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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 and chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with hx of afib on coumadin, CAD s/p DESx3 in ___, ___, with recent fall 4 days ago, who presents with SOB and chest pain. Patient was admitted to plastic surgery on ___ after she fell and suffered facial trauma s/p exploration of L orbital floor fracture and L maxillary sinus w/ removal of foreign body. Today, she experienced sudden onset SOB and CP 45 minutes before ED arrival. In ED initial VS: T 98.6, HR 135, BP 155/119, 94-99% NC (intermittently) Labs significant for: -Normal Chem7 with Cr 0.8 -WBC 15.4 -H/H 10.1/30.5 -> 8.2/25.5 -INR 1.4 -Lactate 2.9 -> 1.6 -Trop negative Patient found to be in afib with RVR in 130s and received 2 doses of IV and 1 dose of PO diltiazem. ALso placed on a diltiazem drip which was stopped after she became hypotensive to 73/57. At that point she received an LIJ and started on levophed. Worked up for PE with CTA that was negative for embolus but suggested pulmonary edema and pleural effusions with possible superimposed infection. Started on levofloxacin. Also empirically treated for C. diff for foul smelling stool with IV flagyl. Of note, patient had a Hb drop from 10.1 to 8.2 and had guaic positive stools. She received 500 cc and 1U RBC in total in ED. On arrival to the MICU, patient was not in acute distress, in positive mood, speaking with providers. She denied recent fever, cough, lower extremity edema, weight gain, abdominal pain, dysuria. Her symptoms of SOB and chest pain were very acute. Besides that, she only endorsed having episodes of nonbloody diarrhea. No melena. Past Medical History: - Atrial Fibrillation (on diltiazem, metoprolol and warfarin at home) - Moderate-Severe Mitral Regurgitation - Heart failure with PRESERVED ejection fraction (had transient severe reduction in ___ in setting of acute MI caused by RCA lesion in ___, EF at that time 20% as measured by LV-gram) - CAD s/p 3 DES ___ (on review of ___ records: s/p MI c/b cardiogenic shock in ___ after R total hip replacement surgery with peak TropI of 30.5, at which time she had 2x stent to RCA and 1x stent to LAD and also required an IABP x2 days; also had a smaller MI in ___ with peak TropI of 0.10) - Hypertension - Hyperlipidemia - H/o CBD stone s/p mechanical lithotripsy, ERCP w/ CBD stent placement, repeat ERCP for successful removal of CBD stent (___) - H/o scoliosis and extensive lumbar spondylosis PAST SURGICAL HISTORY: - Phacoemulsification with posterior chamber intraocular lens implant (left eye, ___ - S/p right total hip replacement surgery ___, ___ ___) - S/p lumbar decompression L2-L3, L3-L4, L4-L5 ___, ___ ___) - S/p bilateral laminectomy of L4 and L5 for sciatic symptoms ___, ___) - H/o fracture of anterior arch of C1 and small nondisplaced fracture of left nasal bone Social History: ___ Family History: Father died of an MI at ___ years of age. Mother died of MI at age ___. Has a sister who has no heart problems. Physical Exam: ======================= ADMISSION PHYISCAL EXAM ======================= VITALS: ___ F HR 105 BP 118/90 98% RA GENERAL: Alert, oriented, no acute distress HEENT: multiple facial ecchymoses,, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: transient mild crackles in left mid-lung, no wheezes CV: tachycardic, irregular rate and rhythm, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Neither warm nor cold, well perfused, 2+ pulses, no clubbing, cyanosis or edema ======================= DISCHARGE PHYISCAL EXAM ======================= VITALS: T98.2 BP 118 / 82 HR 88 RR 18 SpO2 95 Ra WEIGHT: 60.69 kg TELEMETRY: Afib, HR ___ to ___ with occasional spikes to 130s when patient moving. PHYSICAL EXAM: GENERAL: Elderly woman with multiple contusions and lacerations on face, comfortably lying in bed in NAD. HEENT: Facial contusions and laceration present. Sclera anicteric. +R conjuncitivtis. MMM. CARDIAC: Normal rate, irregularly irregular, normal S1, S2. No murmurs/rubs/gallops. No rashes observed. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No BLE edema. RUE in splint. SKIN: Facial contusions and lacerations. PSYCH: No visual hallucinations today. Alert and oriented x3. Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ ___ 10:08PM ___ PTT-25.2 ___ ___ 10:08PM WBC-15.4*# RBC-2.90* HGB-10.1* HCT-30.5* MCV-105* MCH-34.8* MCHC-33.1 RDW-12.8 RDWSD-48.4* ___ 10:08PM proBNP-4394* ___ 10:08PM ALBUMIN-3.9 ___ 10:08PM cTropnT-<0.01 ___ 10:08PM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-70 TOT BILI-0.7 ___ 10:08PM GLUCOSE-175* UREA N-16 CREAT-0.8 SODIUM-140 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 ___ 10:40PM ___ PO2-25* PCO2-37 PH-7.45 TOTAL CO2-27 BASE XS-0 ====================================== DISCHARGE/PERTINENT LABORATORY STUDIES ====================================== ___ 06:45AM BLOOD WBC-10.0 RBC-3.28* Hgb-11.1* Hct-34.0 MCV-104* MCH-33.8* MCHC-32.6 RDW-14.5 RDWSD-54.1* Plt ___ ___ 06:45AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-138 K-5.0 Cl-99 HCO3-27 AnGap-12 ___ 06:45AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.2 =============== IMAGING STUDIES =============== ---- P-MIBI ___ ---- FINDINGS: Study quality limited due to patient motion and positioning. Left ventricular cavity size is 49 mL. Rest and stress perfusion images reveal moderate fixed defects of the septum and inferolateral wall, however the quality of the images is decreased secondary to patient motion. Therefore, attenuation cannot be ruled out. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 57% IMPRESSION: Evidence of moderate fixed septal and inferolateral wall defects, please see above comments. Normal ventricular size and systolic function. ---- CXR ___ ---- IMPRESSION: Bibasilar hazy opacities, which may reflect combination of atelectasis and small effusions, slightly increased. Minimal edema stable. ---- Echo ___ ---- IMPRESSION: Suboptimal image quality. Moderately depressed left ventricular systolic function consistent with multivessel coronary artery disease. Right ventricular apical hypokinesis. Moderate to severe tricuspid regurgitation (clip#64). Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the left ventricular systolic function is worse. The severity of tricuspid regurgitation is worse; the regional wall motion abnormalities are new. Severe pulmonary hypertension is no longer appreciated. ---- Echo ___ ---- Overall left ventricular systolic function is low normal (LVEF 50-55%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with normal free wall contractility. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. ---- CXR ___ ---- 1. Cardiomegaly, mild pulmonary edema, and small bilateral pleural effusions. 2. Increased prominence of right upper and lower lung opacities may be due to pulmonary edema or infection. ---- CT Chest ___ ---- 1. No pulmonary embolus or evidence of aortic injury. 2. Cardiomegaly, diffuse ground-glass opacity likely representing moderate pulmonary edema, and small bilateral nonhemorrhagic pleural effusions suggest cardiac decompensation with possible superimposed infection. 3. Right lateral nondisplaced seventh rib fracture, possibly subacute. 4. No pneumothorax. No evidence of intra-abdominal traumatic injury. 5. 1.3 cm left adrenal nodule, incompletely assessed. See radiology report ============ MICROBIOLOGY ============ ___ Blood Culture: NO GROWTH. ___ C Diff: Negative ___ Urine Culture: NO GROWTH. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Atorvastatin 80 mg PO QPM 3. Furosemide 20 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Propranolol LA 60 mg PO DAILY 6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 7. Diltiazem Extended-Release 240 mg PO DAILY AFib 8. Lisinopril 5 mg PO DAILY 9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 10. Iron Polysaccharides Complex ___ mg PO DAILY 11. Warfarin 1 mg PO QOD 12. Warfarin 2 mg PO QOD Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Aspirin 81 mg PO DAILY 4. Digoxin 0.0625 mg PO DAILY 5. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID 6. Metoprolol Succinate XL 150 mg PO DAILY Please start on ___ 7. Lisinopril 2.5 mg PO DAILY 8. Warfarin 1 mg PO DAILY16 9. Atorvastatin 80 mg PO QPM 10. Iron Polysaccharides Complex ___ mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you follow up with your PCP ___: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Atrial fibrillation with rapid ventricular rate Coronary artery disease Acute on chronic heart failure with reduced ejection fraction Urinary tract infection SECONDARY: Facial Contusions Gastroesophageal Reflux Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: History: ___ with hypotension/gi bleed// central line placement? TECHNIQUE: Portable supine AP chest COMPARISON: Chest CT and radiograph from ___. FINDINGS: Interval left internal jugular central venous catheter terminating in the mid to lower SVC. No pneumothorax. Lungs are moderately well expanded interval improvement in pulmonary edema and right lower and upper lung opacities. Cardiomediastinal silhouette remains prominent. Likely stable small bilateral pleural effusions. IMPRESSION: 1. Left internal jugular central venous catheter in appropriate position. 2. No pneumothorax. Stable small bilateral pleural effusions. 3. Improved pulmonary edema in right upper and lower lung opacities. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: ___ year old woman with CHF who presented with acute SOB, found to have hypotension of unclear etiology// Eval for change in pulmonary edema or consolidation TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph ___ FINDINGS: Interval increase in small left pleural effusion. Stable small right pleural effusion. No acute focal consolidation or pneumothorax. Interval improvement in mild pulmonary edema. Stable mild enlargement of the cardiomediastinal silhouette. A left central venous catheter is seen in unchanged position. IMPRESSION: Interval increase in small left pleural effusion. Improvement in pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman af RVR with new SOB// eval for interval pulm edema TECHNIQUE: 2 frontal views of the chest COMPARISON: ___ FINDINGS: Minimal edema stable. Left basilar hazy opacity, which may be on the basis of atelectasis and small left effusion, slightly increased. New hazy right opacity, which could reflect combination of atelectasis and trace right effusion. No pneumothorax. Left central line has been removed. Moderate cardiomegaly stable. IMPRESSION: Bibasilar hazy opacities, which may reflect combination of atelectasis and small effusions, slightly increased. Minimal edema stable. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Tachycardia Diagnosed with Unspecified atrial fibrillation, Pneumonia, unspecified organism temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: uta level of acuity: 1.0

Dear ___, ___ was a pleasure taking care of you at the ___ ___. During your hospitalization: -You were found to have a fast heart rate, called atrial fibrillation -You also developed chest pressure while you were here and we checked you for a heart attack which you did not have. -We treated you with medication through your IV and eventually transitioned to pills -We got a stress test of your heart, which did not show any new damage to your heart. What should I do after leaving the hospital? - Please take your medications as listed in discharge summary and follow up at the listed appointments. - You were started on a new medication called digoxin that helps prevent you from having a fast heart rate. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fatigue, lower extremity weakness Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old female h/o dCHF (TTE ___ showing LVH and EF>55%) who complains of fatigue. Of relevance, pt s/p recent admission end of ___ for fatigue and weakness at which time she was noted to have diastolic CHF and ___ on CKD. troponins were 0.26 on admission and remained stable at that level x3. BNP elevated at 27,000 and pt with pulm edema. TTE similar to prior, did show LVH and dx of dCHF given. During this admission VQ scan also performed (___) which was negative for PE. Infectious workup was negative, and TSH wnl. She was effectively diuresed and discharged on furosemide QOD (which she had not been taking at home) with downtrending creatinine. . Pt recently admitted with weakness, and sent initially to rehab and then home 1 week ago. Was doing well until two days ago, when she woke up with sudden weakness of her lower extremities (on chronic baseline leg weakness requiring use of a walker). That same day she had 1 episode of vomiting, without nausea. For the last 2 days has had decreased PO intake and leg weakness. No SOB/CP/edema throughout. Called PCP who told her to go to the ED. Pt continues to take her lasix QOD as per last discharge instructions. . In the ___ ED, pt developed new chest pain described as pressure in substernal area. Non radiating. no pleuritic. no orthopnea. no dyspnea on exertion. "Just felt weak". No fevers or cough. No urinary symptoms. . In the ED, initial vitals were 96.7 102 105/53 22 97% 3L. Labs significant for MB 9, proBNP 16,000, Cr of 2.7 (last adm presented with cr 3.0, down to 2.1 at DC), K of 5.0. HCT 36.6 from 28.9 on last DC. ECG showed 1mm ST depressions V4-6 with inverted TW in these same leads, LAD, sr@75. (ST changes new from ___ Patient given aspirin 325mg and heparin gtt was started. Chest pain had resolved on its own without intervention. . On arrival to the floor, patient expresses disgust re having been admitted this time, for which she blames her son/HCP who brought her to the hospital. She is comfortable lying in bed. Denies lower extremity weakness at this time. Denies SOB/CP. Ordered dinner. . REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, +HTN, +HLD 2. CARDIAC HISTORY: congestive heart failure 3. OTHER PAST MEDICAL HISTORY: congestive heart failure Hypertension Anxiety Hyperlipidemia Claudication in LLE supraventricular tachycardia degenerative arthritis, s/p L3-4 laminectomy bilateral carpal tunnel s/p surgery bilateral cataracts s/p surgery left wrist fracture diminished hearing right lung hamartoma s/p resection benign breast nodule s/p excision uterine fibroids Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION: VS: T=97.8 AF BP=135/59, then 124/64 HR= 77 RR=18 O2 sat= 97%RA GENERAL: well appearing female who looks several decades younger than her stated age 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 xanthalesma. NECK: Supple without perceptible JVD CARDIAC: distant heart sounds. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. mild bibasilar crackles. no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ ___ 2+ . AT DISCHARGE: 97.5 114-138/41-60 60-70s 18 96%RA exam otherwise unchanged. Pertinent Results: ADMISSION LABS: ___ 02:30PM BLOOD WBC-7.2 RBC-3.79* Hgb-11.6* Hct-36.6# MCV-97# MCH-30.6 MCHC-31.7 RDW-14.2 Plt ___ ___ 02:30PM BLOOD Neuts-88.1* Lymphs-6.9* Monos-1.4* Eos-3.0 Baso-0.5 ___ 02:30PM BLOOD ___ PTT-25.0 ___ ___ 02:30PM BLOOD Glucose-110* UreaN-62* Creat-2.7* Na-139 K-5.0 Cl-104 HCO3-24 AnGap-16 . CARDIAC ENZYMES: ___ 02:30PM BLOOD CK(CPK)-63 ___ 06:30AM BLOOD LD(LDH)-220 CK(CPK)-10* TotBili-0.3 ___ 02:30PM BLOOD CK-MB-9 ___ ___ 02:30PM BLOOD cTropnT-2.15* ___ 09:30PM BLOOD CK-MB-8 cTropnT-2.43* ___ 04:00AM BLOOD CK-MB-6 cTropnT-2.68* ___ 06:30AM BLOOD CK-MB-2 cTropnT-2.56* . PERTINENT LABS OF HOSPITAL COURSE: ___ 06:30AM BLOOD calTIBC-220* ___ Ferritn-188* TRF-169* ___ 06:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.0 Iron-69 ___ 06:30AM BLOOD Ret Aut-1.8 . URINE STUDIES: ___ 07:33PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR ___ 07:33PM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-1 ___ 07:51PM URINE RBC-2 WBC-5 Bacteri-NONE Yeast-NONE Epi-4 TransE-<1 ___ 07:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG ___ 07:33PM URINE Hours-RANDOM UreaN-812 Creat-95 ___ 07:33PM URINE Osmolal-502 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION . CXR ___: FINDINGS: AP and lateral views of the chest are compared to multiple prior exams dating back to ___ with most recent from ___. There are bibasilar opacities suggestive of atelectasis vs scar given persistence over time. There are trace bilateral effusions, slightly smaller when compared to previous exam. There is no new confluent consolidation. There is no evidence of overt failure. Cardiac silhouette is enlarged but stable in configuration. Osseous structures are unchanged. IMPRESSION: Bibasilar opacities most suggestive of atelectasis versus scarring given persistence over time. Trace bilateral pleural effusions, no evidence of acute cardiopulmonary process. . 2D-ECHOCARDIOGRAM: ___ The left atrium is normal in size. 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 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. . TTE ___ The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%) (cannot exclude focal apical hypokinesis). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The left ventricular inflow pattern suggests marked impairment of early diastolic relaxation. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of ___, apical hypokinesis is now present. Medications on Admission: aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). metoprolol 25mg XL daily lasix 20 mg QOD pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. bromfenac 0.09 % Drops Sig: One (1) Ophthalmic twice a day: OS. 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day as needed for constipation. 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. bromfenac 0.09 % Drops Sig: One (1) Ophthalmic BID (2 times a day). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY non-ST elevation myocardial infarction SECONDARY gastrointestinal bleeding hypertension hyperlipidemia 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, TWO VIEWS: ___ HISTORY: ___ female complains of fatigue with history of CHF with recent admission, doing well until two days ago, now feeling fatigue and generalized weakness. FINDINGS: AP and lateral views of the chest are compared to multiple prior exams dating back to ___ with most recent from ___. There are bibasilar opacities suggestive of atelectasis vs scar given persistence over time. There are trace bilateral effusions, slightly smaller when compared to previous exam. There is no new confluent consolidation. There is no evidence of overt failure. Cardiac silhouette is enlarged but stable in configuration. Osseous structures are unchanged. IMPRESSION: Bibasilar opacities most suggestive of atelectasis versus scarring given persistence over time. Trace bilateral pleural effusions, no evidence of acute cardiopulmonary process. Radiology Report INDICATION: ___ female with persistent abdominal pain, constipation, and guaiac-positive stool, here to evaluate for bowel obstruction or ileus. COMPARISON: No prior studies available. FINDINGS: Frontal and lateral decubitus images of the abdomen show gaseous distention of the small and large bowel with borderline dilatation. No free air is detected. A densely calcified rounded structure in the pelvis likely represents a calcified uterine fibroid. Multiple pelvic phleboliths are noted. Extensive vascular calcifications are present. Severe degenerative changes are seen in the lower thoracic spine. IMPRESSION: Gaseous distention without dilatation of the small and large bowel. No free air. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: FATIGUE Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, ACUTE KIDNEY FAILURE, UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED, HYPERCHOLESTEROLEMIA temperature: 96.7 heartrate: 102.0 resprate: 22.0 o2sat: 97.0 sbp: 105.0 dbp: 53.0 level of pain: 0 level of acuity: 3.0

