT-0.5 SODIUM-138 POTASSIUM-7.0* CHLORIDE-98 TOTAL CO2-32 ANION GAP-15 ___ 12:10PM K+-4.5 ___ 10:18AM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-0 ___ 10:18AM URINE 3PHOSPHAT-MANY ___ 10:18AM URINE MUCOUS-RARE ___ 10:18AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5* LEUK-LG ___ 10:18AM URINE COLOR-Yellow APPEAR-Hazy SP ___ CXR: Tracheostomy is seen. A rebreather mask obscures part of the left upper lung. There is a small right-sided pleural effusion. There is some atelectasis at the lung bases. There is no focal consolidation or signs of overt pulmonary edema CT Neck FINDINGS: There is a tracheostomy. There is no soft tissue gas within the neck or definite swelling. There are severe degenerative changes of the cervical spine with loss of intervertebral disc height at multiple levels and some reversal of the normal cervical lordosis. If there is high concern for soft tissue abnormalities, would recommend a CT scan or MRI. The lung apices are clear Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 3. Aspirin 81 mg PO DAILY 4. Atenolol 25 mg PO DAILY 5. Atorvastatin 10 mg PO HS 6. Docusate Sodium (Liquid) 100 mg PO BID 7. Glycopyrrolate 1 mg PO TID 8. Guaifenesin-CODEINE Phosphate 5 mL PO BID:PRN cough 9. LOPERamide 2 mg PO QID:PRN loose stools 10. Magnesium Citrate 300 mL PO DAILY:PRN constipation 11. OLANZapine 6.25 mg PO DAILY 12. Ondansetron 4 mg PO Q8H:PRN nausea 13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 14. Senna 17.2 mg PO BID:PRN constipation 15. TraZODone 25 mg PO Q12H:PRN anxiety/insomnia 16. Omeprazole 20 mg PO BID 17. Guaifenesin-CODEINE Phosphate 5 mL PO BID 18. Acetylcysteine Inhaled – For interventional pulmonary use only 5 mL NEB Q6H Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 3. Aspirin 81 mg PO DAILY 4. Atenolol 25 mg PO DAILY 5. Atorvastatin 10 mg PO HS 6. Docusate Sodium (Liquid) 100 mg PO BID 7. Glycopyrrolate 1 mg PO TID 8. Guaifenesin-CODEINE Phosphate 5 mL PO BID:PRN cough 9. Guaifenesin-CODEINE Phosphate 5 mL PO BID 10. LOPERamide 2 mg PO QID:PRN loose stools 11. Magnesium Citrate 300 mL PO DAILY:PRN constipation 12. OLANZapine 6.25 mg PO DAILY 13. Omeprazole 20 mg PO BID 14. Ondansetron 4 mg PO Q8H:PRN nausea 15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 16. Senna 17.2 mg PO BID:PRN constipation 17. TraZODone 25 mg PO Q12H:PRN anxiety/insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: bleeding from trach chronic trach and peg status Discharge Condition: does not speak writes down to communicate Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report STUDY: AP chest, ___. CLINICAL HISTORY: Patient with possible right neck soft tissue infection. Evaluate for apical pneumothorax. FINDINGS: Comparison is made to prior radiographs from ___. ___ is seen. A rebreather mask obscures part of the left upper lung. There is a small right-sided pleural effusion. There is some atelectasis at the lung bases. There is no focal consolidation or signs of overt pulmonary edema. Radiology Report STUDY: Neck soft tissues, ___. CLINICAL HISTORY: Patient with laryngeal stenosis. Evaluate for soft tissue neck infection. FINDINGS: There is a tracheostomy. There is no soft tissue gas within the neck or definite swelling. There are severe degenerative changes of the cervical spine with loss of intervertebral disc height at multiple levels and some reversal of the normal cervical lordosis. If there is high concern for soft tissue abnormalities, would recommend a CT scan or MRI. The lung apices are clear. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: TRACH EVAL Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OTHER HEMOPTYSIS, TRACHEOSTOMY STATUS temperature: 97.8 heartrate: 100.0 resprate: 25.0 o2sat: 96.0 sbp: 150.0 dbp: 103.0 level of pain: 13 level of acuity: 2.0

you were hospitalized from some bleeding at your trach site from too much deep suctioning. you should cough up phlegm instead of having deep suctioning