It was a pleasure taking care of you during your recent hospitalization. You came in with weakness. We found that there was evidence on blood tests that you had some injury to your heart. We started a blood thinning medication to protect your heart from further damage. After several days we felt that you were stable and stopped this mediation. However, you developed a condition called anemia, or low blood count. You felt very weak and tired and we thought this was due to the anemia. We gave you a blood transfusion and you felt improved. We think that you may have a slow bleeding source from somewhere in your gastrointestinal tract. We started a new medication called omeprazole to protect your gastrointestinal tract. You should follow up with a gastroenterologist regarding this concern. . We made the following CHANGES to your medications: STOPPED lasix (furosemide) STOPPED pravastatin STARTED atorvastatin (replaces pravastatin) STARTED colase to prevent constipation STARTED senna to prevent constipation STARTED miralax as needed for constipation STARTED omeprazole . Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: PPD black rubber mix Attending: ___. Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: ___ - Bronchoscopy with bronchoalveolar lavage History of Present Illness: ___ with hx of HTN, ILD, RA (on prednisone, MTX, Rituximab), HF with preserved EF who presents with DOE. She was scheduled to undergo PFTs as an outpatient today, however on presentation she was noted to be dyspnic with sats 88% on room air and appeared dypsnic. Sats reportedly improved while the patient was sitting, however dropped to 81% on RA with 20ft ambulation. Patient was also having trouble speaking in complete sentences. CXR reportedly showed bilateral LL infiltrates. Patient was referred to the ___ ED via ___ for further evaluation. On arrival to the ED, patient reported acute SOB which began on ___ and has been constant since. She denies CP. She has a productive cough but no leg swelling, pain or orthopnea. She reports that she always sleeps on ___ pillows On arrival to the ED, initial vitals notable for afebrile, HR 86, BP 110/86, RR 22, 95% on NC. Exam notable for bibasilar crackles, minimal bilateral ___ edema, normal JVD. Patient also tolerated being supine with no exacerbation of symptoms. Labs notable for Chem 7 with bicarb of 21, CBC without leukocytosis and mild anemia with Hgb of 10.7. Lactate 2.2. Trop negative. BNP elevated at 706. INR 1.3. UA with few bacteria but otherwise unremarkable. EKG NSR without evidence of ischemia. CXR with Blood Cx sent. CXR with diffuse interstitial opacities with possible overlying pulmonary edema and a more focal patchy opacity in the RUL. Patient was given a dose of levofloxacin, 20mg IV Lasix and 4mg of Zofran and admitted to the medical service for further evaluation. Upon arrival to the floor, patient resting comfortably in bed. She confirms the above history. The SOB began on ___ and was present when she woke up in the morning. It has been constant and neighter worsening or improving. She has a chronic cough productive of mucus but does not feel that has changed recently. She reports chills but no fevers. She has also been nauseated but has not vomited. No sick contacts. No recent leg swelling. Of note, patient states that she has not taken her Prednisone for ~ 1 week and skipped her Methotrexate dose on ___ as she stops these medications when she feels ill. Past Medical History: Hypothyroidism GErD RA HTN Anemia Interstitial Lung Disease - Rituxan Osteoporosis Obesity OSA Diverticulosis Social History: ___ Family History: CAD/PVD in parents. Colon cancer in maternal aunt. Physical Exam: =============================== PHYSICAL EXAM ON ADMSSION =============================== VITALS: 98.6; 145/65; 98; 28; 92RA GENERAL: Pleasant, well-appearing, in no apparent distress speaking in complete sentences but becomes winded after several minutes of talking during hx HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP not elevated CARDIAC: RRR, normal S1/S2, faint ___ systolic murmur heard along LSB PULMONARY: Bibasilar velco-crackles. No wheezes, ronchi ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, grossly intact with normal sensation, strength ___ throughout. =============================== PHYSICAL EXAM ON DISCHARGE =============================== VS: 98.5 PO 156 / 90 88 18 95 1L GENERAL: Appears comfortable, sitting up in bed HEENT: no scleral icterus, MMM NECK: no JVD appreciated CARDIAC: Regular rate and rhythm, normal S1/S2, no m/r/g appreciated PULMONARY: velco sounding bibasilar crackles, greatest at bases. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding EXTREMITIES: Warm, well-perfused, no edema, no clubbing, bilateral ulnar deviation with swan neck deformities appreciated. SKIN: Without rash NEUROLOGIC: Alert, oriented, moving all extremities spontaneously, fluent speech Pertinent Results: ========================== LABS ON ADMISSION =========================== ___ 05:12PM BLOOD WBC-6.3 RBC-4.14 Hgb-10.7* Hct-34.5 MCV-83 MCH-25.8* MCHC-31.0* RDW-15.7* RDWSD-47.0* Plt ___ ___ 05:12PM BLOOD Neuts-75.2* Lymphs-12.8* Monos-7.6 Eos-3.8 Baso-0.3 Im ___ AbsNeut-4.75 AbsLymp-0.81* AbsMono-0.48 AbsEos-0.24 AbsBaso-0.02 ___ 04:35PM BLOOD ___ PTT-27.6 ___ ___ 04:35PM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-140 K-4.0 Cl-103 HCO3-21* AnGap-20 ___ 04:35PM BLOOD ALT-11 AST-20 AlkPhos-105 TotBili-0.7 ___ 07:12AM BLOOD LD(LDH)-353* ___ 04:35PM BLOOD proBNP-706* ___ 04:35PM BLOOD cTropnT-<0.01 ___ 07:12AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.4* ___ 04:35PM BLOOD TSH-0.26* ___ 05:04PM BLOOD Lactate-2.2* ___ 04:35PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:35PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.0 Leuks-SM ___ 04:35PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-2 ___ 04:35PM URINE Mucous-RARE ___ 04:13PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ========================== BRONCOALVEOLAR LAVAGE STUDIES (___) =========================== ___ 08:33AM OTHER BODY FLUID Polys-60* Lymphs-20* Monos-0 Eos-2* Mesothe-1* Macro-17* INDEX VALUE 0.18 <0.50 ASPERGILLUS AG, EIA, BAL Not Detected Not Detected GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: ~6OOO/ML Commensal Respiratory Flora. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ___: Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. ========================== LABS ON DISCHARGE =========================== ___ 07:08AM BLOOD WBC-12.9* RBC-4.21 Hgb-10.8* Hct-34.0 MCV-81* MCH-25.7* MCHC-31.8* RDW-15.6* RDWSD-44.9 Plt ___ ___ 07:08AM BLOOD Glucose-190* UreaN-20 Creat-0.8 Na-136 K-4.1 Cl-97 HCO3-24 AnGap-19 ___ 07:08AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1 ========================== MICROBIOLOGY =========================== ___ - Fungitell (tm) Assay for (1,3)-B-D-Glucans <31 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL ___ - Aspergillus Ag INDEX VALUE 0.06 <0.50 ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected __________________________________________________________ ___ 5:49 am SPUTUM Source: Induced. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): __________________________________________________________ ___ 9:13 pm SPUTUM Source: Induced. GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. MTB Direct Amplification (Final ___: M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. . NAAT results will be followed by confirmatory testing with conventional culture and DST methods. This TB NAAT method has not been approved by FDA for clinical diagnostic purposes. However, ___ Laboratory Institute (___) has established assay performance by in-house validation in accordance with CLIA standards. __________________________________________________________ ___ 4:43 pm SPUTUM SOURCE: INDUCED, AFB FOR NON TB MYCOBACTERIA. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. __________________________________________________________ ___ 4:13 pm Rapid Respiratory Viral Screen & Culture NASOPHRYNGEAL SWAB. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. __________________________________________________________ ___ 4:35 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 4:15 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ========================== IMAGING/STUDIES =========================== Cardiovascular Report ECG Study Date of ___ 4:54:59 ___ Sinus rhythm. Baseline artifact. Poor R wave progression. Low precordial lead voltage. No previous tracing available for comparison. Cardiovascular Report ECG Study Date of ___ 10:41:32 AM Sinus rhythm. Possible old inferior wall myocardial infarction. Poor R wave progression. Minor non-specific repolarization abnormalities. Compared to the previous tracing of ___ findings are similar. QTc 430 CHEST (PA & LAT) Study Date of ___ 5:27 ___ Diffusely increased interstitial opacities likely reflective of chronic interstitial lung disease, though a component of superimposed interstitial pulmonary edema is not excluded. More focal patchy opacity in the right upper lobe could suggest infection. Moderate size hiatal hernia. Comparison with any previous chest CT imaging is recommended, and if none are available, dedicated high-resolution chest CT is suggested CT CHEST W/O CONTRAST Study Date of ___ 6:14 ___ Fibrotic interstitial lung disease, most suggestive of UIP pattern. Widespread ground-glass opacification is nonspecific the differential considerations include atypical infection including PJP given history of immunosuppression, or acute exacerbation of interstitial lung disease in the appropriate clinical setting. CHEST (PA & LAT) Study Date of ___ 10:07 AM Cardiomegaly and mediastinal contour are stable. Since the prior study there is minimal improvement in diffuse interstitial opacities. No interval development of pleural effusion or pneumothorax is demonstrated. No evidence of new superimposed focal consolidation is seen. Large hiatal hernia is re- demonstrated. ========================== PROCEDURES =========================== BRONCHOSCOPY ___ Airways were visualized to the sub-segmental level bilaterally. There were no endobronchial lesions. Airways were patent. The mucosa was normal. There were no significant airway secretions noted. Lavage was performed with 60 cc of normal saline in the RML bronchus with good return of colorless fluid. ========================== PATHOLOGY =========================== BRONCHIAL LAVAGE - ___ NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages, neutrophils, and bronchial epithelial cells, some reactive; no viral cytopathic changes seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 10 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___) 3. Methotrexate 12.5 mg PO 1X/WEEK (___) 4. FoLIC Acid 1 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Verapamil SR 180 mg PO Q24H 7. Levothyroxine Sodium 300 mcg PO 1X/WEEK (___) Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Omeprazole 40 mg PO BID 4. Verapamil SR 180 mg PO Q24H 5. GuaiFENesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL 5 mL by mouth every six (6) hours Disp ___ Milliliter Milliliter Refills:*0 6. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth Three times per week Disp #*12 Tablet Refills:*0 7. PredniSONE 60 mg PO DAILY Duration: 6 Doses This is dose # 1 of 5 tapered doses RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*18 Tablet Refills:*0 8. PredniSONE 50 mg PO DAILY Duration: 7 Doses This is dose # 2 of 5 tapered doses Tapered dose - DOWN RX *prednisone 10 mg 5 tablet(s) by mouth Daily Disp #*35 Tablet Refills:*0 9. PredniSONE 40 mg PO DAILY Duration: 7 Doses This is dose # 3 of 5 tapered doses Tapered dose - DOWN 10. PredniSONE 30 mg PO DAILY Duration: 7 Doses This is dose # 4 of 5 tapered doses Tapered dose - DOWN 11. PredniSONE 20 mg PO DAILY Duration: 7 Doses This is dose # 5 of 5 tapered doses Tapered dose - DOWN Discharge Disposition: Home Discharge Diagnosis: Acute issues: #Interstitial lung disease c/b hypoxia #Community-acquired pneumonia c/b hypoxia #Rheumatoid arthritis 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 shortness of breath TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Cardiac silhouette size remains mildly enlarged. A moderate-sized hiatal hernia is again noted. Increased interstitial opacities are noted diffusely, more pronounced on the lung bases, likely reflective of chronic interstitial lung disease. Mild superimposed interstitial pulmonary edema is not excluded. More focal opacity within the right upper lobe could reflect an area of infection. There is no pleural effusion or pneumothorax. No acute osseous abnormality is demonstrated. IMPRESSION: Diffusely increased interstitial opacities likely reflective of chronic interstitial lung disease, though a component of superimposed interstitial pulmonary edema is not excluded. More focal patchy opacity in the right upper lobe could suggest infection. Moderate size hiatal hernia. Comparison with any previous chest CT imaging is recommended, and if none are available, dedicated high-resolution chest CT is suggested. Radiology Report EXAMINATION: DIFFUSE LUNG DZ INDICATION: ___ with hx of HTN, ILD, RA (on prednisone, MTX, Rituximab), HFrEF // eval for worsening ILD, infection, acute pathology TECHNIQUE: Multi detector helical scanning of the mid and lower chest was performed with the patient prone at end inspiration, then of the full chest with the patient supine, first at end inspiration then at end expiration. Prone images were reconstructed as 1.25 mm thick axial images. Supine inspiratory scanning was reconstructed as 1.25 and 5 mm thick axial images, and 2.5 mm thick coronal and parasagittal images. Supine expiratory scanning was reconstructed as 1.25 and 5 mm thick axial and 2.5 mm thick coronal images. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.1 s, 24.6 cm; CTDIvol = 9.1 mGy (Body) DLP = 223.2 mGy-cm. 2) Spiral Acquisition 0.8 s, 6.4 cm; CTDIvol = 5.2 mGy (Body) DLP = 32.9 mGy-cm. 3) Spiral Acquisition 4.1 s, 32.0 cm; CTDIvol = 13.0 mGy (Body) DLP = 416.1 mGy-cm. 4) Spiral Acquisition 3.9 s, 30.5 cm; CTDIvol = 12.4 mGy (Body) DLP = 378.6 mGy-cm. Total DLP (Body) = 1,051 mGy-cm. COMPARISON: None prior FINDINGS: MEDIASTINUM: The imaged thyroid is normal. No pathologically enlarged supraclavicular, axillary, hilar or mediastinal lymph nodes. HEART AND GREAT VESSELS: The aorta and pulmonary arteries are normal in size. The heart size is mildly enlarged and there is no pericardial effusion. Coronary artery calcifications are severe. PLEURA: There is no pneumothorax. There is no pleural effusion. LUNGS AND TRACHEOBRONCHIAL TREE: Heterogeneous areas of ground-glass opacification without zonal predominance, and slightly asymmetrically worse in the right upper and bilateral lower lobes. Subpleural honeycombing with a basilar predominance. There is traction bronchiectasis also worse in the lung bases. No substantial air trapping on the expiratory scan. Suture chain in the left lower lobe, suggest prior wedge resection. BONES AND CHEST WALL: There are no destructive focal osseous or chest wall lesions concerning for malignancy within the imaged thoracic skeleton. There is a bone island in the T4 vertebral body. UPPER ABDOMEN: Although this study is not designed for the evaluation of subdiaphragmatic structures, the imaged upper abdomen demonstrates a large hiatal hernia and uncomplicated cholelithiasis. IMPRESSION: Fibrotic interstitial lung disease, most suggestive of UIP pattern. Widespread ground-glass opacification is nonspecific the differential considerations include atypical infection including PJP given history of immunosuppression, or acute exacerbation of interstitial lung disease in the appropriate clinical setting. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with RA, ILD, HFpEF with hypoxemia and dyspnea planning for steroid pulse // eval for interval change, acute process eval for interval change, acute process IMPRESSION: Cardiomegaly and mediastinal contour are stable. Since the prior study there is minimal improvement in diffuse interstitial opacities. No interval development of pleural effusion or pneumothorax is demonstrated. No evidence of new superimposed focal consolidation is seen. Large hiatal hernia is re- demonstrated. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea on exertion Diagnosed with Shortness of breath temperature: 98.7 heartrate: 86.0 resprate: 22.0 o2sat: 95.0 sbp: 110.0 dbp: 86.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___. You were admitted for difficulty breathing and were treated for a lung infection as well as for interstitial lung disease. You completed a course of antibiotics and will be discharged on a steroid taper. We have prescribed you home oxygen so that you may return home sooner. Take care, and we wish you the best. Sincerely, Your ___ medicine team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Epinephrine / Ciprofloxacin / Vicodin / ___ Containing / Morphine Attending: ___ Chief Complaint: Fatigue and weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with PMH of kidney and pancreas transplant in ___ and DM1 who p/w progressive weakness and fatigue for the past ___ weeks. Patient went to ___ who told her to go to ED which she did via EMS. Patient states her balance has been off over same period of time, and she attributes this to overall muscle weakness. She has also had headaches since ___ that have been getting worse, located "all over" her head. She describes the pain as an "explosion" which can then feel like a "nail." They occur daily, and last anywhere from a couple seconds to a few hours. Noise makes it worse but she notes no photophobia. It helps when she lays down and closes her eyes. She has not tried any medications for headache. She denies any associated nausea or vision changes. She notes that she feels the exact same way as when she has previously presented to the hospital. She has had stable dyspnea ascending 1.5 flights of stairs and stable chest pain that comes on randomly. It feels like a "poking" that goes away on its own since NSTEMI earlier this year. In the ED intial vitals signs were: 98.6, 88, 130/70, 18, 100% RA. Exam was significant for minimal lower abdominal tenderness and no CVA tenderness. She was given Bactrim and linezolid due to previous VRE urine cultures. Nephrology was consulted and they recommended admission and continued antibiotics for her UTI. They recommended half dose bactrim, continued immunosuppresion with a morning tacrolimus level. Past Medical History: - Type I diabetes and CKD s/p renal and pancreas transplant in ___ in ___. DM controlled after transplant but continues to have proteinuria. - Hyperlipidemia - NSTEMI s/p PCI and DES x3 to RCA for 2VD (___) - Hypothyroidism - Obstructive sleep apnea - C. difficile colitis (vancomycin finished ___ - Hiatal hernia - Osteopenia - Axonal peripheral neuropathy - Restless leg syndrome - Anxiety and depression - ___ splenic vein thrombosis - IPMN (benign pancreatic nodule) Social History: ___ Family History: Notable for mother with dementia. Father is healthy with some cardiac disease. She has two brothers, one with hyperlipidemia and another with some form of cardiovascular disease. Physical Exam: ADMISSION EXAM VS: 98, 86, 127/77, 18, 98% RA General: AAOx3, NAD, anxious HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD, paracervical spinal muscles mildly tender CV: RRR, nl S1/S2, ___ SEM at ___ Lungs: CTAB, no wheezes/rales/rhonchi Abdomen: Soft, mildy LLQ tenderness, normoactive bowel sounds GU: Deferred Ext: Warm, ___, no cyanosis/clubbing/edema Neuro: CN ___ grossly intact Skin: No concerning lesions DISCHARGE EXAM VS: 97, 76, 133/75, 20, 100% RA General: AAOx3, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD CV: RRR, nl S1/S2, ___ SEM at ___ Lungs: CTAB, no wheezes/rales/rhonchi Abdomen: Soft, NTND, normoactive bowel sounds GU: Deferred Ext: Warm, ___, no cyanosis/clubbing/edema Neuro: CN ___ grossly intact Skin: No concerning lesions Pertinent Results: ADMISSION LABS ___ 06:24PM BLOOD ___ ___ Plt ___ ___ 06:24PM BLOOD ___ ___ ___ 06:24PM BLOOD ___ ___ ___ 06:24PM BLOOD ___ CK(CPK)-42 ___ ___ ___ 06:24PM BLOOD ___ ___ 06:24PM BLOOD ___ ___ 07:39PM BLOOD ___ ___ 08:32PM BLOOD ___ ___ 06:24PM URINE ___ Sp ___ ___ 06:24PM URINE ___ ___ ___ 06:24PM URINE ___ Epi-<1 ___ 06:24PM URINE ___ DISCHARGE LABS ___ 05:00AM BLOOD ___ ___ Plt ___ ___ 05:00AM BLOOD ___ ___ ___ 05:00AM BLOOD ___ ___ ___ 05:00AM BLOOD ___ ___ 05:00AM BLOOD ___ MICROBIOLOGY Blood cultures pending on discharge. URINE CULTURE (Preliminary): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IDENTIFICATION AND Susceptibility testing requested by ___ ___ (___) ___. - ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. - GRAM POSITIVE BACTERIA. ___ ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. - ESCHERICHIA COLI. <10,000 organisms/ml. PRESUMPTIVE IDENTIFICATION. IMAGING Renal US (___): Mild renal transplant collecting system fullness, similar to prior. Unremarkable renal transplant vasculature with unchanged resistive indices. Urinary bladder debris. PVR of 85 cc. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO QSUN 2. Atorvastatin 80 mg PO DAILY 3. Citalopram 40 mg PO DAILY 4. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm 5. Gabapentin 300 mg PO Q24H 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO HS 8. Multivitamins 1 TAB PO DAILY 9. Mycophenolate Mofetil 500 mg PO BID 10. Prasugrel 10 mg PO DAILY 11. PredniSONE 5 mg PO DAILY 12. Prograf (tacrolimus) 2 mg ORAL Q12H 13. Sodium Bicarbonate 650 mg PO TID 14. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY 15. Calcarb 600 With Vitamin D (calcium ___ D3) 600 mg(1,500mg) -400 unit Oral 2 tabs BID 16. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Gabapentin 300 mg PO Q24H 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO HS 6. Multivitamins 1 TAB PO DAILY 7. Mycophenolate Mofetil 500 mg PO BID 8. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY 9. Prasugrel 10 mg PO DAILY 10. PredniSONE 5 mg PO DAILY 11. Prograf (tacrolimus) 2 mg ORAL Q12H 12. Sodium Bicarbonate 1300 mg PO TID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a day Disp #*180 Tablet Refills:*1 13. Alendronate Sodium 70 mg PO QSUN 14. Calcarb 600 With Vitamin D (calcium ___ D3) 600 mg(1,500mg) -400 unit Oral 2 tabs BID 15. Linezolid ___ mg PO Q12H RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 16. Cefpodoxime Proxetil 400 mg PO Q24H RX *cefpodoxime 200 mg 2 tablet(s) by mouth DAILY Disp #*28 Tablet Refills:*0 17. Outpatient Lab Work Please collect urine for culture in 3 weeks. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Urinary tract infection Secondary diagnosis: Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ woman with renal transplant, now with tenderness over the graft site. COMPARISON: Multiple prior exams, most recently renal transplant ultrasound of ___. FINDINGS: Grayscale and Doppler ultrasound images of the renal transplant were obtained. Mild fullness of the renal collecting system is unchanged. The renal morphology is otherwise normal with normal cortical thickness and echogenicity. The renal pyramids and the renal sinus fat have a normal appearance. No perinephric fluid collection. The resistive index of intrarenal arteries range from 0.71-0.80, similar to the prior exam. Acceleration times and peak systolic velocities of main renal artery are unchanged as well. The renal vein is patent and shows a normal waveform. Vascularity is symmetric throughout the transplant. The prevoid bladder contains a small amount of debris and has a volume of 197 cc. The postvoid bladder has a volume of 85 cc. Postsurgical changes are present adjacent to the right aspect of the bladder. IMPRESSION: 1. Mild renal transplant collecting system fullness, similar to prior. 2. Unremarkable renal transplant vasculature with unchanged resistive indices. 3. Urinary bladder debris. Postvoid residual of 85 cc. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: GENERALIZED WEAKNESS Diagnosed with URIN TRACT INFECTION NOS temperature: 98.6 heartrate: 88.0 resprate: 18.0 o2sat: 100.0 sbp: 130.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you while you were a patient at ___. You came to us with headache, fatigue, and weakness. You were found to have a UTI for which you were treated with antibiotics. This resulted in improvement in your symptoms. While you were here you were seen by Urology. They recommended that you continue to catheterize yourself a minimum of twice a day. This will help to prevent UTI. Please be sure to call your primary care physician if you develop symptoms of UTI such as pain or buring on urination, urinary frequency, or urinary urgency. Please take all of your medications as listed below. Do NOT take citalopram (Celexa) or cyclobenzaprine (Flexeril) while you are taking linezolid as there is potential for a dangerous medication interaction. Please be sure to keep all of your ___ appointments. Please discuss ___ these medications when you see your primary care doctor and after you are done with the linezolid.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ w h/o asthma per chart (no PFTs apparent), never been intubated, obesity, HTN p/w 2 weeks of progressive SOB. Pt was in USOH until 2 weeks ago then developed progressive SOB with wheezing and cough. Onset was gradual. No chest pain at onset but then with all the coughing, starting having pain only with coughing. Denies ___, weight gain, ___ trauma, h/o clots. Endorses cough worse at night which limits sleeping. Some PND from this. Denies f/n/v/d/rhinorrhea/sick contacts (but works in a hospital as a ___)/recent abx/recent med changes. Has a cat. No large dust exposure or cleaning or mold exposure. Got flu shot this year (just prior to decompensation which she thinks is the cause). Cough is non-productive. Denies abd pain, diarrhea, constipation, rash, joint pain. Reports chronic LBP at baseline. Reports "chills" for ___ years. In the ED, 98.5 95 ___. -->98.6 96 150/67 20 95% 4L. In ED, received: methylprednisolone 60, duoneb, azithromycin, magnesium, azithromycin. CXR no intrahtoracic process. Past Medical History: - Obesity - Hypertension Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: Discharge exam: Constitutional: VSS, satting in mid ___ on RA HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM without exudate CV: RRR no mrg, JVP difficult to assess Resp: diffuse mild end expiratory wheezing, moderate air movement GI: sntnd, NABS GU: no foley MSK: no obvious synovitis Ext: wwp, neg edema in BLEs Skin: no rash grossly visible Neuro: A&Ox3, DOWB intact, ___ BUE/BLE, SILT BUE/BLE, CN II-XII intact Psych: normal affect, pleasant Pertinent Results: RESULTS: DATA: I have reviewed the relevant labs, radiology studies, tracings, medical records, and they are notable for: ___ 02:20PM BLOOD WBC: 7.9 RBC: 5.26* Hgb: 13.9 Hct: 45.3* MCV: 86 MCH: 26.4 MCHC: 30.7* RDW: 14.5 RDWSD: 45.___ ___ 02:20PM BLOOD Neuts: 51.8 Lymphs: ___ Monos: 10.7 Eos: 4.2 Baso: 0.9 Im ___: 0.8* AbsNeut: 4.08 AbsLymp: 2.48 AbsMono: 0.84* AbsEos: 0.33 AbsBaso: 0.07 ___ 02:20PM BLOOD Glucose: 94 UreaN: 11 Creat: 0.8 Na: 141 K: 4.8 Cl: 106 HCO3: 23 AnGap: 12 ___ 02:20PM BLOOD Calcium: 9.8 Phos: 4.2 Mg: 2.1 ___ 02:44PM BLOOD Type: ___ pO2: 53* pCO2: 47* pH: 7.37 calTCO2: 28 Base XS: 0 I personally reviewed the [X-ray, ECG] and my interpretation is: CXR: I agree w radiology. The lung volumes are low which accentuates the pulmonary vasculature. Hazy and streaky opacities at the lung bases are felt to be related to bibasilar atelectasis and overlying soft tissues. There is no definite focal consolidation, pulmonary edema, large pleural effusion or pneumothorax. The cardiomediastinal silhouette is at the upper limit of normal, unchanged. EKG (my read): NSR, nl axis, QTc 490, Q in III, biphasic Ts in V3-V4 (new since ___ Discharge labs: ___ 04:40PM BLOOD WBC-9.0 RBC-5.73* Hgb-14.8 Hct-48.8* MCV-85 MCH-25.8* MCHC-30.3* RDW-14.4 RDWSD-44.7 Plt ___ ___ 04:40PM BLOOD Glucose-335* UreaN-25* Creat-0.8 Na-135 K-4.6 Cl-94* HCO3-27 AnGap-14 ___ 04:40PM BLOOD %HbA1c-6.4* eAG-137* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*5 2. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily Disp #*30 Capsule Refills:*0 3. Montelukast - NEW medication 4. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 mL by mouth three times daily Refills:*0 5. Lidocaine 5% Patch 1 PTCH TD QPM RX *lidocaine [Lidocaine Pain Relief] 4 % apply to back once daily Disp #*10 Patch Refills:*5 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 8. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation Discharge Condition: Stable Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with dyspnea// evaluate for intra-thoracic process TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___. FINDINGS: The lung volumes are low which accentuates the pulmonary vasculature. Hazy and streaky opacities at the lung bases are felt to be related to bibasilar atelectasis and overlying soft tissues. There is no definite focal consolidation, pulmonary edema, large pleural effusion or pneumothorax. The cardiomediastinal silhouette is at the upper limit of normal, unchanged. IMPRESSION: No acute intrathoracic process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Unspecified asthma with (acute) exacerbation temperature: nan heartrate: 95.0 resprate: 24.0 o2sat: 89.0 sbp: 217.0 dbp: 102.0 level of pain: 10 level of acuity: 1.0

You were admitted with an asthma exacerbation. We treated you with prednisone and nebulizers. You should start taking montelukast on discharge to control your symptoms and follow up with your primary care doctor, who can do a pulmonary function test to assess the severity of your asthma.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: shrimp Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHx recurrent DVT/PE on warfarin, pulmonary HTN, CKD on 4L home O2 at night who presented with 1 week of right sided pleuritic chest pain similar to previous PE. Pain is pleuritic, dull, right sided. Denies associated fever, chills, cough, leg swelling, n/v/d, abdominal pain, headache, dizziness. Does report travelling to ___ last week. In the ED, initial VS were: T98.3 HR72 BP138/87 RR18 90%RA. EKG showed no ischemic changes and an s1q3t3 pattern. Labs were fairly unremarkable. CTPA was performed, which showed a large left lower lobar pulmonary embolism, which extends into multiple segmental and subsegmental branches. It was not initially appreciated that this was a chronic finding, so he was started on heparin. Admitted to medicine for further management. Past Medical History: Recurrent VTE since his ___ has been on long-term Coumadin therapy. Patient states he had a thorough workup (to the extent this was possible ___ years ago) with no etiology found. S/p remote bilateral femoral vein ligation to prevent PEs. Pulmonary hypertension (presumed WHO group IV) with chronic hypoxic respiratory failure (documented as low as the 70's on exertion). Last RHC was ___ at ___. Hypercholesterolemia Hypertension Borderline diabetes- not on medications BPH (s/p TURP) CKD Prior + PPD Gout s/p Hemorrhoidectomy Primary open angle glaucoma Left Cataract Left Posterior Vitreous Detachment Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VS: 98.5 PO 143 / 78 R Lying 74 16 96 2l GENERAL: NAD, no increased WOB 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: good airmovement through out, bibasilar crackles R>L 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: ======================= Vitals: 98.6F BP 142/73 HR 68 RR 16 95% on 4L General: Awake, alert, oriented, no acute distress, elderly man laying in bed comfortably HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD Lungs: Normal respiratory effort. Decreased airflow throughout. Bibasilar crackles (R>L). Otherwise clear. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no guarding, no organomegaly. Ext: Warm, well perfused, 2+ pulses, 1+ edema to the mid-shins bilaterally Neuro: Alert and interactive, moves all extremities. Psych: Normal mood and affect Pertinent Results: ADMISSION LABS: ============== ___ 02:10PM BLOOD WBC-6.0 RBC-4.99 Hgb-13.6* Hct-43.8 MCV-88 MCH-27.3 MCHC-31.1* RDW-15.0 RDWSD-48.0* Plt ___ ___ 02:10PM BLOOD Glucose-90 UreaN-17 Creat-1.4* Na-140 K-5.3* Cl-101 HCO3-29 AnGap-10 ___ 02:10PM BLOOD Neuts-63.8 ___ Monos-11.6 Eos-1.8 Baso-0.7 Im ___ AbsNeut-3.79 AbsLymp-1.30 AbsMono-0.69 AbsEos-0.11 AbsBaso-0.04 ___ 02:10PM BLOOD CK-MB-2 proBNP-499 ___ 02:30PM BLOOD pO2-20* pCO2-65* pH-7.33* calTCO2-36* Base XS-4 PERTINENT LABS/MICRO: ==================== ___ 02:10PM BLOOD cTropnT-0.02* ___ 02:10PM BLOOD CK-MB-2 proBNP-499 ___ 07:40AM BLOOD ___ 02:30PM BLOOD Lactate-2.0 ___ 02:30PM BLOOD pO2-20* pCO2-65* pH-7.33* calTCO2-36* Base XS-4 ___ Urine culture: No growth ___ Blood culture: NGTD DISCHARGE LABS: ============== ___ 07:45AM BLOOD WBC-5.1 RBC-4.32* Hgb-12.1* Hct-38.0* MCV-88 MCH-28.0 MCHC-31.8* RDW-14.9 RDWSD-47.9* Plt ___ ___ 07:45AM BLOOD Glucose-101* UreaN-18 Creat-1.4* Na-147* K-4.6 Cl-105 HCO3-23 AnGap-19* PERTINENT IMAGING: ================= ___ Chest Xray: Low lung volumes with bibasal atelectasis and scarring. Contour abnormality at the left pulmonary hilum for which nonemergent chest CT is recommended to further assess. ___ CTA Chest: 1. There is a large left lower lobar pulmonary embolism which extends into multiple segmental and subsegmental branches. There is dilatation of the main pulmonary artery, measuring up to 3.9 cm, as well as the bilateral pulmonary arteries. No CT evidence of right heart strain. 2. The right lower lobar pulmonary arteries and veins are not visualized. Recommend correlation with prior procedure. If there are none, this may represent sequelae of prior pulmonary embolism with atretic right lower lobe pulmonary artery, although acute pulmonary embolism not entirely excluded. If acute embolism, the 4.8 x 2.5 cm consolidation below may represent a pulmonary infarction. 3. There is ground-glass opacity and 4.8 x 2.5 cm consolidation in right lower lobe, concerning for aspiration with possible superimposed pneumonia. Follow-up to resolution is recommended to exclude underlying mass. ___ BLE Ultrasound: 1. Partially occlusive thrombus in the right mid superficial femoral vein, which extends to the distal right superficial femoral vein, where it becomes occlusive. 2. Partially occlusive thrombus in the left mid and distal superficial veins. ___ TTE: The left atrial volume index is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. Tricuspid annular plane systolic excursion is normal (1.9 cm; nl>1.6cm) consistent with normal right ventricular systolic function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: 1) Moderate to severe pulmonary hypertension with normal LV diastolic/systolic function and normal LVEDP as well as no ___ ___ suggestive of likely type III pulmonary hypertension (considering patient's age). There is significant elevation of pulmonary vascular resistance with calculated PVR ranging from 4 - 7 ___ (depending on method of calculation) corroborated by mid-systolic notching of pulmonary VTI and short acceleration time thereof. RV size and function appear normal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Finasteride 5 mg PO DAILY 3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 4. Warfarin 5 mg PO DAILY16 5. Furosemide 20 mg PO DAILY 6. Allopurinol ___ mg PO DAILY 7. Calcitriol 0.25 mcg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Enoxaparin Sodium 80 mg SC Q12H RX *enoxaparin 80 mg/0.8 mL 80 mg sc every 12 hours Disp #*14 Syringe Refills:*0 3. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap inhaled daily Disp #*30 Capsule Refills:*0 4. Warfarin 7.5 mg PO DAILY16 RX *warfarin 2.5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 5. Allopurinol ___ mg PO DAILY 6. Calcitriol 0.25 mcg PO DAILY 7. Finasteride 5 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 10.Oxygen Diagnosis: Pulmonary Hypertension (ICD I27.0) Home oxygen at 4L/min continuous via nasal cannula; conserving device for portability. Length of Time: Indefinite ___ ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: #Primary: Pulmonary embolism #Secondary: Severe pulmonary hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with PE. Evaluate for further clot burden. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: CTA chest from ___. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common veins. However, there is partially occlusive thrombus in the right mid superficial femoral vein extending to the distal superficial femoral vein, where it becomes occlusive. There is also partially occlusive thrombus in the left mid and distal superficial veins. There is poor visualization of the right-sided peroneal veins, due to overlying edema. Normal color flow is demonstrated in the bilateral posterior tibial and left peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Partially occlusive thrombus in the right mid superficial femoral vein, which extends to the distal right superficial femoral vein, where it becomes occlusive. 2. Partially occlusive thrombus in the left mid and distal superficial veins. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 10:46 on ___, 2 minutes after discovery. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Other chest pain temperature: 98.3 heartrate: 72.0 resprate: 18.0 o2sat: 90.0 sbp: 138.0 dbp: 7.0 level of pain: 4 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. Why you were admitted: - You presented with right-sided chest pain What we did while you were here: - Imaging of your lungs showed that the pulmonary embolism in your lungs on the left had grown a small amount, and that you have another one on the right, which is new in the last ___ years but has been there for more than a month - You were switched from warfarin to lovenox injections - You talked with our pulmonologist and decided that you would continue on oxygen at home and not start any new medications for your pulmonary hypertension. You were ok with getting some oxygen to keep in your car. - An echo of your heart showed somewhat worsened pulmonary hypertension What you should do once you go home: - Continue doing lovenox twice daily as instructed while waiting for your INR to get within goal range. Your new goal range for now is INR 2.5-3.5 - Please start taking warfarin 7.5 mg daily for now - You will need to follow-up at your ___ (___ ___ Program) in the next ___ days. You can walk in and do not need an appointment - Please follow-up with your primary care provider. You should then get referrals to a pulmonologist and a hematologist - Please start using the Spiriva inhaler daily as well We wish you the best. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Meperidine / Fentanyl / Morphine / ciprofloxacin / Flagyl / Demerol Attending: ___. Chief Complaint: Abdominal Pain/Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of multiple abdominal surgeries/complications since her Roux-en-Y gastric bypass in ___, previous ___ ___ tear, iron deficiency, depression, recent c. diff infection ___ (one positive c diff in OMR, pt reports multiple recurrent infections), and ulcer noted at her anastomosis site last month (___) presents with abdominal pain. Pt reports sudden onset of LLQ pain at 1am ___ which awakened her from sleep with ___ left-sided periumbilical pain that was non-radiating, deep, cramping and sharp in quality. She reports inability to tolerate PO due to nausea, vomited x5, denies hematemesis, coffee ground emesis. She also has associated loose BM diarrhea (___), no melena or BRBPR recently (albeit reports small amount of blood in her stool 1 week ago). Reports a fever of ___ yesterday, measured with a thermometer, +chills. No dysuria or hematuria. No sick contacts. Pt reports that she has had recurrent c diff infections since ___ where she initially presented with n/v, diarrhea ___ BM/day, and abd pain; similar to her symptoms today. She states that she completed one course of 10d Vanco, sxs did not improve. She repeated another 10d course which did not improve her sxs. Since sxs did not improve with the second course, she was started on a taper which she is currently on and has not decreased her dose from 125mg PO q6h yet. In ___, there is one +c diff during her admission in late ___ (d/c ___. PCP and bariatric surgeon appear to be based in ___ and we do not have access to their notes. She attributes her current symptoms to c diff. Her most recent admission to ___ was from ___ for abdominal pain, with unremarkable imaging. She was found to be C Diff positive and was treated with 10 day course of PO Vanc. She was also started on Reglan (and lidocaine which she is not taking currently). Previous to this admission, she had a similar presentation in early ___. At that time, she was found to be c diff negative. In addition, she left AMA after her EGD as she thought her nausea and pain were not being well controlled. She was noted to have a anastomotic ulcer for which she was prescirbed high dose PPI and sulcrafate (meds she was already on, compliance was stressed). In the ED intial vitals were: 8 98.9 116 113/66 18 100% RA. - Labs were significant for H/H of 9.2/ 32.4 which is her baseline, no leukocytosis, normal chem 7, normal lactate, and neg UA. - Imaging: CT abd/pelvis w/ IV contrast showed no evidence of obstruction, leakage, or intrabdominal abscess. - Patient was given viscous lidociane, sucralfate, IV tylenol, compazine, zofran, protonix, and PO Vanc, banana bag, and 2L NS. - She was seen by bariatric surgery who recommended admission to medicine with GI consult. Admitted given inability to tolerate PO. - GI was also made aware of pt and will see her on the floor. Vitals prior to transfer were: 98.3 83 99/44 16 98% RA. On the floor, she reports ___ abd pain in LLQ, and nausea. Past Medical History: - s/p ex-lap for appendectomy, washout of pelvic abscesses w/ SBR ___ - ex-lap LOA for SBO ___ - gastric bypass surgery ___ c/b multiple intraabdominal perforations and SBOs, lost 225 lbs since, was originally 360 lbs, done at ___ - gastric ulcers - cholecystitis s/p CCY - "enlarged spleen" on imaging ___ - h/o prior cocaine abuse - s/p L lumpectomy (benign pathology) in ___ - s/p tonsillectomy - hx of headaches, eval by neuro ___ - depression - iron-deficiency anemia - ___ tear - c diff infection ___, pt reports multiple infecitons (only one + in OMR) - perforated GJ ulcer with repair in ___ - perforated GJ ulcer with non-operative management ___ Social History: ___ Family History: Grandmother with "colitis", aunt with ___ disease; no other family history of GI illness. Physical Exam: On admission: Vitals: 97 96/48 57 18 99%RA GEN: A&Ox3, comfortable. Cigarette odor filled room, unable to determine if from patient or boyfriend in room (also noted in consult notes) HEENT: NCAT, anicteric, pink conj, MMM, PERRLA CV: S1S2 RRR no m/g/c/r PULM: CTAB ABD: Soft, nondistended, TTP in LLQ, no r/g, hypoactive BS, no palpable masses Ext: No ___ edema, WWP, 2+ peripheral pulses Neuro: CN2-12 in tact grossly Rectal: Guaic negative in ED On discharge: Not performed; patient eloped. Pertinent Results: ===================== Labs: ===================== ___ 10:10AM BLOOD WBC-7.1 RBC-4.08* Hgb-9.2* Hct-32.4* MCV-79* MCH-22.6* MCHC-28.5*# RDW-14.8 Plt ___ ___ 10:10AM BLOOD Neuts-67.5 ___ Monos-5.4 Eos-3.6 Baso-0.8 ___ 10:10AM BLOOD ___ PTT-29.6 ___ ___ 10:10AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-139 K-4.5 Cl-104 HCO3-27 AnGap-13 ___ 10:10AM BLOOD ALT-18 AST-22 LD(LDH)-209 AlkPhos-72 TotBili-0.3 ___ 10:10AM BLOOD Lipase-40 ___ 10:10AM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.9 Mg-1.9 ___ 10:23AM BLOOD Lactate-1.3 ===================== Micro: ===================== ___ blood cultures x2: negative as of ___ at 2pm ___ urine culture pending ___ 6:22 am STOOL CONSISTENCY: SOFT Source: Stool. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): ===================== Imaging: ===================== CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:20 ___ FINDINGS: The lung bases are clear and the visualized heart and pericardium are unremarkable. CT ABDOMEN: The patient is status post gastric bypass surgery. At the postsurgical anatomy is unremarkable, with a patent gastrojejunostomy and occasionally and jejunojejunostomy without dilatation to suggest obstruction and absence of contrast in the biliary limb. There is no evidence of leak or intraperitoneal fluid collection. No free air is identified in the abdominal cavity. The liver enhances homogeneously, without focal lesions or intrahepatic biliary duct dilatation. The patient is status post cholecystectomy. The portal vein is patent. The pancreas, spleen, adrenal glands are within normal limits. The kidneys show symmetric nephrograms and excretion of contrast. There is no focal renal lesion or hydronephrosis bilaterally. The small and large bowel are within normal limits, without evidence of wall thickening or dilatation to suggest obstruction. The appendix is not seen but there is no evidence of appendicitis. The aorta and its main branches are patent and nonaneurysmal. There is no mesenteric or retroperitoneal lymph node enlargement by CT size criteria. There is no ascites or abdominal wall hernia. CT PELVIS: The urinary bladder and ureters are unremarkable. The uterus and adnexae are unremarkable. Two dropped surgical clips are seen in the pouch of ___. There is no pelvic wall or inguinal lymphadenopathy. No pelvic free fluid is observed. OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for malignancy. IMPRESSION: No CT findings to explain the symptoms. Unremarkable post gastric bypass anatomy. No evidence of obstruction, leakage or intra-abdominal abscess. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sucralfate 1 gm PO QID 2. Metoclopramide 10 mg PO TID 3. Ondansetron 8 mg PO BID 4. Omeprazole 40 mg PO BID 5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain 6. Vancomycin Oral Liquid ___ mg PO Q6H Discharge Medications: Patient eloped from hospital; no specific changes made to preadmission medications. Discharge Disposition: Home Discharge Diagnosis: Abdominal pain of unclear etiology Discharge Condition: Not evaluated: pt eloped from hospital Followup Instructions: ___ Radiology Report HISTORY: ___ female with gastric bypass in ___ with history of perforations and a small bowel obstruction now with recurrent abdominal pain. COMPARISON: Multiple prior CT abdomen and pelvis, most recent on ___ TECHNIQUE: Axial helical MDCT images were obtained from the lung bases to the pubic symphysis after administration of IV and oral contrast. Coronal and sagittal reformations were generated. DLP: 686 mGy-cm FINDINGS: The lung bases are clear and the visualized heart and pericardium are unremarkable. CT ABDOMEN: The patient is status post gastric bypass surgery. At the postsurgical anatomy is unremarkable, with a patent gastrojejunostomy and occasionally and jejunojejunostomy without dilatation to suggest obstruction and absence of contrast in the biliary limb. There is no evidence of leak or intraperitoneal fluid collection. No free air is identified in the abdominal cavity. The liver enhances homogeneously, without focal lesions or intrahepatic biliary duct dilatation. The patient is status post cholecystectomy. The portal vein is patent. The pancreas, spleen, adrenal glands are within normal limits. The kidneys show symmetric nephrograms and excretion of contrast. There is no focal renal lesion or hydronephrosis bilaterally. The small and large bowel are within normal limits, without evidence of wall thickening or dilatation to suggest obstruction. The appendix is not seen but there is no evidence of appendicitis. The aorta and its main branches are patent and nonaneurysmal. There is no mesenteric or retroperitoneal lymph node enlargement by CT size criteria. There is no ascites or abdominal wall hernia. CT PELVIS: The urinary bladder and ureters are unremarkable. The uterus and adnexae are unremarkable. Two dropped surgical clips are seen in the pouch of ___. There is no pelvic wall or inguinal lymphadenopathy. No pelvic free fluid is observed. OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for malignancy. IMPRESSION: No CT findings to explain the symptoms. Unremarkable post gastric bypass anatomy. No evidence of obstruction, leakage or intra-abdominal abscess. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: n/v/d, BRBPR Diagnosed with CLOSTRIDIUM DIFFICILE temperature: 98.9 heartrate: 116.0 resprate: 18.0 o2sat: 100.0 sbp: 113.0 dbp: 66.0 level of pain: 8 level of acuity: 3.0

Patient eloped from hospital. By telephone, she was advised to return to the hospital if she felt unwell or if symptoms persisted or worsened.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cephalexin Attending: ___. Chief Complaint: cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ year-old lady residing at the dementia unit ___ with a history of HTN, hearing loss and eczema who presents referred by her PCP with new cellulitis. Per daughter and health aide she had a mechanical fall on her right lower extremity about a week ago that resulted in skin erosions right below her right knwee that were healing well. Last night her home health aide noticed some subtle redness in the area. This morning she was found to have edema, erythema and pain extending from the area of the wound until her ankle. Her PCP was made aware and referred her to the ED for evaluation. In the ED, initial vitals were: 97.4 66 143/48 16 100% - Labs were significant for *CBC: 7.6> 9.7/29.6 < 266 *mild hyperkalemia at 5.3, mild alkalosis at 29, BUN 25 / Cr 1.1 (b/l 0.9-1.0), normal lactate *UA: negative for leuk esterase, nitrites, ketones - Imaging revealed : *tib/fib XR negative for fractures ___ negative for DVT - The patient was given: CTX 1g iv, Vancomycin 1g iv, APAP 1g Po - Admission was discussed with geriatrics fellow Vitals prior to transfer were: 98.0 88 152/65 16 100% RA Upon arrival to the floor, the patient complained of mild pain in her right lower extremity but mostly of pruritus in the anterior surfaces of both lower extremities. Past Medical History: - Alzheimer's type dementia, - four episodes of breast cancer BRCA1 negative - hypothyroidism - elevated cholesterol - GERD - hypertension - COPD Social History: ___ Family History: - Brother: prostate cancer - Father: MI in ___ Physical Exam: ADMISSION LABS Vitals: 97.9 | 156/56 | 85 | 18 | 95%RA General: Alert, oriented to self, pleasant, repeatedly scratching the skin of her lower extremities. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated. CV: Regular rate and rhythm, normal S1 + S2, harsh mid-systolic murmur radiating to carotids. No rubs, gallops Lungs: Clear to auscultation bilaterally, diffuse wheezes, no ronchi. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses. Skin: RLE with slightly tender indurated erythematous lesion extending from below the knee into the ankle. No purulence. Rest of the skin in lower extremities and upper torso with multiple erythematous nodules with licheniphication and chronic excoriations. Neuro: AOx1 (self), very hard of hearing in spite of hearing aid, moves all four extremities at will, speech is fluent, gait deferred. DISCHARGE LABS Vital Signs: 98.2, 143/48, 74, 18, 98% on RA General: Alert to self, no acute distress HEENT: Sclera anicteric, MMM Lungs: diffuse wheeze in posterior lung fields CV: RRR, nl S1 S2, systolic ejection murmur RUSB/LUSB, radiating to the LLSB and the carotids b/l Abdomen: soft, non-tender, non-distended Ext: WWP, right leg with tender, erythematous, crusted lesion on upper calf, with erythema surrounding crusted abrasion extending to the ankle and above the knee, regressed x 1 inch below initial markings Skin: lower extremities and upper torso with multiple hypopigmented nodules with lichenophication and chronic excoriation Neuro: hard of heading, moves all extremities spontaneously Pertinent Results: ADMISSION LABS ___ 12:49PM BLOOD WBC-7.6 RBC-3.24* Hgb-9.7* Hct-29.6* MCV-91 MCH-29.9 MCHC-32.8 RDW-13.3 RDWSD-44.1 Plt ___ ___ 12:49PM BLOOD Neuts-71.1* Lymphs-11.7* Monos-13.9* Eos-2.6 Baso-0.3 Im ___ AbsNeut-5.40 AbsLymp-0.89* AbsMono-1.06* AbsEos-0.20 AbsBaso-0.02 ___ 12:49PM BLOOD Plt ___ ___ 12:49PM BLOOD Glucose-83 UreaN-25* Creat-1.1 Na-141 K-5.3* Cl-103 HCO3-29 AnGap-14 ___ 12:49PM BLOOD Phos-4.1 ___ 12:59PM BLOOD Lactate-1.3 ___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG RIGHT ___ ULTRASOUND ___ Please note that this study is slightly limited by significant tenderness elicited with the transducer probe. There is normal compressibility, flow and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial veins. Peroneal veins are not well visualized. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. There is significant subcutaneous edema in the right calf. IMPRESSION: 1. Limited evaluation of the right peroneal veins. No evidence of deep venous thrombosis in the visualized right lower extremity veins. 2. Subcutaneous edema in the right calf. XRAY TIB/FIB ___ The bones diffusely demineralized. There is no acute fracture. Well corticated rounded calcific density seen adjacent to the inferior aspect of the right fibula appears chronic. No significant degenerative changes identified. Diffuse subcutaneous edema is noted. There is no radiopaque foreign body. IMPRESSION: No acute fracture. DISCHARGE LABS ___ 06:25AM BLOOD WBC-7.7 RBC-3.35* Hgb-9.8* Hct-30.6* MCV-91 MCH-29.3 MCHC-32.0 RDW-13.2 RDWSD-44.1 Plt ___ ___ 06:25AM BLOOD Plt ___ ___ 06:25AM BLOOD Glucose-91 UreaN-18 Creat-1.0 Na-143 K-4.5 Cl-106 HCO3-26 AnGap-16 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO TID 2. Cyanocobalamin 1000 mcg PO 1X/WEEK (MO) 3. Vitamin D 1000 UNIT PO DAILY 4. Donepezil 5 mg PO QAM 5. Ferrous GLUCONATE 240 mg PO 3X/WEEK (___) 6. Melatin (melatonin) 3 mg oral QHS 7. Albuterol 2 mg PO BID 8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 9. Atorvastatin 10 mg PO QPM 10. Levothyroxine Sodium 25 mcg PO DAILY 11. Acidophilus (L.acidoph & ___ acidophilus) 10 mg oral DAILY 12. ammonium lactate 12 % topical DAILY dry scaly skin 13. Clobetasol Propionate 0.05% Cream 1 Appl TP BID rash Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Albuterol 2 mg PO BID 3. Atorvastatin 10 mg PO QPM 4. Donepezil 5 mg PO QAM 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Acidophilus (L.acidoph & ___ acidophilus) 10 mg oral DAILY 8. ammonium lactate 12 % topical DAILY dry scaly skin 9. Cyanocobalamin 1000 mcg PO 1X/WEEK (MO) 10. Ferrous GLUCONATE 240 mg PO 3X/WEEK (___) 11. Melatin (melatonin) 3 mg oral QHS 12. Amoxicillin 500 mg PO Q8H Duration: 8 Days Please take until ___ RX *amoxicillin 500 mg 1 capsule(s) by mouth every 8 hours Disp #*24 Capsule Refills:*0 13. Sulfameth/Trimethoprim DS 1 TAB PO Q12H Duration: 8 Days Please take until ___ RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth every 12 hours Disp #*16 Tablet Refills:*0 14. Betamethasone Valerate 0.1% Cream 1 Appl TP BID apply to affected area, do not apply to right lower calf while patient has cellulitis RX *betamethasone valerate 0.1 % Apply to affected area two times per day Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Cellulitis Mechanical Fall, skin abrasion Secondary Diagnosis: Eczema, prurigo nodularis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ with RLE pain, swelling, ? cellulitis // eval ? DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: Please note that this study is slightly limited by significant tenderness elicited with the transducer probe. There is normal compressibility, flow and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial veins. Peroneal veins are not well visualized. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. There is significant subcutaneous edema in the right calf. IMPRESSION: 1. Limited evaluation of the right peroneal veins. No evidence of deep venous thrombosis in the visualized right lower extremity veins. 2. Subcutaneous edema in the right calf. Radiology Report INDICATION: ___ with injury // r/o fracture, osteo TECHNIQUE: AP, oblique, and lateral views of the right knee. AP and lateral views the right tibia and fibula. COMPARISON: None. FINDINGS: The bones diffusely demineralized. There is no acute fracture. Well corticated rounded calcific density seen adjacent to the inferior aspect of the right fibula appears chronic. No significant degenerative changes identified. Diffuse subcutaneous edema is noted. There is no radiopaque foreign body. IMPRESSION: No acute fracture. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: R Leg pain, R Leg swelling Diagnosed with CELLULITIS OF LEG temperature: 97.4 heartrate: 66.0 resprate: 16.0 o2sat: 100.0 sbp: 143.0 dbp: 48.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, Thank you for allowing us to participate in your care at ___. You were admitted to the hospital with cellulitis which is an infection of your skin. We believe this happened because of the cut on your leg from your recent fall. Scratching your legs may have also contributed to your infection. You were evaluated with a ultrasound of the leg which showed no clots. You were also evaluated with an xray which did not show any fractures in your lower leg. You were treated with IV antibiotics for 2 days and we switched you to antibiotics by mouth after that. After discharge you should continue to taken amoxicillin and bactrim through ___. You should try to avoid scratching your skin. You should continue to put a dressing or an ace bandage on your right leg to prevent yourself from scratching that area. We wish you the best! Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Codeine / Penicillins / Oxycodone / Clindamycin / Vagifem / Latex Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ with multiple prior abdominal operations and small bowel obstructions managed non-operatively who presented at this admission with 24 hours of abdominal pain associated with nausea. She denied flatus and had one small BM on the day of admission. She reported nausea without emesis. Review of systems notable for URI, mild lightheadedness and dizziness, and increased urinary frequency. She denies fever, chills, and dysuria. Past Medical History: Past Medical History: Irritable bowel syndrome, Diverticulitis, constipation, allergic rhinitis, benign breast mass, chronic low back pain, small bowel obstructions, chronic pelvic pain, DJD, gastritis, GERD, migraine headaches, optic neuritis, pancreatitis and positive PPD Past Surgical History: ___ - Open appendectomy, ___ - Partial hysterectomy, ___ - Ovarectomy, ___ - R shoulder surgery Social History: ___ Family History: Mother died of "intestinal perforation," otherwise non-contributory Physical Exam: Discharge Physical Exam VS: 98.4 67 117/60 18 99%ra Gen: alert and oriented x3 NAD CV: RRR Pulm: CTAB Abd: soft, mildly distended, no palpable masses, no rebound/gaurding Ext: WWP Pertinent Results: ___ CT abd/pelvis IMPRESSION: 1. Dilated segment of ileum demonstrating mural edema, thickening, and adjacent stranding with a transition point noted in the caliber of the lumen in the mid abdomen. Findings are worrisome for an early small bowel obstruction with ischemia. 2. No evidence of diverticulitis. Medications on Admission: butalbital-acetaminophen-caff 50/325 prn migraine, omeprazole 20'', valacyclovir 500'', biotin, bisocodyl 5, docusate, polyethylene glycol Discharge Medications: 1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO three times a day as needed for headache. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. biotin 1 mg Tablet Sig: One (1) Tablet PO three times a day. 5. bisacodyl 10 mg Suppository Sig: One (1) Rectal twice a day as needed for constipation. 6. docusate calcium 240 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Chronic abdominal pain including diverticulitis. Severe pain localized most to the left lower quadrant. TECHNIQUE: MDCT images were obtained from the lung bases to the pelvic outlet after administration of intravenous contrast. Coronal and sagittal images were acquired. COMPARISON: None. CT ABDOMEN: The lung bases are clear. The visualized portions of the heart and pericardium are unremarkable. A segment of ileum is dilated to 2.7 cm with mural edema and thickening, as well as surrounding mesenteric fat stranding. A transition point in the caliber of the small bowel is noted in the anterior mid abdomen (2:47). The liver enhances homogenously and there is no focal liver lesion. The gallbladder, pancreas, spleen, and adrenals are normal. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or stone. The stomach is 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 appendicitis. The colon, adnexa, and urinary bladder are unremarkable. The uterus is not visualized. There is no pelvic lymphadenopathy or free fluid. OSSEOUS STRUCTURES: There is no lytic or blastic lesion suspicious for malignancy. IMPRESSION: 1. Dilated segment of ileum demonstrating mural edema, thickening, and adjacent stranding with a transition point noted in the caliber of the lumen in the mid abdomen. Findings are worrisome for an early small bowel obstruction with ischemia. 2. No evidence of diverticulitis. Findings were discussed by Dr. ___ with Dr. ___ by phone at 8:49 p.m. on ___. Gender: F Race: HISPANIC OR LATINO Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 98.2 heartrate: 84.0 resprate: 18.0 o2sat: 100.0 sbp: 134.0 dbp: 89.0 level of pain: 3-10 level of acuity: 3.0

You were admitted to the ___ surgery service for treatment of a small bowel obstruction. This has resolved and you are tolerating a regular diet. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. 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 4000 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 20 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: F Service: MEDICINE Allergies: Penicillins / Augmentin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: ___ w/ Crohn's s/p L hemicolectomy and diverting colostomy ___ and recent C. diff s/p fecal transplant on ___ who presents with abdominal pain and fevers. Patient was admitted ___ to ___ for Crohn's flare. She was initially covered with Cipro/flagyl but stool studies including CDiff were negative. She was started on prednisone 60mg daily and has been tapering as an outpatient with good improvement in her symptoms. She then underwent FMT on ___, and biopsies at that time showed severe active colitis. Following her FMT she noted some mild abdominal pain. She then developed new diarrhea and was diagnosed with CDiff colitis at ___ in ___ approximatley 10 days ago. She then restarted po vanco. Her diarrhea improved but starting approximately 5 days ago, she developed new and worsening lower abdominal pain, described as up to ___ stabbing pain radiating from her lower abdomen around to her back. She presented to urgent care and underwent an ultrasound NOS which was apparently normal. She was started on cefixime for possible UTI, which she has been taking for the last three days. Due to progressive pain and new fevers over the last few days, she then presented to the ___ ED. In the ED intial vitals were pain 10, T 98.4, HR 115, BP 120/77, RR 18, O2 99%RA. Initial labs were notable for WBC 23.3 with 93%PMN, 847 Plt, and HCT 35.4. UA was negative and remainder of chem7 and lactate were wnl. KUB showed no evidence of obstruction and CT A/P showed colitis. Patient was given flagyl, IV morphine, IV dilaudid, and IV zofran along with 2LNS and admitted to medicine for further management. On the floor, patient notes abdminal pain and fevers as above. Her stools remain formed, and denies frank blood in stool but has noticed her stoma is irritated and occasionally bleeds. She has mild nausea but no emesis. No recent headaches, shortness of breath or cough. No dysuria. She is sexually active with her boyfriend, but reports a monogomous relationship and no history of STD. ROS is otherwise unremarkable. Past Medical History: - Crohns disease, diagnosed age ___, no past surgeries - c. diff ___ - asthma - migraines since age ___, previously had a neurologist - depression Social History: ___ Family History: CAD, GF with colon cancer, cousin with UC, another cousin with autoimmune hepatitis. Physical Exam: Admission Physical Exam Vitals-98.4 97/63 18 98%RA General- Pleasant, 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, left ostomy in place with reddish pink stoma and brown stool, TTP suprapubically and LLQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Discharge Physical Exam Vitals: 98.0 75 104/64-120/79 18 100% RA General: Alert, Oriented, NAD HEENT: Sclera anicteric, MMM, no scleral injection, no mouth ulcers Neck: supple, no JVD Lungs: CTAB CV: RRR no murmurs Abdomen:+BS ostomy in place mild ttp around site, no rebound or guarding Ext:WWP, no erythema nodosum, no clubbing, cyanosis, or edema Neuro: A+Ox3, Pertinent Results: Admission Labs ===================================== ___ 07:53PM URINE MUCOUS-RARE ___ 07:53PM URINE RBC-4* WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 07:53PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 07:53PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:53PM URINE UCG-NEGATIVE ___ 07:53PM URINE HOURS-RANDOM ___ 09:40PM PLT COUNT-847*# ___ 09:40PM NEUTS-93.2* LYMPHS-4.4* MONOS-2.0 EOS-0.1 BASOS-0.3 ___ 09:40PM WBC-23.3*# RBC-4.33 HGB-10.8* HCT-35.4* MCV-82 MCH-24.9*# MCHC-30.5* RDW-12.9 ___ 09:40PM ALT(SGPT)-20 AST(SGOT)-16 ALK PHOS-91 TOT BILI-0.2 ___ 09:40PM estGFR-Using this ___ 09:40PM GLUCOSE-93 UREA N-7 CREAT-0.6 SODIUM-139 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-19 ___ 09:56PM LACTATE-1.8 ___ 08:15AM PLT COUNT-689* ___ 08:15AM WBC-16.8* RBC-3.47* HGB-8.8* HCT-28.1* MCV-81* MCH-25.3* MCHC-31.2 RDW-12.9 ___ 08:15AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.9 ___ 08:15AM GLUCOSE-84 UREA N-6 CREAT-0.6 SODIUM-137 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 ___ 11:46PM URINE MUCOUS-RARE ___ 11:46PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 TRANS EPI-<1 ___ 11:46PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 11:46PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:46PM URINE UHOLD-HOLD Imaging KUB ___ Nonspecific bowel gas pattern without findings to suggest obstruction. CT Abd/pelvis ___ Mucosal edema with mural thickening and surrounding inflammatory changes along the distal left colon leading to left lower quadrant diverting colostomy are consistent with colitis, likely secondary to underlying Crohn disease flare. Mild inflammatory changes are also present about the rectal stump with adjacent mild pelvic lymphadenopathy. No evidence of abscess or obstruction. US abdomen ___ cm subcutaneous fluid collection medial to the stoma, which is not amenable to percutaneous drainage. Aspiration could be considered if clinically indicated. CXR ___ In comparison with study of ___, there is little change and no evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. MICRO DATA ___ 7:53 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 11:03 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. 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. ___ 7:30 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 11:46 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. ___ 7:00 am BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Discharge Labs ___ 06:00AM BLOOD WBC-14.8* RBC-3.95* Hgb-9.7* Hct-32.6* MCV-83 MCH-24.6* MCHC-29.8* RDW-14.0 Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-140 K-4.4 Cl-99 HCO3-31 AnGap-14 ___ 06:00AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze 3. Citalopram 40 mg PO DAILY 4. Montelukast Sodium 10 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. Vancomycin Oral Liquid ___ mg PO Q6H 7. PredniSONE 15 mg PO DAILY Tapered dose - DOWN 8. Suprax (ceFIXime) unknown oral unknown 9. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze 3. Citalopram 40 mg PO DAILY 4. Montelukast Sodium 10 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. DiCYCLOmine 20 mg PO QID This medication may cause drowsiness or sedation RX *dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp #*60 Tablet Refills:*0 7. Hyoscyamine 0.25 mg SL QID This medication may cause drowsiness or sedation RX *hyoscyamine sulfate 0.125 mg 2 tablets sublingually four times a day Disp #*120 Tablet Refills:*0 8. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine pls do not take this medication and oxycodone at the same time. 9. PredniSONE 30 mg PO DAILY RX *prednisone 20 mg 1.5 (One and a half) tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 10. Calcium Carbonate 1000 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. OxycoDONE (Immediate Release) 25 mg PO Q4H:PRN break through pain RX *oxycodone 20 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Crohn's Colitis 2. Clostridium Difficile Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with Crohn's, with right lower quadrant and left lower quadrant pain and blood from the left lower quadrant stoma. Evaluation for intra-abdominal abscess. TECHNIQUE: MDCT images were obtained of the abdomen and pelvis after the administration of intravenous and oral contrast. Reformat coronal and sagittal images were also reviewed. DLP: 289.66 mGy-cm. COMPARISON: Comparison is made to CT of the abdomen and pelvis from ___. FINDINGS: CT ABDOMEN: The liver enhances homogeneously, with no evidence focal lesions. There is no intra or extrahepatic biliary ductal dilatation. The portal vein is patent. The pancreas, spleen, bilateral adrenal glands, bilateral kidneys and gallbladder are unremarkable. The stomach, duodenum and proximal small bowel are normal in appearance, with no evidence of wall thickening or obstruction. Enteric contrast material is seen to the level of the distal ileum. There is no evidence of intra-abdominal fluid collection or abscess. The patient is status post left colectomy, with left lower quadrant ostomy. The ostomy and the distal left colon again demonstrates mucosal edema, and surrounding inflammatory changes, consistent with colitis (2:33), the extending to the ostomy site (2:42). The findings are similar when compared to the prior study, and are concerning for colitis in the setting of acute Crohn's flare. There is no evidence of obstruction. CT PELVIS: The rectal pouch again seen, and demonstrates mild mucosal edema, likely inflammatory, with a trace amount of fluid in the pelvis (2:62). The terminal ureters and bladder are unremarkable. The uterus is normal in appearance. No adnexal masses are seen. Several prominent lymph nodes are identified. OSSEOUS STRUCTURES: No lytic or blastic lesions suspicious for malignancy is identified. IMPRESSION: Mucosal edema with mural thickening and surrounding inflammatory changes along the distal left colon leading to left lower quadrant diverting colostomy are consistent with colitis, likely secondary to underlying Crohn disease flare. Mild inflammatory changes are also present about the rectal stump with adjacent mild pelvic lymphadenopathy. No evidence of abscess or obstruction. Radiology Report INDICATION: History of Crohn's disease status post colectomy with left lower quadrant ostomy, now with fever and leukocytosis and palpable swelling around the ostomy site, here to evaluate for underlying fluid collection. COMPARISON: Same day CT of the abdomen and pelvis with contrast. TECHNIQUE: Targeted sonographic assessment was performed in the region of the patient's palpable abnormality medial to the left lower quadrant ostomy site. FINDINGS: Corresponding to the patient's palpable abnormality medial to the left lower quadrant stoma, there is a relatively hypoechoic collection in the subcutaneous fat of the anterior abdominal wall, measuring 14 x 8 x 7 mm with internal echoes compatible with debris. There is no internal vascularity on color Doppler analysis. This likely corresponds to a focal subcutaneous hypodensity on a same day CT. IMPRESSION: 1.4 cm subcutaneous fluid collection medial to the stoma, which is not amenable to percutaneous drainage. Aspiration could be considered if clinically indicated. Radiology Report HISTORY: Fever. FINDINGS: In comparison with study of ___, there is little change and no evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with CLOSTRIDIUM DIFFICILE, REGIONAL ENTERITIS NOS temperature: 98.4 heartrate: 115.0 resprate: 18.0 o2sat: 99.0 sbp: 120.0 dbp: 77.0 level of pain: 10 level of acuity: 3.0

Dear ___: It was a pleasure caring for you during your stay at ___. As you know, you were admitted due to abdominal pain, and concern for flare of your Crohn's disease. You were treated with IV steroids to reduce inflammation, and received medication for pain management. We consulted the gastroenterologists to assist in your care. You had a colonoscopy which showed evidence of colitis, and irritation of your colon. It was felt that your pain may be due to pain around your rectal stoma. Given that your pain was better controlled after the IV steroids, we felt that you were stable to return home. Please follow up with your primary care doctor as well as your gastroenterologist Dr. ___. Thank you for allowing us the opportunity to care for you. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: HMED ATTENDING ADMISSION NOTE ADMIT DATE: ___ ADMIT TIME: ___ . ___ yo F with h/o GERD and cholelithiasis, s/p lap chole ___ for gallstone pancreatitis complicated by bile leak s/p ERCP with stent placement ___ and right abdominal hematoma s/p percutaneous abdominal drain who is transferred from ___ ___ with abdominal pain, new fluid collection and dilated common bile duct. . Patient initially presented to ___ on ___ with abdominal pain, nausea and vomiting and was found to have gallstone pancreatitis (also with facial cellulitis and otitis externa). Patient underwent a lap chole on ___ complicated by a cystic duct bile leak for which she was transferred to ___. Patient underwent ERCP with stent placement on ___. Patient was discharged home on ___ however continued to have persistent abdominal pain, nausea and vomiting. She was evaluated by her PCP, found to have a bili of 2 and CT scan showed an intra-abdominal fluid collection. Patient was admitted to the hospitalist service on ___. ___ performed a CT-guided placement of drain in the fluid collection on ___ which was consistent with a hematoma. She had a HIDA scan which was negative for bile leak. Drain was pulled and patient was discharged on ___. . Patient initially felt well after hospital discharge - minimal pain and nausea (never fully resolved). Approximately one week ago, RUQ pain returned. Described as intermittent, sharp/cramping, ___ at maximum. Two days ago developed nausea and anorexia. No vomiting. No fever, + chills. No cp, sob, diarrhea, brbpr or melena. . Presented to ___ ED yesterday and found to have a dilated CBD of 1.8 cm (per ED report, no imaging in chart) with normal bilirubin. Transferred to ___ for ERCP evaluation. . ED: 97.7 73P 109/69 16 98%RA; zofran 4mg iv, unasyn 3gm, CT a/p with contrast - extruded biliary stent in duodenum, stable moderate biliary ductal dilatation, decrease in RLQ fluid collection; surgery consulted - fluid collection seen on CT scan prior to lap chole - biloma vs hematoma, no surgical intervention, consider drainage. ERCP consulted with plan for ERCP and stent replacement in the am. . ROS as per HPI, otherwise 10 pt ROS negative Past Medical History: GERD MVC with head injury Nasal drip Right hydronephrosis Cholelithiasis s/p CCY, c/b bile leak and abdominal hematoma; s/p subsequent ERCP with stent placement Social History: ___ Family History: Father deceased from pancreatic cancer Physical Exam: VS 96.8 126/70 80 18 99%RA Appearance: alert, NAD Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmd, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, obese, + RUQ ttp, no distension, +bs, no rebound/guarding, neg ___ Msk: ___ strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn ___ grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical ___ ___ Results: ___ 05:13PM LACTATE-0.9 ___ 05:02PM GLUCOSE-84 UREA N-9 CREAT-0.6 SODIUM-140 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 ___ 05:02PM ALT(SGPT)-49* AST(SGOT)-39 ALK PHOS-272* TOT BILI-0.9 ___ 05:02PM LIPASE-83* ___ 05:02PM WBC-5.7 RBC-4.26 HGB-12.2 HCT-36.6 MCV-86 MCH-28.7 MCHC-33.4 RDW-13.3 ___ 05:02PM NEUTS-64.3 ___ MONOS-3.7 EOS-2.5 BASOS-0.4 ___ 05:02PM PLT COUNT-291 . ___ BCx: pending, no growth to date . ___ CT a/p with contrast: wet read -Extruded biliary stent - now located in the ___ portion of the duodenum -Stable moderate intra- and extrahepatic biliary ductal dilatation. -Pancreatic ductal dilatation - 4 mm - unchanged. Normal enhancement of the pancreatic parenchyma without signs of acute inflammation or necrosis -Known RLQ fluid collection decreased in size since ___ though still measuring 3.4 x 6.7 x 8.1 cm. Fluid remains hyperdense and could represent a biloma or contained hematoma. Collection demonstrates rim enhancement which could represent superinfection - correlate clinically. -Normal bowel - no obstruction or inflammation . ___ 06:55AM BLOOD WBC-5.5 RBC-4.07* Hgb-12.0 Hct-35.4* MCV-87 MCH-29.6 MCHC-33.9 RDW-13.4 Plt ___ ___ 06:55AM BLOOD Glucose-50* UreaN-5* Creat-0.5 Na-136 K-3.8 Cl-102 HCO3-19* AnGap-19 ___ 09:05AM BLOOD ALT-45* AST-37 AlkPhos-255* TotBili-1.1 ___ 06:55AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.7 . ___ HIDA Scan - Normal post-operative hepatobiliary scan, specifically with no evidence of biliary leak. . ___ MRCP - 1. Patient is status post cholecystectomy with mild central intrahepatic and extrahepatic biliary dilatation with no evidence for choledocholithiasis. Of note, the stent is noted still within the distal common bile duct and is draining freely into the third portion of the duodenum. 2. Normal hepatobiliary excretion of the contrast agent Eovist from the liver with no evidence of bile leak from the cystic duct remnant. 3. Right upper abdominal collection with imaging characteristics consistent with a liquefied hematoma. No evidence for biloma. 4. Moderate narrowing at the origin of the celiac axis with associated post-stenotic dilatation. . Medications on Admission: 1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily) as needed for rhinitis. Discharge Medications: 1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily) as needed for rhinitis. 3. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*56 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: abdominal hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report MRCP INDICATION: History of laparoscopic cholecystectomy for gallstones, pancreatitis with common cystic duct leak postoperatively. Had ERCP with stent placement. Evaluate an abdominal wall hematoma, which had an ___ drain. He has had one week of abdominal pain. Please evaluate fluid collection, evidence for bile leak. COMPARISON: Gallbladder scan ___, CT abdomen and pelvis ___, CT interventional procedure ___ and CT abdomen and pelvis ___. TECHNIQUE: Multiplanar T1- and T2-weighted imaging was acquired on a 1.5 Tesla magnet including dynamic 3D imaging obtained prior to, during, and after the uneventful intravenous administration of 7.5 mL of Magnevist and 7.5 mL of Eovist. In addition, 5 mL of Magnevist was administered orally with 75 mL of water. FINDINGS: The imaged lung bases are clear. There are small bilateral pleural effusions. There is normal hepatic parenchymal signal intensity without focal liver lesion. There is mild central intrahepatic biliary dilatation and the common bile duct is dilated measuring up to 12 mm in its more proximal portion, however, tapers normally towards the head of the pancreas. There is evidence of pneumobilia, but no evidence for choledocholithiasis. The biliary stent is noted within the lower one-third of the common bile duct (series 6, image 1) extending into the duodenum distally. Post administration of Eovist there is prompt excretion of the hepatobiliary agent from the intra- and extra-hepatic biliary tree with no evidence for bile leak. There is normal filling of the cystic duct remnant with no evidence for a leak from the cystic duct stump. There is conventional hepatic arterial anatomy, and the visualized hepatic and portal veins are patent. The spleen measures 11 cm. The pancreas has homogeneous signal intensity and enhances uniformly. There is mild prominence of the pancreatic duct in the head of the pancreas measuring up to 4 mm without irregularity. No focal concerning cystic lesions are identified. Both adrenal glands are unremarkable. Both kidneys are normal with a simple cyst noted in the interpolar region of the right kidney measuring 8 mm which is hyperintense relative to renal parenchyma on T2-weighted imaging (series 12, image 30) and does not enhance post-contrast. Incidental note is made of moderate narrowing of the origin of the celiac axis with associated post-ostial dilatation (series 901, image 722). The visualized superior mesenteric and inferior mesenteric arteries are patent. The abdominal aorta is normal in caliber with no evidence for focal aneurysm or dissection. Within the mid abdomen on the right side, a collection is identified which measures 7.4 craniocaudal x 6.0 cm AP x 3.4 cm in transverse diameter, which previously measured 9.1 cm x 10.7 cm x 5.3 cm on ___. On T1-weighted imaging there is a bright rim (series 7, image 126) which is dark on T2-weighted imaging (series 12, image 42). The central component of the collection is of high signal intensity on T2-weighted imaging, consistent with liquidation within the collection. There is no significant enhancement post-contrast administration and findings are consistent with a hematoma. There are no retroperitoneal masses or adenopathy. No abnormally dilated or thickened small or large bowel loop in the visualized upper abdomen. No free fluid. Bone marrow signal is normal and no osseous lesions were identified. IMPRESSION: 1. Patient is status post cholecystectomy with mild central intrahepatic and extrahepatic biliary dilatation with no evidence for choledocholithiasis. Of note, the stent is noted still within the distal common bile duct and is draining freely into the third portion of the duodenum. 2. Normal hepatobiliary excretion of the contrast agent Eovist from the liver with no evidence of bile leak from the cystic duct remnant. 3. Right upper abdominal collection with imaging characteristics consistent with a liquefied hematoma. No evidence for biloma. 4. Moderate narrowing at the origin of the celiac axis with associated post-stenotic dilatation. Findings were discussed with Dr. ___ via telephone by Dr. ___ ___ at 10:30 a.m. on ___. Gender: F Race: ASIAN - ASIAN INDIAN Arrive by AMBULANCE Chief complaint: HEMATOMA SURG SITE Diagnosed with DIS OF BILIARY TRACT NEC, ABDOMINAL PAIN OTHER SPECIED temperature: 97.7 heartrate: 73.0 resprate: 16.0 o2sat: 98.0 sbp: 109.0 dbp: 69.0 level of pain: nan level of acuity: 3.0

You were admitted to the hospital with abdominal pain and nausea. You were evaluated by the Medical, Surgical, and ERCP teams. You had imaging studies done, including a CT scan, a HIDA scan and an MRCP (MRI) which did not show any evidence of bile leak. You still have a fluid collection in your abdomen which is most likely a resolving blood clot (hematoma). On the CT scan, it was noted that your previously placed pancreatic stent had migrated and was now in the small intestine. This stent should pass on its own through your GI tract. . New Medications: 1. Phenergan . Please follow-up with your doctors as listed below. You will see a Gastroenterologist affiliated with your PCP's office. You will need to have a follow-up x-ray of your abdomen to evaluate for passage of the stent. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M h/o of reflux nephropathy, BPH, presents with 1 week of chills, sweats, fevers, found to have pyelonephritis. Began to feel unwell 1 week prior to admission with a feeling of "wooziness," malaise that progressed over several days. He then presented to urgent care 1 day prior to admission where he was diagnosed with pyelonephritis and prescribed Ciprofloxacin. Despite taking several doses he continued to have fevers to 102 at home and felt unwell. He called urgent care the day of admission who told him to present to the ED. He was started on Ceftriaxone/Vancomycin and given 4L IVF in the ED. Lactate normal. His blood pressure briefly dipped into the mid ___ systolic without change in mental status and this quickly improved with fluids. His heart rate was in the ___ throughout. On arrival to the floor he is feeling much better. He continues to have some chills. He relays a recent history of urinary urgency with mild dysuria and flank pain. CT urogram revealed right-sided pyelo w/o abscess. Past Medical History: Psoriasis Hypercholesterolemia ADHD, predominantly inattentive type Reflux nephropathy Benign non-nodular prostatic hyperplasia Social History: ___ Family History: Family history of Liver Cancer in his mother. ___ Cancer in his father. Physical Exam: ADMISSION EXAM: VS: Afebrile and vital signs stable (reviewed in bedside record) General Appearance: pleasant, comfortable, no acute distress Eyes: PERLL, EOMI, no conjuctival injection, anicteric ENT: no sinus tenderness, MMM, no JVD, Respiratory: CTA b/l with good air movement throughout Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM Extremities: no cyanosis, clubbing or edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert, oriented to self, time, date, reason for hospitalization. Cn II-XII intact. ___ strength throughout. fluent speech. Psychiatric: pleasant, appropriate affect GU: R sided CVAT Patient was examined on day of discharge, afebrile, no costovertebral angle tenderness. Pertinent Results: LABORATORY RESULTS: ___ 05:00PM BLOOD WBC-18.8* RBC-4.26* Hgb-13.3* Hct-38.5* MCV-90 MCH-31.2 MCHC-34.5 RDW-12.6 RDWSD-41.5 Plt ___ ___ 06:50AM BLOOD WBC-11.3* RBC-3.91* Hgb-12.2* Hct-35.4* MCV-91 MCH-31.2 MCHC-34.5 RDW-12.5 RDWSD-41.9 Plt ___ ___ 05:00PM BLOOD Glucose-109* UreaN-20 Creat-1.0 Na-132* K-3.7 Cl-94* HCO3-23 AnGap-15 ___ 06:50AM BLOOD Glucose-116* UreaN-10 Creat-0.9 Na-138 K-3.4* Cl-99 HCO3-22 AnGap-17 ___ 05:00PM BLOOD ALT-24 AST-23 AlkPhos-81 TotBili-0.5 ___ 05:00PM BLOOD Albumin-3.9 ___ 05:34PM BLOOD Lactate-1.4 CTU Abd/Pelvis 1. Right pyelonephritis and mild ureteritis. No perinephric abscess is identified. 2. No additional acute process within the abdomen or pelvis. 3. Mild splenomegaly. MICROBIOLOGY: SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Aspirin 81 mg PO DAILY 3. Amphetamine-Dextroamphetamine 15 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Twice daily Disp #*8 Tablet Refills:*0 2. Amphetamine-Dextroamphetamine 15 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Sepsis due to pyelonephritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with right flank to RLQ pain, rigors despite ___// assess for pyelonephritis, infected stone, perinephric abscess TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired prior to and after intravenous contrast administration with the patient in prone position. The non-contrast scan was done with low radiation dose technique. The contrast scan was performed 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 6.6 s, 51.6 cm; CTDIvol = 10.7 mGy (Body) DLP = 551.5 mGy-cm. 2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 3) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 10.8 mGy (Body) DLP = 556.9 mGy-cm. Total DLP (Body) = 1,120 mGy-cm. COMPARISON: None available. FINDINGS: LOWER CHEST: Minimal dependent atelectasis. Otherwise no focal consolidation 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 measures 13.5 cm without focal lesion. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Striated appearance of the right kidney is consistent with pyelonephritis. The left kidney demonstrate normal nephrogram. There is no nephrolithiasis or ureterolithiasis. There is no hydronephrosis. There is no perinephric abnormality. There is no evidence of focal renal lesions. The right ureter demonstrate mild surrounding stranding (series 4, image 67), consistent with mild ureteritis. The left ureter is unremarkable. The urinary bladder is unremarkable. No perinephric abscess is identified. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. Appendix is unremarkable. PELVIS: There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is mildly enlarged. The seminal vesicles are unremarkable. LYMPH NODES: Scattered retroperitoneal lymph nodes are not enlarged by CT criteria. No 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. Degenerative changes of the lumbar spine are mild. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Right pyelonephritis and mild ureteritis. No perinephric abscess is identified. 2. No additional acute process within the abdomen or pelvis. 3. Mild splenomegaly. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever, R Flank pain Diagnosed with Fever, unspecified, Unspecified abdominal pain, Weakness temperature: 99.1 heartrate: 79.0 resprate: 20.0 o2sat: 98.0 sbp: 108.0 dbp: 50.0 level of pain: 2 level of acuity: 3.0

You were admitted with pyelonephritis -- a urinary infection that spread to your kidneys. You required IV medications for several days, and you were initially septic. Fortunately, you grew a sensitive organism called enterococcus. You will finish a 10 day course of antibiotics (ciprofloxacin). If you ever have urinary symptoms again, you should immediately go to urgent care to have your urine tested. Fortunately, you should be able to do almost any antibiotic (including Bactrim).

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: ___: Left hip hemiarthroplasty History of Present Illness: ___ male history of hypertension, prostate cancer, left patella fracture status post ORIF ___, ___ who presents with left hip pain status post mechanical fall. Patient was walking home from the assisted living facility in which his wife with dementia resides, when he tripped and fell on the sidewalk today. He tried to get up and then fell again. He was unable to bear weight on his left side. EMS brought him into the hospital for evaluation. He currently complains of pain "all over". He is accompanied by his son who states that he has been recently seen by neurology for evaluation of his cognitive decline. He denies any numbness or tingling in his left lower extremity. Positive head strike, negative loss of consciousness. Patient son states that he has been prescribed some home medications, however he has not been taking any. Past Medical History: HTN, prostate cancer, MGUS, PUD, depression Social History: ___ Family History: non-contributory Physical Exam: Exam: Vitals: ___ 0451 Temp: 98.1 PO BP: 129/73 R Lying HR: 95 RR: 18 O2 sat: 97% O2 delivery: Ra General: Well-appearing, NAD Resp: Normal WOB, symmetric chest rise CV: Extremities WWP MSK: Left Lower Extremity: SILT ___ distributions Firing ___, FHL, TA, GSC Incisional dressing clean dry and intact Pertinent Results: ___ 07:07AM BLOOD WBC-7.6 RBC-3.39* Hgb-10.7* Hct-32.4* MCV-96 MCH-31.6 MCHC-33.0 RDW-12.2 RDWSD-42.7 Plt Ct-86* ___ 07:07AM BLOOD Glucose-131* UreaN-22* Creat-1.0 Na-140 K-3.8 Cl-108 HCO3-23 AnGap-9* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO DAILY 2. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough 3. LORazepam 0.5 mg PO Q6H:PRN anxiety 4. TraZODone 50 mg PO QHS:PRN Insomnia 5. Valsartan 80 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Once nightly Disp #*30 Syringe Refills:*0 5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Third Line 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet by mouth Every 4 hours as needed Disp #*25 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY constipation 8. Senna 17.2 mg PO HS 9. Citalopram 10 mg PO DAILY 10. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough 11. LORazepam 0.5 mg PO Q6H:PRN anxiety 12. TraZODone 50 mg PO QHS:PRN Insomnia 13. Valsartan 80 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: FEMUR (AP AND LAT) LEFT INDICATION: History: ___ with left hip fx, had recurrent fall out of bed// eval ich; eval knee injury TECHNIQUE: Frontal, lateral and cross-table lateral views of the right knee were obtained. COMPARISON: Multiple prior knee radiographs, most recently ___. Hip radiograph dated ___. FINDINGS: A single view of the left hip again demonstrates foreshortening of the left femoral neck, consistent with femoral neck fracture. Brachy therapy seeds are again noted overlying the lower pelvis. Moderate degenerative change at the left hip joint is again noted. No additional fracture or dislocation is seen. Depression of the anterior surface of the patella is likely chronic and related to the prior patellar fracture. Re-demonstrated are cerclage wires and pins in the patella. There is a fracture through one of the superior cerclage wire loops, similar to prior. Re-demonstrated is mild degenerative change along the medial compartment as evidenced by tiny osteophytes. There is no knee joint effusion. There is normal osseous mineralization. No suspicious lytic or sclerotic lesions are identified. Note is made of a fabella posteriorly. IMPRESSION: 1. Re-demonstrated is foreshortening of the left femoral neck, consistent with a femoral neck fracture. 2. There are new fractures within the cerclage wires since the ___ study with irregularity of the anterior aspect of the patella on the lateral view. Please correlate with patellar pain to exclude an acute on chronic patellar fracture. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST. INDICATION: History: ___ with left hip fx, had recurrent fall out of bed// eval ich; eval knee injury. TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 9.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 4.0 s, 8.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 401.4 mGy-cm. Total DLP (Head) = 1,304 mGy-cm. COMPARISON: Head CT dated ___ at 22:11. FINDINGS: The examination is partially limited due to patient motion, within this limitation, grossly there is no evidence of acute territorial infarction, intracranial hemorrhage, edema, or mass effect. The ventricles and sulci are prominent keeping with age-related involutional change. Moderate periventricular and subcortical white matter hypodensities are nonspecific, but likely represent sequela of chronic ischemic microvascular disease. No acute fractures are seen. Re-demonstrated is a small subgaleal hematoma overlying the left frontal bone measuring up to 7 mm in thickness (03:47). There is new soft tissue swelling overlying the right frontal bone measuring up to 5 mm in thickness. A small amount of subcutaneous gas likely reflects known laceration. Aside from mild mucosal thickening in the bilateral ethmoid air cells, the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. There is a new small subgaleal hematoma overlying the right frontal bone. 2. Re-demonstrated is a small hematoma overlying the left frontal bone with an overlying laceration, and subcutaneous emphysema. 3. No acute intracranial hemorrhage or fracture. Radiology Report EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT INDICATION: History: ___ with R shoulder pain s/p fall// eval fx TECHNIQUE: AP and Y-view of the right shoulder were obtained. COMPARISON: None FINDINGS: There is no fracture or dislocation involving the glenohumeral or AC joint. There are mild degenerative changes in the right acromioclavicular joint. No suspicious lytic or sclerotic lesions are identified. No periarticular calcification or radio-opaque foreign body is seen. The visualized portion of the lungs are clear, IMPRESSION: 1. No acute fracture. 2. Mild degenerative disease in the acromioclavicular joint. Radiology Report EXAMINATION: Left hip radiograph, single AP portable view, intraoperative. INDICATION: Immediately status post left hip hemiarthroplasty. COMPARISON: Prior study from ___. FINDINGS: Patient is immediately status post left hip hemiarthroplasty. Hardware appears intact. Brachy therapy seeds again project along the lower central pelvis. IMPRESSION: Anticipated postoperative appearance immediately status post left hip hemiarthroplasty. Gender: M Race: ASIAN Arrive by AMBULANCE Chief complaint: Facial injury, L Hip pain, s/p Fall Diagnosed with Fracture of unsp part of neck of left femur, init, Unspecified fall, initial encounter temperature: 98.1 heartrate: 84.0 resprate: 18.0 o2sat: 97.0 sbp: 184.0 dbp: 88.0 level of pain: 8 level of acuity: 2.0

Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -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 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. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your 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 <30 DAYS OF REHAB Treatments Frequency: Skin staples in place, to be removed at 2-week follow-up

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, diarrhea, hematochezia Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: ___ year old male w/no significant PMH who presents for 3 weeks of diarrhea and bloody stools. He endorses a baseline stool of ___ and now is stooling large, loose stools with mucus and blood approximately ___ daily for the last 3 weeks. He has had red clot and blood streaked stool but no melena. He has not traveled recently, only has eaten sushi in terms of raw/undercooked foods. He is not aware of a family history of IBD or autoimmune disease. He has cut lactose out of his diet w/out effect. He thinks he may have hemorrhoids. He has been having gradually worsening crampy abdominal pain that is exacerbated by eating and has not been able to tolerate PO for the last 24h. He describes it as sharp pain that occurs all over the abdomen 5 minutes after eating, which is not immediately resolved with defecation, as he has had tenesmus, but is unable to pass stool at times. He had a scheduled GI appointment as an outpatient but couldn't wait. He presented today for worsening pain to ___. He endorses chills, denies fevers. + NS. He endorses nausea, denies vomiting. He does note some pain when hitting a pothole while driving. In the ED, initial vitals were: 97.9 64 122/74 16 99% - Labs were significant for Lipase 120, Lactate 1.2. AP140. - Imaging revealed panproctocolitis. - The patient was given IVF and zofran. Vitals prior to transfer were: 98.0 62 127/78 16 100% RA Upon arrival to the floor, patient notes pain is much better (___) since not eating. Notes the zofran given to him in the ED helped with nausea, as well as some of the gas discomfort. REVIEW OF SYSTEMS: (+) Per HPI. otherwise negative. Past Medical History: History of exercise-induced asthma Social History: ___ Family History: Negative for inflammatory bowel disease. Diabetes mellitus in maternal grandmother. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Tmax 98.8 Tc 98.8 HR ___ BP 106/56-116/65 RR ___ SpO2 100% RA General: Well-appearing in NAD SKIN: Warm and well perfused, no lesions or rashes HEENT: Sclera clear, moist mucus membranes, no oropharynx lesions or ulcers NECK: No jugular venous distension, supple Heart: Regular rate and rhythm, no murmurs or rubs Lungs: Clear to auscultation bilaterally, no ronchi, rales, or wheezes Abdomen: Soft, tenderness to palpation diffusely. Slight rebound tenderness. Genitourinary: No foley Extremities: No cyanosis, clubbing, or edema Neurological: Moving all extermities, grossly within normal limits DISCHARGE PHYSICAL EXAM: VS: 97.7, afebrile overnight BP 116/61 HR 58 RR 20, O2 98% on RA GENERAL: No acute distress SKIN: Warm and well perfused, no lesions or rashes HEENT: Anicteric sclerae, pink conjunctivae. MMM NECK: Nontender supple neck CARDIAC: Regular rate and rhythm, normal S1/S2; no murmurs, gallops, or rubs LUNG: Breathing comfortably without use of accessory muscles, clear to auscultation bilaterally, no wheezes, rales, or rhonchi ABDOMEN: + Bowel sounds. Soft, nontender, nondistended, no organomegaly. No rebound or guarding. EXTREMITIES: No cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally NEURO: Alert and appropriate, normal gait Pertinent Results: ADMISSION LABS: ___ 03:22PM BLOOD WBC-9.9 RBC-5.89 Hgb-15.5 Hct-47.1 MCV-80* MCH-26.3* MCHC-32.8 RDW-14.8 Plt ___ ___ 03:22PM BLOOD Neuts-69.4 ___ Monos-7.0 Eos-4.5* Baso-0.2 ___ 03:22PM BLOOD Glucose-79 UreaN-13 Creat-1.0 Na-140 K-4.2 Cl-102 HCO3-29 AnGap-13 ___ 03:22PM BLOOD ALT-33 AST-26 AlkPhos-140* TotBili-1.2 ___ 03:22PM BLOOD Lipase-120* ___ 03:22PM BLOOD Albumin-4.2 Iron-45 ___ 03:22PM BLOOD calTIBC-303 Ferritn-123 TRF-233 ___ 03:27PM BLOOD Lactate-1.2 ___ 03:22PM BLOOD CRP-3.0 ___ 07:25AM BLOOD CRP-5.1* ___ 03:44PM BLOOD SED RATE-17 ___ 07:25AM BLOOD SED RATE-6 ___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE ___ 09:00AM BLOOD HCV Ab-NEGATIVE ___ 09:00AM QUANTIFERON(R)-TB GOLD-NEGATIVE ___ 02:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 02:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 02:45PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 ___ 02:45PM URINE MUCOUS-MANY DISCHARGE LABS: ___ 07:00AM BLOOD CRP-7.1* ___ 07:25AM BLOOD WBC-8.4 RBC-5.29 Hgb-14.3 Hct-41.2 MCV-78* MCH-27.0 MCHC-34.7 RDW-14.0 Plt ___ ___ 09:00AM BLOOD Na-139 K-4.1 Cl-103 ___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE MICROBIOLOGY: ___ OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. MANY POLYMORPHONUCLEAR LEUKOCYTES. FEW RBC'S. ___ - C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. - FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. - CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. - OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. - 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. IMAGING/STUDIES: ___ CT ABD & PELVIS WITH CONTRAST IMPRESSION: Proctocolitis, with wall thickening involving the entire ___, most pronounced in the cecum and ascending ___, findings which are likely infectious or inflammatory in etiology. No small bowel involvement. ___ Sigmoidoscopy Impression: Ulceration, granularity, friability, erythema, congestion and abnormal vascularity in the rectum, sigmoid, and descending ___ compatible with moderate-severe colitis. Otherwise normal sigmoidoscopy to distal descending ___. ___ Sigmoidoscopy PATHOLOGIC DIAGNOSIS: ___, mucosal biopsy (sigmoidoscopy): Chronic moderately active colitis. No granulomata or dysplasia identified. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Calcium Carbonate 500 mg PO TID W/MEALS RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1 tablet(s) by mouth TID W/MEALS Disp #*90 Tablet Refills:*0 2. PredniSONE 40 mg PO ONCE Duration: 1 Dose RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 3. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Ulcerative colitis Secondary diagnosis: History of exercise-induced asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with 3 weeks of bloody diarrhea, abdominal pain, evaluate for colitis. TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis after the administration of intravenous contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. Oral contrast was administered. DLP: 470 mGy-cm COMPARISON: None available. FINDINGS: CHEST: The visualized lung bases are clear. The heart is normal in size and there is no evidence of pericardial effusion. ABDOMEN: The liver enhances homogeneously and is without focal lesions. The portal venous system is patent. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is normal and without radiopaque gallstones. The spleen and adrenal glands are unremarkable. The pancreas enhances homogenously and is without focal lesions. The kidneys display symmetric nephrograms and excretion of contrast. Subcentimeter hypodensity in the upper pole of the left kidney posteriorly is too small to characterize. There is no hydronephrosis. The ureters are normal in caliber and course to the bladder. The distal esophagus is normal without a hiatal hernia. The small bowel, including the terminal ileum, is normal without focal wall thickening. Oral contrast extends through the colon and rectum. There is diffuse wall thickening of the entire colon and rectum, with wall thickening most pronounced in the cecum and ascending colon. There is no evidence of obstruction. The appendix is well-visualized and normal. There is no intra-abdominal free fluid or free air. The abdominal aorta and its major branches are patent. There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. PELVIS: The bladder is well distended and normal. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is identified. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: Proctocolitis, with wall thickening involving the entire colon, most pronounced in the cecum and ascending colon, findings which are likely infectious or inflammatory in etiology. No small bowel involvement. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED, MELENA temperature: 97.9 heartrate: 64.0 resprate: 16.0 o2sat: 99.0 sbp: 122.0 dbp: 74.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, It was a pleasure caring for you during your hospitalization at the ___. You were admitted for abdominal pain, diarrhea, and blood in your stool. We did a CT scan of your abdomen, a sigmoidoscopy, and tests for infection. Based on these tests, and the recommendations of our gastroenterology doctors, we found that you have moderate to severe ulcerative colitis. We also did tests that showed that you do not have a gastrointestinal infection. We gave you steroids IV then switched you to take steroids as a pill. We also monitored your symptoms, and had a nutritionist talk with you about nutritional tips for people with ulcerative colitis. Please take your medications as instructed, including prednisone 40 mg orally once daily- this will be the dose until you see your GI doctors on ___. Please also take a calcium and vitamin D supplement while you are taking prednisone, because prednisone can lower your calcium levels. Please follow up with your scheduled primary care and gastroenterology appointments (see below). Please seek medical attention urgently if you develop any concerning symptoms, including bloody stool, severe abdominal pain, or fever. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Compazine / IV Dye, Iodine Containing Attending: ___. Chief Complaint: RLE numbness and weakness Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a ___ year-old R-handed woman with PMHx of partial seizures and a recent dental infection with numerous complications who presents with RLE weakness and numbness on the R foot. The patient's recent history begins on ___ when she had a cavity filled and then had air tracking into the R side of her face with eyelid swelling. This then tracked into her neck and mediastinum. She was seen at ___ where she had unequal pupils, nystagmus, blurred vision and difficulty with tandem gait. She had a NCHCT there that was read as no acute intracranial abnormalities and a CT neck that showed extensive subcutaneous emphysema throughout the bilateral cervical soft tissues extending to the right orbit superiorly and right supraclavicular fossa and superior mediatsium inferiorly. She was given IV augmentin and pain medication and was discharged on ___ on PO augmentin after her neurological sx resolved. She continued to have facial pain at home, which slowly resolved. Then on ___ around 7pm she had the sudden onset of "excruciating" abdominal pain in the middle of her abdomen. She lay upside down on the stairs and this made it feel "a little bit better". She went to the ___ where she was noted to have a temperature of 102.5. She had blood cultures done which were negative and a CXR which was also negative. She was changed from augmentin to clindamycin (which she was supposed to take until ___. She also at this time started to notice a dull chest pressure. On ___ in the morning she noticed that the tip of her R ___ finger and the tips of her L ___ and ___ R finger were dusky and dark. She saw her PCP also on the ___, and he ordered an echo for concern of endocarditis. The echo was read as normal. She also got a "spiral CT of the torso" at ___ given her chest pain and this was read as normal except for some incidentaal small granulomas, per the patient that they felt could be worked up non-urgently. The CT showed interval resolution of the cutaneous emphysema and pneumomediastinum. Then on ___ and ___ she felt "better", but still with some mild chest pressure. She went for a run on the ___ without any issues. She also flew to ___ on ___. On ___ she had "terrible diarrhea" so she stopped her clindamycin 1 day early. She returned home without incident from her trip. She saw her oral surgeon who prescribed her with an antibiotic mouthwash on ___, but that same evening she had the onset of the same mid jaw pain up to her R eardrum that she had had previously with the crepitus, but this time there was no sensation of "crackling" under her skin. She did feel feverish on that day also. She still ahd some augmentin left over from her previous Rx, so she took that BID. On ___ she no longer had jaw pain. Then today (___) she went to church, and when looking up she felt "dizzy" and "funky", but when pressed to explain the sensation more she was unable to better describe it. This went away if she looked straight or down and would return when she looked up again. This happened at 11am. Shortly after that she felt like she had difficulty paying attention. She went home and at around 1pm she went for a run. She was able to run ___ of a mile before she felt her R leg "fly out from under me". She slumped to the ground but didn't fall. She tried to "walk it off" and had no difficulty with walking. Then she tried to run again and her R leg "flew out again". She again slumped to the ground but didn't fall. She had numbness of her R foot below her ankle at this time. She was again able to walk, and then again tried to run and this time also had the same sensation and was forced to walk the rest of the distance to her car. When she got into her car, she felt unsafe driving home because she "could barely press down on the accelerator" and so she called her husband, who brought her to the ___. There, she had a ___ that was read as showing a "basilar artery issue". She was transferred to ___ for further workup as there was no MRI tech available there. In the ___ at ___, the patient reported that her numbness improved slowly. However, she had some involuntary movements that she felt were seizures in the ___. Starting at 5:30pm she had ___ seconds of bilateral leg shaking, which self-resolved. She had 4 more episodses like this between 5:30pm and 6:15pm and each time she felt that the shaking got a "little bit more severe". Then at 6:15pm she had an episode lasting 5 seconds where her bilateral arms and legs were shaking. She reports that she "looked down and thought, I can't stop these". Her husband witnessed the shaking. She had another episode with arm and leg shaking shortly after this one. She was given 2mg IV ativan. She did not have any further shaking episodes after the ativan but did feel "shaky" still. Past Medical History: seizures depression/anxiety four cesarean sections multiple hernia repairs hypothyroidism Social History: ___ Family History: Her paternal grandfather and father had "fits of rage" which she believes was undiagnosed TLE. She also believes her father had generalized convulsions after having meningitis. He also had a known history of PD and dementia. She has one older brother who is healthy. She has one son with refractory epilepsy. Physical Exam: Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to red pin testing. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Subtle low amplitude high frequency tremor with arms outstretched, slightly worse on the R than L. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5* 5 5 5 5 5 5 * unable to determine if she had giveway weakness at R IP versus very very subtle ___ weakness -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: MRI/MRA w/ and w/out contrast: (prelim read) Head MRI: No acute intracranial process. Scattered bilateral FLAIR hyperintense foci were seen on the prior MRI from ___ and are likely secondary to chronic small vessel ischemic disease. Head /neck MRA: No large vessel occlusion, flow limiting stenosis, or aneurysm greater than 3 mm. Medications on Admission: - clonezepam 1mg QHS - hydroquinone microsphere ER 4% topical cream ER QHS - lamictal XR 225mg BID - synthroid 75mcg QD (recently increased from 75mcg QOD and 50mcg QOD) - ativan 1mg QD PRN seizures - methylphenidate ER 36mg QAM - propranolol 10mg PRN public speaking - vitamin D 400mg BID - docusate 100-200mg QHS PRN constipation - omega 3 1,000mg BID Discharge Medications: 1. Clonazepam 1 mg PO QHS 2. Vitamin D 400 UNIT PO DAILY 3. Lorazepam 1 mg PO DAILY:PRN increased seizure frequency 4. Levothyroxine Sodium 75 mcg PO DAILY 5. LaMICtal XR *NF* (lamoTRIgine) 225 mg Oral BID 6. Concerta *NF* (methylphenidate) 36 mg Oral QAM prn inattention 7. Fish Oil (Omega 3) 1000 mg PO BID 8. Docusate Sodium 100 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Transient neurologic event: Migraine varient vs Seizure varient vs other? Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ woman with right lower extremity foot drop. Basilar artery abnormality on CT. Evaluate vascular pathology. COMPARISON: MRI brain, ___. Head CT, ___. TECHNIQUE: Multi sequence multi planar imaging of the brain was performed both prior to and following the intravenous administration of 15 mL MultiHance as per standard department protocol. An MRA of the brain was performed utilizing 3D time-of-flight technique with rotational reconstructions. Two dimensional time-of-flight MRA of the neck was performed with coronal VIBE imaging during infusion of intravenous contrast. Rotational reformatted images were prepared. FINDINGS: MRI head: The ventricles, sulci, and subarachnoid spaces are normal in size and configuration. There is no evidence of acute infarct or hemorrhage. Scattered punctate foci of nonspecific T2 FLAIR signal hyperintensity are noted in the periventricular, subcortical, and deep white matter bilaterally, most likely representing the sequela of chronic small vessel disease. There is no abnormal intra or extra-axial fluid collection, no shift of normally midline structures, and no mass lesion or mass effect. There is no abnormal enhancement. The visualized paranasal sinuses, mastoids, and orbits are unremarkable. MRA brain: The vertebral and basilar arteries are normal in appearance with a normal branching pattern. There is no evidence of significant stenosis, occlusion, dissection, or aneurysm. The intracranial internal carotid arteries and the anterior, middle, and posterior cerebral arteries are normal in appearance without evidence of significant stenosis, occlusion, dissection, or aneurysm. MRA neck: The right common, internal, and external carotid arteries are normal in appearance without evidence of a hemodynamically significant stenosis, dissection, or occlusion. The distal right internal carotid artery measures 6 mm. The left common, internal, and external carotid arteries are normal in appearance without evidence of hemodynamically significant stenosis, dissection, or occlusion. The distal left internal carotid artery measures 5.5 mm. The bilateral vertebral arteries are normal in appearance without evidence of dissection, stenosis, or occlusion. The aortic arch and the origins of the great vessels are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. No evidence of infarct. 2. Unremarkable MR angiography of the head and neck. 3. Nonspecific white matter signal abnormality most likely represents the sequela of chronic small vessel disease. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: NEURO CHANGES Diagnosed with MUSCSKEL SYMPT LIMB NEC, HYPOTHYROIDISM NOS temperature: 98.6 heartrate: 72.0 resprate: 18.0 o2sat: 99.0 sbp: 128.0 dbp: 76.0 level of pain: 2 level of acuity: 1.0

You were placed on the neurology service for events concerning for possible seizure and right leg wekaness. Your evaluation thus far was normal including the physical exam, the MRI, and lumbar puncture study. We are not to sure what the etiology of your presentation was. We will have you follow up as needed. No further tests are needed now.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diverticulitis Major Surgical or Invasive Procedure: CT guided aspiration of intraabdominal collection ___ Procedure History of Present Illness: ___ no sig PMH p/w ___ weeks of abdominal pain. He states that for the past ___ weeks he's had LLQ abdominal pain, fatigue, malaise, fevers/chills, and anorexia. He does state that he typically has hard stools and chronic constipation. He denies melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency. He has never had a colonoscopy, and never had symptoms like this before. Past Medical History: Past Medical History: HTN, HLD, ___ abscess s/p I+D Past Surgical History: ___ abscess I+D Social History: ___ Family History: Family History: No hx of Crohn's, UC, or cancer Physical Exam: Admission Physical Exam: Temp: 98.2 HR: 89 BP: 131/89 Resp: 18 O(2)Sat: 97 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Neck is supple Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, moderate LLQ tenderness and minimal RLQ tenderness with palpation, Nondistended Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation ___: No petechiae Discharge Physical Exam: Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Neck is supple Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, mid line incision- skin open dressed with VAC, LLQ colostomy- functional and viable, abdomen soft and Non-distended Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation ___: No petechiae Pertinent Results: ___ CT Abdomen Pelvis: Successful CT-guided aspiration of the 2 largest fluid pockets of the collection without drainage catheter placement due to multiple septations within the collection. Samples were sent for microbiology evaluation. ___ CXR: No acute findings. ___ 08:18AM BLOOD WBC-10.5* RBC-3.64* Hgb-10.3* Hct-30.9* MCV-85 MCH-28.3 MCHC-33.3 RDW-14.4 RDWSD-43.8 Plt ___ ___ 08:18AM BLOOD Plt ___ ___ 07:40AM BLOOD ___ ___ 08:18AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-135 K-4.2 Cl-98 HCO3-20* AnGap-21* ___ 08:18AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0 ___ 07:45AM BLOOD Ferritn-1002* ___ 07:45AM BLOOD Triglyc-78 Medications on Admission: atenolol 50 mg tablet once daily Hydrochlorothiazide 25 mg tablet once daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. 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 4. Atenolol 50 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Diverrticular abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT-GUIDED ASPIRATION INDICATION: ___ year old man with complicated diverticulitis and complex anterior pelvic collection. COMPARISON: CT abdomen/pelvis from ___ (Atrius) PROCEDURE: CT-guided aspirate of anterior pelvic collection. OPERATORS: Drs. ___ and ___, radiology fellows and Dr. ___, attending radiologist. Dr. ___ supervised the trainees 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 aspiration 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 WIRE WAS ADVANCED THROUGH THE NEEDLE IN anticipation of catheter placement, however the wire coiled at the tip of the needle, due to septations in the collection. The ___ needle was then repositioned into a different pocket which again was too small for catheter placement. Approximately 5 cc of purulent fluid were aspirated at both needle positions with a sample sent for microbiology evaluation. The needle was then removed. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.5 s, 26.1 cm; CTDIvol = 20.4 mGy (Body) DLP = 506.0 mGy-cm. 2) Stationary Acquisition 9.8 s, 1.4 cm; CTDIvol = 101.6 mGy (Body) DLP = 146.3 mGy-cm. Total DLP (Body) = 662 mGy-cm. SEDATION: Analgesia was provided by administering divided doses of 50 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: Complex anterior pelvic collection with a small fluid component amenable to aspiration. IMPRESSION: Successful CT-guided aspiration of the 2 largest fluid pockets of the collection without drainage catheter placement due to multiple septations within the collection. Samples were sent for microbiology evaluation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with diverticulitis, febrile// please eval for injury TECHNIQUE: Chest single view COMPARISON: None FINDINGS: Right cardiophrenic angle fullness may represent prominent cardiophrenic angle fat pad, diaphragmatic hernia, less likely cyst. Shallow inspiration accentuates heart size. Normal pulmonary vascularity. No edema. No infiltrates. Trace left pleural effusion or thickening. No pneumothorax. IMPRESSION: No acute findings. Gender: M Race: BLACK/AFRICAN Arrive by AMBULANCE Chief complaint: Abd pain, Abnormal CT Diagnosed with Dvtrcli of lg int w perforation and abscess w/o bleeding temperature: 98.2 heartrate: 89.0 resprate: 18.0 o2sat: 97.0 sbp: 131.0 dbp: 89.0 level of pain: 5 level of acuity: 3.0

Dear Mr. ___, You were admitted to the Acute Care Surgery service on ___ with an abscess/infection in your large bowel caused by diverticulitis. You were initially managed with antibiotics and aspiration of the fluid collection. Your symptoms did not improved and therefore surgical removal of the affected piece of your colon was recommended. You tolerated the procedure well. Post operatively you were given IV fluids until your ostomy started functioning. Your diet was then progressed to regular with good tolerability. You were seen by the wound and ostomy nurse to help learn how to care for your colostomy and for your VAC dressing on your midline wound. You are now doing better, pain is controlled, and you are tolerating a regular diet. You are now ready to be discharged home with visiting nursing services and 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: *You had a special dressing applied to your surgical incision called a wound vac. This dressing will be changed approximately every 3 days.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman found down by ___ after an unwitnessed fall. The patient states that she was laying in bed and accidentally rolled off the edge onto the floor striking her head and left shoulder. She does not recall feeling dizzy, lightheaded, SOB, chest pain, palpitations, or any other preceeding symptoms. However, the EMS reports state that the patient reported falling as she was returning from the bathroom when she became dizzy and fell. Unclear whether she lost consciousness. She reports pain in her head, left shoulder, lower back, and right knee. . In the ED, initial VS were 97.6, 62, 177/67/14, 96% RA. Labs notable for HCT 33.1, UA with a few bacteria and trace leuk esterase. CT head neg for acute process. CT c-spine with severe DJD and congenital non-fusion of posterior arch of C1. CXR neg for acute process. EKG showed sinus at 58, incomplete LBBB. Patient was given 4mg IV morphine. Past Medical History: - Known chronic left shoulder dislocation, which orthopedics has advised previously does not warrant urgent repair ___ chronicity - Chronic LUE lymphedema ___ lymph node resection - Breast CA s/p partial mastectomy on R and lumpectomy on L - Diastolic HF - Likely CAD given apical reversible defect on stress test ___ - Borderline DM - Hypertension - Hyperlipidemia - PVD - Depression - Anxiety - S/p bilateral hip and knee replacements Social History: ___ Family History: Has 2 daughters, one who passed away several years ago from an unknown type of cancer and another who has cerebral palsy. Physical Exam: ADMISSION EXAM: VS: 98.0, 150/70, 61, 16, 96% RA, 62.8 kg GENERAL: NAD, comfortable, appropriate HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK: Supple, no thyromegaly, no JVD HEART: ___ SEM at ___ LUNGS: Scattered rales at both bases, no wheezing ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: LUE with significant edema (chronic), 2+ pitting edema bilaterally to knees SKIN: no rashes or lesions NEURO: Awake, A&Ox3 but forgetful, CNs II-XII grossly intact, muscle strength ___ throughout (limited by arthritis in her hands and knees), sensation grossly intact throughout, gait not assessed . DISCHARGE EXAM: GENERAL:VSS 98.6 (98.6)- 132/46 - 64 - 18 - 96%RA HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK: Supple, no thyromegaly, no JVD HEART: ___ SEM at ___ LUNGS: Scattered rales at both bases, no wheezing ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: LUE with significant edema (chronic), SKIN: no rashes or lesions NEURO: Awake, A&Ox3 but forgetful, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS: ___ 11:59AM BLOOD WBC-4.8 RBC-3.60* Hgb-11.2* Hct-33.1* MCV-92 MCH-31.1 MCHC-33.8 RDW-14.7 Plt ___ ___ 11:59AM BLOOD Neuts-55.5 ___ Monos-7.6 Eos-1.9 Baso-0.5 ___ 11:59AM BLOOD Glucose-122* UreaN-17 Creat-0.8 Na-141 K-3.7 Cl-103 HCO3-28 AnGap-14 ___ 11:59AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7 ___ 11:59AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:59AM BLOOD CK(CPK)-41 ___ 12:10PM BLOOD Lactate-1.5 ___ 12:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 12:35PM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 . DISCHARGE LABS: . MICROBIOLOGY: ___ Blood cultures: no growth to date ___ Urine culture: <10,000 organisms . IMAGING: ___ CT Head w/o con: No acute intracranial process. . ___ CT C-spine w/o con: 1. No evidence of fracture or traumatic malalignment. Congential non-fusion of posterior arch of C1. 2. Severe degenerative changes as noted in full report. . ___ PA/LAT CXR: 1. Left anterior shoulder dislocation. 2. Pulmonary vascular congestion. . ___ AP/LAT Lumbosacral spine x-ray: Multilevel severe degenerative changes, difficult to assess the lumbosacral junction particularly L5. If there is high clinical concern for acute fracture, CT is more sensitive and should be considered. . ___ Right knee x-ray: Status post right knee arthroplasty with prosthesis in anatomic alignment. On the oblique image, there is a linear lucency projecting over the lateral distal femur thought to most likely be artifactual. Not seen on the additional images. Small suprapatellar joint effusion. . ___ Left shoulder x-ray: Persistent anterior inferior displacement of the left humeral head in relation to the glenoid. Medications on Admission: 1. Acetaminophen 325 mg PO BID 2. Citalopram 20 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Hydrocortisone Cream 1% 1 Appl TP QID apply to skin on chest BID until healed 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Nystatin Cream 1 Appl TP BID apply to groin and abdominal folds until healed 7. Oxybutynin 2.5 mg PO BID 8. Simvastatin 80 mg PO DAILY 9. Acetaminophen 325 mg PO Q4H:PRN pain 10. nystatin *NF* 100,000 unit/g Topical apply to groin twice daily as needed 11. Aspirin 81 mg PO DAILY 12. Milk of Magnesia 15 mL PO DAILY:PRN constipation 13. Naproxen 500 mg PO Q12H 14. BusPIRone 5 mg PO BID Discharge Medications: 1. Acetaminophen 325 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Simvastatin 80 mg PO DAILY 6. Acetaminophen 325 mg PO Q4H:PRN pain 7. BusPIRone 5 mg PO BID 8. Hydrocortisone Cream 1% 1 Appl TP QID apply to skin on chest BID until healed 9. Milk of Magnesia 15 mL PO DAILY:PRN constipation 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Naproxen 500 mg PO Q12H 12. nystatin *NF* 100,000 unit/g Topical apply to groin twice daily as needed 13. Nystatin Cream 1 Appl TP BID apply to groin and abdominal folds until healed 14. Oxybutynin 2.5 mg PO BID 15. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Mechanical fall 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: Spine and left shoulder pain. TECHNIQUE: Supine frontal radiograph. COMPARISON: Chest radiograph ___ FINDINGS: The heart size is mildly enlarged. The cardiomediastinal silhouette and hilar contour is stable. There is stable mild widening of the mediastinal contour likely related to tortuous aorta. There is stable cephalization of the pulmonary vasculature compatible with congestion. There is no focal consolidation, effusion or pneumothorax. There is anterior dislocation of the left shoulder better visualized on same date dedicated glenohumeral joint radiographs. There are extensive degenerative changes of the right glenohumeral joint. IMPRESSION: 1. Left anterior shoulder dislocation. 2. Pulmonary vascular congestion. Radiology Report EXAM: Left shoulder, three views. CLINICAL INFORMATION: Left shoulder pain. ___. FINDINGS: Three views of the left shoulder were obtained. Again seen, there is persistent anterior dislocation/subluxation of the left humeral head in relation to the glenoid. No definite acute fracture is seen. Degenerative changes are seen involving the left shoulder as well as the left acromioclavicular joint. A surgical clip is again seen projecting over the left mid hemithorax. Partially imaged left lung demonstrates low lung volumes and please see dedicated chest radiograph for further evaluation. IMPRESSION: Persistent anterior inferior displacement of the left humeral head in relation to the glenoid. Radiology Report EXAM: Lumbar spine, AP and lateral views. CLINICAL INFORMATION: Head and spine pain. COMPARISON: None. FINDINGS: AP and lateral views of lumbar spine were obtained. There are multilevel degenerative changes including severe intervertebral disc space narrowing throughout and marginal sclerosis with anterior osteophytosis. It is difficult to exclude a subtle fracture particularly at the lumbosacral junction and if it is of high clinical concern, CT is more sensitive and should be considered. There is minimal dextroscoliosis of the lumbar spine. Patient is status post bilateral hip replacement with prosthesis partially imaged; the femoral component of the prosthesis on the right appears to be slightly superior in location in relation to the acetabular cup, unclear whether this is due to positioning. The pubic symphysis is intact as there are vascular calcifications. The sacrum is partially obscured by bowel gas. IMPRESSION: Multilevel severe degenerative changes, difficult to assess the lumbosacral junction particularly L5. If there is high clinical concern for acute fracture, CT is more sensitive and should be considered. Radiology Report EXAM: Right knee, three views. CLINICAL INFORMATION: Right knee pain. COMPARISON: None. FINDINGS: Three views of the right knee were obtained. Patient is status post right knee replacement with prosthesis in anatomic alignment. On the oblique image, there is a subtle lucency projecting obliquely along the lateral distal femur which is felt to most likely be artifactual, not well seen on the other images. There appears to be a small suprapatellar joint effusion. IMPRESSION: Status post right knee arthroplasty with prosthesis in anatomic alignment. On the oblique image, there is a linear lucency projecting over the lateral distal femur thought to most likely be artifactual. Not seen on the additional images. Small suprapatellar joint effusion. Radiology Report HISTORY: Status post unwitnessed fall presenting with head and spine pain. TECHNIQUE: Contiguous axial MDCT images of the head were obtained without IV contrast. Multiplanar reformatted images were generated in the coronal and sagittal planes as well as thin section bone algorithm images. DLP: 1538.57 mGy-cm. COMPARISON: None available. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or acute large territory infarct. Prominent ventricles and sulci are suggestive of age-related involutional change. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. Atherosclerotic calcifications are visualized in the vertebral arteries and carotid siphons. IMPRESSION: No acute intracranial process. Radiology Report HISTORY: Status post unwitnessed fall presenting with head and spine pain. TECHNIQUE: Axial helical MDCT images were obtained from skull base to the level of C3-C4. Multiplanar reformatted images were generated in the coronal and sagittal planes. DLP: 830.25 mGy-cm. COMPARISON: None available. FINDINGS: There is posterior non-fusion of C1 which is likely congenital. No acute fracture is identified. No traumatic malalignment is identified. There are severe degenerative changes of the cervical spine with most severe degenerative change and complete fusion of C5-C6. Grade 1 anterolisthesis of C7 on T1 is likely chronic and degenerative in nature. Prominent posterior osteophytes at the level of C3-C4 and C5-C6 minimally indents the thecal sac. There is significant facet joint and uncovertebral hypertrophy which narrow the neural foramina at multiple levels. Coarse calcifications medial to the right mandible in the soft tissue possibly represent sialoliths however there is no enlargement of the associated submandibular gland. The imaged lung apices are clear. IMPRESSION: 1. No evidence of fracture or traumatic malalignment. 2. Severe degenerative changes as noted above. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with SYNCOPE AND COLLAPSE, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE, HYPERTENSION NOS temperature: 97.6 heartrate: 62.0 resprate: 14.0 o2sat: 96.0 sbp: 177.0 dbp: 67.0 level of pain: 13 level of acuity: 2.0

Ms. ___, It was a pleasure caring for you at ___ ___. You were admitted after you fell. You had a cat scan of your head and x-rays of your shoulders, hips, and knees, which did not show any fracture or other concerning findings. . You were evaluated by physical therapy while here, and they felt that you were better off by going to rehab first. We have found you a place at rehab.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dark stools, lightheadedness Major Surgical or Invasive Procedure: ___ Esophagogastroduodenoscopy (EGD) History of Present Illness: Mr ___ is a ___ yo male with h/o ESRD on HD, CAD, distant seizure, gout, who presents from ___ with concern for UGIB. The patient reports had black stools for ___ days and was feeling nauseous and weak, so he went to ___. There, he was found to have BP 84/51 and HCT of 22. He was given 500cc NS with improvement. His stools were guaiac positive. He was started on protonix 80mgbolus then 8mg/hr, given 1U pRBCs and transferred here. Upon arrival here, the patient had no complaints in ED. In the ED, initial VS were: 99.5 64 129/71 15 100% 2L. HCT here was 23, hgb 8, WBC 11.2 w/ neutrophil predominance CK: 38 MB: 2 Trop 0.21 @1:15am, K 5.4, Bicarb 21 with AG 12 and Lactate:0.9, BUN/creat 105/6.3. . EKG NSR 67, RBBB, LAD, ST depressions in V4 to V5. hemodynamically stable. CXR with no acute changes. He was ordered for 2 more units of PRBCs, transfused 1L NS infusing at 125cc/hr, 2 18g IVs were placed, protonix drip at 8Mg/hr. Prior to transfer the patient’s VS were 125/70 - 64 - 20 - 98% RA. Upon arrival to the MICU the patient was comfortable and denied chest pain, palpitations, shortness of breath or abdominal pain. He did reports occasional lower abdominal cramping and some loose watery stools. He denies fevers, chills, or sick contacts. The patient also reports that he has recently been taking plavix and ASA 325mg. He originally discontinued Plavix as recommended by his cardiologist and increased ASA from 81mg to 325mg. However, he resumed Plavix inadvertently and so was on plavix and ASA 325mg. In addition, he was treated last week with prednisone and indomethacin for a gout flare. The patient had an EGD done today, and is subsequently transferred to the floor. Currently, he denies complaint. His most recent BM was several hours ago, and he reports this as being formed, but is unsure of the color. He feels better than when he was admitted, but is still feels tired. No CP, SOB, cough, f/c/s. Past Medical History: - HTN - hyperlipidemia - NSTEMI - chronic LBP and h/o spinal stenosis - peripheral neuropathy - h/o head injuries ___ left forehead vs window in MVA, age ___ boxing injury to right side of head; neither of these with reported LOC) - chronic renal failure on HD ___, and on transplant list - left upper arm graft for HD since ___ s/p mult thrombectomies and stent - MRA showed small basilar stenosis (50%), 1-2 mm aneurysm of the A2 segment and carotid US with ulcerative plaque in the left bulb area recently evaluated by Dr. ___ in ___ without recommendation of further intervention - h/o of gout attack in left elbow -simple partial seizures consisting of left arm jerking with occasional secondary generalization -Diverticulosis of the sigmoid and ascending colon on colonoscopy -Prostate cancer Past Surgical History: - s/p coronary stent in ___, per patient was told that he may have had a small stroke associated with this procedure - right hip replacement ___ - total knee replacement in ___ & ___ - prostate surgery Social History: ___ Family History: Denies family history of seizures or psych history. Mother with ?esophageal and liver disease. Father with prostate cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:144/51 62 100RA 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, ___ systolic murmur LSB 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, ___ strength upper/lower extremities, grossly normal sensation Discharge: Vitals: 98.1 146/75 97%RA General: Alert, oriented, no acute distress, pleasant HEENT: MMM Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur LSB Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation Pertinent Results: ADMISSION LABS: ___ 01:15AM BLOOD WBC-11.2*# RBC-2.35* Hgb-8.0* Hct-23.9* MCV-102* MCH-33.8* MCHC-33.3 RDW-15.6* Plt ___ ___ 01:15AM BLOOD Neuts-87.5* Lymphs-9.1* Monos-2.5 Eos-0.7 Baso-0.2 ___ 01:15AM BLOOD ___ PTT-27.1 ___ ___ 01:15AM BLOOD Glucose-128* UreaN-105* Creat-6.3* Na-139 K-5.4* Cl-106 HCO3-21* AnGap-17 ___ 01:15AM BLOOD ALT-19 AST-15 CK(CPK)-38* AlkPhos-54 TotBili-0.2 ___ 01:15AM BLOOD CK-MB-2 ___ 01:15AM BLOOD cTropnT-0.21* ___ 01:15AM BLOOD Albumin-3.6 ___ 01:24AM BLOOD Lactate-0.9 CHEST X-RAY (___): The lungs are clear. Again seen is an azygos fissure. Mild-to-moderate cardiomegaly is unchanged. There is no central venous congestion or pulmonary edema. No significant pleural effusions or pneumothorax. IMPRESSION: Stable cardiomegaly. No evidence of volume overload. EGD ___ Esophagus: Mucosa: Localized granularity, friability and erythema of the mucosa with a small nodular area with contact bleeding were noted in the gastroesophageal junction. These findings are compatible with esophagitis. Protruding Lesions A single 4 mm nodule of benign appearance was seen in the upper third of the esophagus. Stomach: Excavated Lesions A single superficial non-bleeding 1.5 cm ulcer was found in the pylorus extending into the pyloric channel. Duodenum: Mucosa: Friability and erythema with ulceration of the mucosa with contact bleeding were noted in the duodenal bulb and second part of the duodenum. Impression: Nodule in the upper third of the esophagus Granularity, friability and erythema with a small nodular area in the gastroesophageal junction compatible with esophagitis Ulcer in the pylorus Friability and erythema with ulceration in the duodenal bulb and second part of the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: Omeprazole 40mg BID. Hpylori serology. ADAT. Outpatient repeat egd in ___ weeks for biopsies of esophageal nodule, GE junction and evaluation to ensure ulcer healing. Discharge labs: ___ 08:48AM BLOOD WBC-8.0 RBC-3.01* Hgb-9.6* Hct-29.4* MCV-98 MCH-31.7 MCHC-32.5 RDW-14.8 Plt ___ ___ 08:48AM BLOOD Glucose-97 UreaN-70* Creat-6.2*# Na-141 K-4.2 Cl-102 HCO3-27 AnGap-16 ___ 08:48AM BLOOD Calcium-8.0* Phos-5.0* Mg-2.1 LABS PENDING RESULTS: ___ 8:05 am HELICOBACTER PYLORI ANTIBODY TEST Medications on Admission: -Atenolol 12.5 mg a day -amlodipine 10 mg a day -simvastatin 20mg a day -Dyazide -aspirin 325 mg -Renal Caps -Sensipar 60mg daily -Renagel (Sevelamer) -lamotrigine 100 b.i.d. (100 mg extra after dialysis) -levetiracetam 250 b.i.d. -plavix 75mg daily Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day. 5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS): As previously prescribed, discuss dosing with your nephrologist. 6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 100mg extra after HD. 7. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Esophagitis Pyloric ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with GI bleeding and end-stage renal disease. ___. CHEST, AP UPRIGHT: The lungs are clear. Again seen is an azygos fissure. Mild-to-moderate cardiomegaly is unchanged. There is no central venous congestion or pulmonary edema. No significant pleural effusions or pneumothorax. IMPRESSION: Stable cardiomegaly. No evidence of volume overload. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LGIB Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS temperature: 99.5 heartrate: 64.0 resprate: 15.0 o2sat: 100.0 sbp: 129.0 dbp: 71.0 level of pain: 4 level of acuity: 2.0

You were admitted for low blood pressure and bleeding from your bottom. This was most likely caused by an ulcer in your stomach, which was seen on EGD (a procedure to look down your throat into your stomach). It will be important for you to STOP TAKING PLAVIX AND INDOMETHACIN!! You should also avoid ALL NSAIDs, like ibuprofen as these medications put you at a risk of more bleeding. Please make an appointment with your primary doctor as soon as possible after discharge, and discuss referral to a gastroenterologist. You should also make sure to follow-up the results of the H. pylori test (the bacteria that can lead to ulcers in the stomach). Please note the following medication changes: -Please DO NOT TAKE PLAVIX -Please DO NOT TAKE INDOMETHACIN or other NSAIDs -Please START omeprazole to reduce the amount of acid in your stomach -Please discuss with the doctor at dialysis whether your blood pressure is at a safe level after dialysis to start your blood pressure medications. These are: --Atenolol --Amlodipine --Dyazide. If safe, you should consider first re-starting atenolol, then amlodipine. You should also discuss this with your primary doctor. - Increase renvela to 800 mg three times a day with meals, as your phosphate was high during this admission. Please discuss this dosing with your kidney doctor.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vancomycin Attending: ___. Chief Complaint: Acute Kidney Injury / Hyperkalemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o man with hx of CAD s/p NSTEMI, T1DM (last A1c 8.5%), ___, and multiple prior debridements for non-healing L foot ulcers recently hospitalized for cellulitis of right foot. He was discharged home and when he came back for follow up four days, he was found to have hyperkalemia and ___ from his bloodwork. For his cellulitis, he was initially treated with empiric IV vancomycin and zosyn, transitioned to PO bactrim, cipro, and flagyl per wound culture showing polymicrobial growth (notably MRSA and GNR's). His foot ulcer and cellulitis improved significantly and the pain subsided. Additionally, the leg swelling associated with cellulitis improved. However, he reports that he did not feel great even after the treatment. He reported frequent large volume urination, even though he was drinking just ___ coffees a day. He reported that he was feeling tired, and he did not want to move because of aches. The abnormal elevated Creat, hyperkalemia and hyponatremia prompted ED admission. Notably, the patient reported constipation for 6 days. Today he had a small bowel movement but he still feels bloated. He reported that he had a rectal exam in the ED yesterday and the MD did not think that he was impacted or had stool in the rectal vault. In the ED, initial vitals were: 22:11 0 97.8 63 167/55 16 99% RA - Labs were significant for initial K 6.0 with creat 1.7, Na130, u/a negative. - ECG showed QWI in I/AVL and TWI AVL consistent with prior with no peaked T waves - Foot xray showed a foreign object - needle inside his foot. - The patient was given 500cc NS, 10U regular insulin, 25gm 50% dextrose, 2g calcium gluconate, 1500mg IV vancomycin. Vitals prior to transfer were: Today 04:46 0 97.8 64 138/95 20 96% RA Upon arrival to the floor, the patient reported that he was tired from staying up in the ED. He slept well and did not complain of pain, shortness of breath or fevers. Past Medical History: -T1DM (most recent A1c 8.5% in ___ -Hypertension -Hypercholesterolemia -Diastolic CHF -GERD -Depression -Neuropathy -History of fungal bloodstream infections, polymicrobial wound infections (enterobacter, MRSA, prevotella, corynebacterium, -CAD: NSTEMI ___ with PCI of an OM branch with DES. -UGIB PAST SURGICAL HISTORY: -DES to OM1 -cholecystectomy -Hx of multiple debridement on L foot for non-healing ulcers -Tonsilectomy Social History: ___ Family History: Father - leukemia Mother - colon ca Physical Exam: =============== ADMISSION EXAM: =============== 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, ___ systolic murmur Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, moderately distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, palpable AT and DP, no clubbing, cyanosis or edema. Large partially open ulcer in the R bug toe, no surrounding erythema or tenderness. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. LABS: See below =============== DISCHARGE EXAM: =============== Vitals: 98.0, 144/62, 68, 20, 98% on 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, ___ systolic murmur Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, moderately distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, palpable AT and DP, no clubbing, cyanosis or edema. Large partially open ulcer in the R bug toe, no surrounding erythema or tenderness. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: =============== ADMISSION LABS: =============== ___ 10:00PM GLUCOSE-265* UREA N-25* CREAT-1.6* SODIUM-132* POTASSIUM-6.0* CHLORIDE-103 TOTAL CO2-21* ANION GAP-14 ___ 10:00PM estGFR-Using this ___ 10:00PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.7 ___ 03:20PM GLUCOSE-296* UREA N-25* CREAT-1.6* SODIUM-131* POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-22 ANION GAP-14 ___ 03:20PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-1.8 ___ 09:35AM GLUCOSE-302* UREA N-25* CREAT-1.6* SODIUM-131* POTASSIUM-6.2* CHLORIDE-100 TOTAL CO2-21* ANION GAP-16 ___ 09:35AM CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-1.7 ___ 02:13AM URINE HOURS-RANDOM ___ 02:13AM URINE UHOLD-HOLD ___ 02:13AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:13AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 11:16PM K+-5.5* ___ 11:00PM GLUCOSE-169* UREA N-26* CREAT-1.7* SODIUM-130* POTASSIUM-5.6* CHLORIDE-99 TOTAL CO2-21* ANION GAP-16 ___ 11:00PM WBC-6.6 RBC-3.62* HGB-10.3* HCT-31.4* MCV-87 MCH-28.5 MCHC-32.8 RDW-14.1 RDWSD-43.9 ___ 11:00PM NEUTS-76.2* LYMPHS-15.6* MONOS-6.9 EOS-0.0* BASOS-0.8 IM ___ AbsNeut-5.05 AbsLymp-1.03* AbsMono-0.46 AbsEos-0.00* AbsBaso-0.05 ___ 11:00PM ___ PTT-30.3 ___ ___ 02:50PM GLUCOSE-107* UREA N-28* CREAT-1.8* SODIUM-132* POTASSIUM-6.0* CHLORIDE-98 TOTAL CO2-23 ANION GAP-17 ================== PERTINENT RESULTS: ================== ___ 09:36PM BLOOD K-5.1 ___ 04:18PM BLOOD K-5.4* ___ 11:16PM BLOOD K-5.5* XR R Foot (___): Retained needle adjacent to the second metatarsal. =============== DISCHARGE LABS: =============== ___ 07:15AM BLOOD WBC-6.3 RBC-3.54* Hgb-10.2* Hct-31.6* MCV-89 MCH-28.8 MCHC-32.3 RDW-14.6 RDWSD-46.0 Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-211* UreaN-20 Creat-1.4* Na-133 K-5.1 Cl-100 HCO3-24 AnGap-14 ___ 05:40AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7 ___ 07:15AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.8 ___ 09:36PM BLOOD ___ pO2-60* pCO2-44 pH-7.37 calTCO2-26 Base XS-0 Comment-GREEN-TOP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Carvedilol 6.25 mg PO BID 5. Chlorthalidone 25 mg PO DAILY 6. Gabapentin 600 mg PO QHS 7. HydrALAzine 25 mg PO BID 8. Lisinopril 40 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Sertraline 50 mg PO DAILY 11. Cetirizine 10 mg PO DAILY:PRN pruritis 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Ciprofloxacin HCl 500 mg PO Q12H 14. Sulfameth/Trimethoprim DS 2 TAB PO BID 15. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 16. Glargine 66 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Carvedilol 6.25 mg PO BID 5. Cetirizine 10 mg PO DAILY:PRN pruritis 6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days Please take for total of 14 days with last dose on ___ 7. Gabapentin 600 mg PO QHS 8. HydrALAzine 25 mg PO BID 9. Glargine 66 Units Bedtime Humalog 12 Units Breakfast Humalog 12 Units Lunch Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin 10. Omeprazole 20 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Sertraline 50 mg PO DAILY 13. Clindamycin 300 mg PO Q6H Duration: 5 Days Take for 5 days (Last Dose evening of ___ RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #*20 Capsule Refills:*0 14. Outpatient Lab Work Hyperkalemia Repeat Chem-7 To be drawn at follow-up on ___ Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Acute Kidney Injury - Hyperkalemia Secondary Diagnosis: -T1DM -Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ year old man with recent admission for RLE cellulitis, hx of stepping on insulin needle with ?retention // any retained foreign body any retained foreign body TECHNIQUE: Three views right foot COMPARISON: None. FINDINGS: Extensive postsurgical changes are seen in the right foot including amputation of the second metatarsal head and phalanges as well as osteotomy of the fifth digit. There is moderate soft tissue swelling. A linear foreign body is noted adjacent to the residual distal second metatarsal, consistent with needle per patient's history. No definite bony erosions are noted to suggest osteomyelitis. IMPRESSION: Retained needle adjacent to the second metatarsal. NOTIFICATION: These results were discussed with The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at approximately 745 am. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Non-prs chronic ulcer oth prt right foot w unsp severity, Acute kidney failure, unspecified temperature: 97.8 heartrate: 63.0 resprate: 16.0 o2sat: 99.0 sbp: 167.0 dbp: 55.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for high levels of potassium and kidney injury, which were attributed to a combination of taking lisinopril and bactrim, as well as low fluid intake. You were given IV fluids, insulin and sugar, kayexalate, and lactulose to control the potassium levels. Your kidney function improved with IV fluids. You were given a new antibiotic regimen for you to continue to take (Clindamycin and Ciprofloxacin). Please do not take lisinopril or chlorthalidone until you follow-up with your primary care physician, who will order a blood test to determine your current potassium level. You can continue to take the ciprofloxacin that was prescribed to you, and you have been given a prescription for the clindamycin. Please take your antibiotics through ___. It is important that you take all of your medications as prescribed, and that you attend all of your follow-up appointments as scheduled. Please Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you the best of health, Your Care Team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ibuprofen Attending: ___. Chief Complaint: Aphasia Major Surgical or Invasive Procedure: Thrombectomy History of Present Illness: THis is a ___ with significant history of tobacco use who presented with aphasia. Last known well ___ AM when his wife left him to go to work. Per wife, the patient had returned from early AM shift and she had prepared breakfast for him. He ate breakfast and was quite jovial. He then went to lie down at 08:45. Wife left to work at that time. The patient's brother randomly called throughout the day and noted that the patient wasn't making sense on the phone. Wife was alerted and EMS was called. He was taken to OSH and subsequently transferred for left M1 occlusion for evaluation of thrombectomy as he was outside tPA window on arrival to OSH. Past Medical History: Glaucoma Tobacco use Social History: ___ Family History: did not obtain prior to thrombectomy Physical Exam: ON ADMISSION: PHYSICAL EXAMINATION: Vitals: 96.8 83 12 130/67 General: Awake, semi-cooperative with exam, visibly frusturated HEENT: no scleral icterus noted, MMM Pulmonary: Normal work of breathing. Breath w tobacco essence. Cardiac: warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Neurologic: -Mental Status: Alert, oriented to self and to wife and daughters at bedside. Unable to relate history. Attentive to examiner and to exam. Expressive aphasia with possible component of conductive aphasia. Can only follow some one-step commands with verbal request. Can follow commands with mimic. Cannot repeat. Speech output is spontaneous but mostly nonsensical, although occasional he says "I'm ok" to his wife. Can only name some high frequency objects but not low frequency objects. Perseverates over objects "hand hand hand" in response to different objects, although first one was indeed a glove. Cannot describe scene around him or cookie cutter image. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. V: Facial sensation intact to light touch. VII: Right NLFF w delayed activation. VIII: Hearing intact to conversation. IX, X: Palate elevates symmetrically. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5 5 5 5 5 5 R 4 5 5- 5- 5- 5- 5- 5 5 5 5 5 -Sensory: No deficits to light touch. Extinguishes on right on repeat attempts, appears consistent and not in setting of aphasia and inability to appropriately identify side. -Reflexes: Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF or HKS. + + + + + + + + + + + + + + + + ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ON DISCHARGE: General: Comfortable, awake, NAD HEENT: NC/AT Pulmonary: Breathing comfortably on room air Cardiac: Well-perfused Abdomen: soft, ND Extremities: WWP, no C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -MS: Brightly awake, alert, oriented x3. Naming intact to high and low frequency words though with some hesitation. Spontaneous speech with slight delay, word finding difficulty, and with slightly shortened but grammatically normal phrases. Slowed reading (unclear baseline). Writes simple sentences with some grammatical errors. Repetition intact to complex phrases. Evidence of left-right confusion, subtle finger agnosia, and acalculia but able to do simple additions. Amble to follow simple and two step commands. -CN: R pupil 4mm nonreactive, L pupil 4-3mm. R eye poor vision. L eye VF full. EOMI, no nystagmus. Mild R NLFF. Tongue midline with equal excursions bilaterally. -Motor: Normal bulk and tone. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 -Sensory- Intact to LT throughout. No extinction. -Coordination- FNF intact bilaterally. -Gait- Good initiation. Narrow-based, normal stride and arm swing. Pertinent Results: ___ 10:22PM BLOOD WBC-8.0 RBC-4.86 Hgb-12.0* Hct-36.5* MCV-75* MCH-24.7* MCHC-32.9 RDW-16.9* RDWSD-44.7 Plt ___ ___ 04:16AM BLOOD WBC-6.5 RBC-4.58* Hgb-11.2* Hct-33.9* MCV-74* MCH-24.5* MCHC-33.0 RDW-16.4* RDWSD-43.3 Plt ___ ___ 10:22PM BLOOD Neuts-46.2 ___ Monos-6.6 Eos-1.6 Baso-0.2 Im ___ AbsNeut-3.70 AbsLymp-3.63 AbsMono-0.53 AbsEos-0.13 AbsBaso-0.02 ___ 01:53AM BLOOD Neuts-43.8 ___ Monos-6.3 Eos-1.7 Baso-0.2 Im ___ AbsNeut-2.81 AbsLymp-3.06 AbsMono-0.40 AbsEos-0.11 AbsBaso-0.01 ___ 10:22PM BLOOD ___ PTT-27.5 ___ ___ 07:00AM BLOOD ___ PTT-27.9 ___ ___ 10:22PM BLOOD UreaN-15 Creat-1.2 ___ 07:00AM BLOOD Glucose-100 UreaN-9 Creat-1.0 Na-145 K-4.1 Cl-108 HCO3-24 AnGap-13 ___ 10:22PM BLOOD ALT-13 AST-17 AlkPhos-66 TotBili-0.4 ___ 01:53AM BLOOD ALT-11 AST-14 LD(LDH)-141 CK(CPK)-172 AlkPhos-59 TotBili-0.4 ___ 10:22PM BLOOD cTropnT-<0.01 ___ 01:53AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:22PM BLOOD Albumin-3.7 ___ 07:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0 ___ 01:53AM BLOOD %HbA1c-5.5 eAG-111 ___ 01:53AM BLOOD Triglyc-61 HDL-46 CHOL/HD-3.3 LDLcalc-92 ___ 01:53AM BLOOD TSH-2.0 ___ 01:53AM BLOOD CRP-1.9 ___ 10:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 10:30PM BLOOD Glucose-85 Na-140 K-4.2 Cl-105 calHCO3-25 CT PERFUSION IMPRESSION: 1. CBF<30%: 0 ml 2. Mildly increased MTT in the left MCA territory. No significant missmatch on the CBV and CBF. THROMBECTOMY IMPRESSION: Left M1/2 occlusion of the middle cerebral artery. TICI 2B to be revascularization of left middle cerebral artery following successful mechanical thrombectomy. TTE: IMPRESSION: No intracardiac source of thromboembolism identified. Normal biventricular cavity sizes, regional/global systolic function. Mild mitral regurgitation. Normal estimated pulmonary artery systolic pressure. MR HEAD W/O CONTRAST IMPRESSION: 1. Scattered cortical, subcortical and white matter DWI hyperintensities in the left frontal and parietal lobes are consistent with acute infarction after incomplete revascularization of a distal left M1 occlusion. 2. Punctate focus of microhemorrhage in the left parietal lobe. 3. Mild paranasal sinus disease as described above. Medications on Admission: sildafenil PRN eye drops Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 2. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*3 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Discharge Disposition: Home Discharge Diagnosis: Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with L M1 occlusion s/p thrombectomy// please perform ___ at 2300. eval extent of L MCA infarct 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 from ___ and cerebral angiogram from ___. FINDINGS: Cortical DWI hyperintensities along the left insula (series 4, image 15 and 16), left anterior frontal lobe (series 4, image 17 and 19) and cortical and subcortical DWI hyperintensities in the left parietal lobe (series 4, image ___ scattered DWI foci are seen in the left periventricular white matter. There is an ADC correlate for the majority of these lesions, compatible with acute infarct after incomplete revascularization of a distal left M1 occlusion. Punctate focus of subcortical microhemorrhage in the left parietal lobe (series 11, image 15 Caliber and configuration of the ventricles and sulci is within normal limits. Mild mucosal thickening in the left frontoethmoidal junction, ethmoid air cells and bilateral maxillary sinuses with a small mucous retention cyst in the left maxillary sinus. The sphenoid sinuses are clear. The mastoid air cells are clear. The orbits are normal. IMPRESSION: 1. Scattered cortical, subcortical and white matter DWI hyperintensities in the left frontal and parietal lobes are consistent with acute infarction after incomplete revascularization of a distal left M1 occlusion. 2. Punctate focus of microhemorrhage in the left parietal lobe. 3. Mild paranasal sinus disease as described above. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Aphasia, Transfer Diagnosed with Other cerebral infarction temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Mr. ___, You were hospitalized due to problems with your speech (aphasia) 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. The blood clot causing your stroke was removed during a thrombectomy procedure. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - high cholesterol - tobacco use - use of stimulants We are changing your medications as follows: - continue aspirin 81mg daily - continue atorvastatin 40mg daily Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Macrolide Antibiotics / clindamycin / antiemetic Attending: ___. Chief Complaint: ovarian mass ovarian torsion Major Surgical or Invasive Procedure: right salpingo-oophorectomy via mini-laparotomy History of Present Illness: This is a ___ yo G3P___ with several days of intermittent, colicky RLQ pain. Reports that ___ night she awoke from sleep with well localized RLQ pain, and was able to go back to sleep and go into work. Same thing happened ___ night. ___ morning she awoke from sleep with pain again, was able to drink some tea, do some yoga, and eventually had significant enough resolution to go to work. She has a one episode of diarrhea and a BM that day with worsening of her pain, and noted that it continued to come and go. She was seen at the ___ in ___ where blood tests, urine tests, and a KUB were reassuring, and she was called with these results. ___ mornign the pain came again, but resolved enough for her to go out to dinner ___ night. This morning the pain awoke her from sleep at 3am and did not abate. She felt it ___, intense pain, radiating from her RLQ down her anterior leg. During these pain episodes, she felt she could not sit still, and would instead move all around. Today she has had nausea and ___ episodes of vomitting. She has been NPO since 3am. She has never had any similar episodes prior. In the ED she has required 3 doses of morphine 4mg IV. Past Medical History: GynHx: LMP ___ or ___. No hx of abn Pap or STI. No hx of ovarian cyst. ObHx: - LTCS x3 via Phannensteil, all term, first for NRFHT. Kids ages ___, ___, ___ now. PMH: - autoimmune hepatitis ___, normalization of LFTs per pt - depression PSH: LTCS x3 only Social History: ___ Family History: denies t/e/d Physical Exam: on day of discharge: afebrile, VSS NAD, comfortable RRR, CTAB abd soft, appropriately tender, ND mini-laparotomy intact, no erythema or drainage no edema Pertinent Results: ___ 05:09PM BLOOD WBC-8.8 RBC-3.96* Hgb-12.2 Hct-35.0* MCV-88 MCH-30.9 MCHC-34.9 RDW-12.4 Plt ___ ___ 07:45AM BLOOD WBC-6.8 RBC-4.34 Hgb-13.6 Hct-38.4 MCV-88 MCH-31.3 MCHC-35.4* RDW-12.3 Plt ___ ___ 07:45AM BLOOD Glucose-119* UreaN-13 Creat-0.8 Na-136 K-4.2 Cl-103 HCO3-26 AnGap-11 ___ 07:45AM BLOOD ALT-23 AST-25 AlkPhos-72 TotBili-0.2 Medications on Admission: - unknown antidepression, likely SSRI, 10mg qd - lorazepam prn sleep - MVI, Vitamins C, D, calcium, fish oil, probiotic Discharge Medications: 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp:*30 Tablet(s)* Refills:*2* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ovarian torsion, adnexal mass (pathology pending) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with lower abdominal pain. Evaluate for kidney stone or other source of abdominal pain. COMPARISON: None. TECHNIQUE: Non-contrast followed by post-contrast MDCT imaging of the abdomen and pelvis performed. Axial, coronal, and sagittal reformats were prepared and reviewed. CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: Visualized lung bases are clear. There is no nodule, mass, or consolidation. There is no pleural or pericardial effusion. The liver is normal in size and attenuation. There is no intra- or extra-hepatic biliary ductal dilation, and the gallbladder is normal. The hepatic and portal veins are patent. The spleen, pancreas, and adrenal glands are normal. There is symmetric renal parenchymal enhancement. There is no hydronephrosis. Incidental note is made of partial duplication of the left renal collecting system, extending to the level of the mid ureter. Stomach, duodenum, and intra-abdominal loops of small and large bowel are normal. There is no bowel distension or bowel wall thickening. There is no free air. The aorta and mesenteric vessels are normal in caliber. There is no mesenteric or retroperitoneal adenopathy. CT PELVIS WITH INTRAVENOUS CONTRAST: Distal ureters and bladder are normal. Uterus is unremarkable, as is the left adnexa. However, at the right posterior aspect of the uterus, there is a mixed solid and cystic lesion likely representing ovary, measuring up to 7.5 x 6.0 x 7.1 cm. There is no significant surrounding inflammatory change, though small amount of fluid is seen dependently adjacent to the anterior abdominal wall (scanned prone). Portions of this right adnexal lesion are hyperdense on pre-contrast images, which could represent hemorrhage, with no enhancement following contrast administration. There is no associated fat within the lesion. There is no calcification. BONE WINDOWS: There are degenerative changes in the lower lumbar spine at L4-5 and L5-S1. There are no lytic or sclerotic lesions concerning for malignancy. IMPRESSION: 1. Right adnexal mass, likely ovarian in origin. Given the clinical history, resulting ovarian torsion cannot be excluded, and ultrasound of the pelvis is recommended for further evaluation. Trace dependent free fluid. 2. Incidentally noted partially duplicated left renal collecting system. Dr. ___ was informed by phone by Dr. ___ at 9:45 a.m. on ___. Radiology Report INDICATION: ___ female with abdominal pain and right ovarian abnormality seen on CT. COMPARISON: CT, ___. LMP: Unknown. The patient is perimenopausal. PELVIC ULTRASOUND: Transabdominal and endovaginal imaging of the pelvis was performed, the latter to better evaluate the endometrium and adnexa. The uterus measures 10.5 x 4.2 x 5.9 cm. There are no focal uterine abnormalities. The endometrium is 9 mm in thickness, without focal abnormality. The left ovary is normal in size and appearance, with normal arterial and venous waveforms. However, what appears to be the right ovary is markedly enlarged, measuring up to 7.8 x 3.6 x 6.2 cm. It contains a single large simple cyst, measuring up to 3.7 cm, and a second rounded echogenic lesion, measuring 3.9 cm, which could represent a solid mass or a markedly complex hemorrhagic cyst. No flow can be demonstrated within this; however, flow can also not be well seen within the remainder of the right ovary, which could all be secondary to ovarian torsion given the patient's pain, with these large ovarian lesions acting as lead points. Moderate amount of complex free fluid is also seen in the pelvis. IMPRESSION: 1. Large right ovary, measuring up to 7.8 cm, with two lesions within. One is a simple cyst, the other may be a solid mass or a complex hemorrhagic cyst. No flow is seen within the possible mass or the ovary in general, which strongly suggests a consideration of ovarian torsion. 2. Moderate free complex fluid, likely hemorrhage. 3. Thickened endometrium measuring 9 mm, should be correlated with the patient's hormonal status. Discussed in detail with OB-GYN service by Dr ___. Operative exploration was performed. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: RT.LQPAIN Diagnosed with ABDOMINAL PAIN RLQ, ABDOM/PELV SWELL/MASS UNSP SITE temperature: 97.6 heartrate: 64.0 resprate: 18.0 o2sat: 100.0 sbp: 121.0 dbp: 90.0 level of pain: 7 level of acuity: 2.0

General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Percocet / Percodan Attending: ___. Chief Complaint: Right leg pain Major Surgical or Invasive Procedure: R tibial IMN History of Present Illness: ___ ped struck by ___ green line, brought in by EMS with R leg pain and deformity. Patient was struck directly in the R leg by train. Per report, the mirror struck her on the back of her head. She reports brief LOC. Past Medical History: Glaucoma, vertigo, stress incontinence Social History: ___ Family History: nc Physical Exam: A&O, NAD, Pain well controlled AFVSS RLE: Incision c/d/i, ___, SILT s/s/sp/dp/pt, WWP Pertinent Results: xray of right tibia fracture and after surgical fixation of the fracture Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Oxybutynin 5 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H Pain 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 3. Enoxaparin Sodium 40 mg SC QPM Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe sq qpm Disp #*14 Syringe Refills:*0 4. Senna 8.6 mg PO BID 5. Oxybutynin 5 mg PO QHS 6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Right tibia fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with assistance Followup Instructions: ___ Radiology Report INDICATION: ___ with MVC // ICH? Fx? TECHNIQUE: Portable chest and pelvis films. COMPARISON: None. FINDINGS: Chest: The lungs are clear within limitation of overlying trauma board and external hardware. The cardiomediastinal silhouette is within normal limits. No displaced fractures identified. Pelvis: Within the limitation of overlying trauma board, there is no visualized fracture. The pubic symphysis and SI joints are preserved. Soft tissues are unremarkable. IMPRESSION: No acute cardiopulmonary process. No pelvic fracture. Radiology Report EXAMINATION: DX TIB/FIB AND ANKLE INDICATION: ___ with MVC // ICH? Fx? TECHNIQUE: Right knee, tib/fib, and ankle radiographs, 2 views. COMPARISON: None available. FINDINGS: RIGHT KNEE: There is no fracture or dislocation identified involving the right knee. Mild tricompartmental degenerative changes are noted, most prominent with the patellofemoral compartment with superior and posterior spurring. RIGHT TIBIA/FIBULA: There is an transverse fracture through the mid diaphysis of the right tibia. Comminuted mid fibular fracture is also identified. There is significant rotation at the fracture site with the distal fracture fragments rotated laterally. Significant lateral displacement and foreshortening seen at the tibial fracture fragment. RIGHT ANKLE: A transversely oriented, lucent line is seen extending through the distal tibial metaphysis, suggestive of a nondisplaced fracture extending to the syndesmosis. The ankle mortise is symmetric and preserved. Plantar calcaneal spurring is noted. IMPRESSION: Fractures through the mid diaphysis of the right tibia and fibula. Nondisplaced distal fibular fracture. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with MVC // ICH? Fx? TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: CTDIvol: 52.8 mGy DLP: 1003.42 mGy-cm COMPARISON: None available. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or large territorial infarction. Prominent ventricles and sulci suggest age-related involutional changes or atrophy. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. A large, subgaleal hematoma and soft tissue swelling is noted extending along the right frontoparietal region. A rounded, focal high-density structure adjacent overlying the right parietal region has the appearance of a partially calcified sebaceous cyst, although foreign body following a head striking against the ground is also possible. No displaced skull fracture is identified. The paranasal sinuses, middle ear cavities, and mastoid air cells are clear. The orbits are unremarkable. IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. Large right frontoparietal subgaleal hematoma with possible calcific foreign body material versus partially calcified sebaceous cyst. No underlying displaced fracture is identified. 3. Moderate cerebral volume loss. Radiology Report EXAMINATION: CT C-spine without contrast. INDICATION: ___ with MVC // ICH? Fx? TECHNIQUE: 2.5 mm helical axial MDCT sections were obtained from the skull base through the cervical spine. Axial images were interpreted in conjunction with coronal and sagittal reformats. CTDIvol: 36.98 MGy DLP: ___ MGy-cm COMPARISON: None available. FINDINGS: There is no definitive evidence of acute fracture or traumatic malalignment. There is no prevertebral soft tissue abnormality. Mild anterolisthesis of C4 on C5 and retrolisthesis of C5 on C6 is age indeterminate, but likely degenerative. Moderate, multilevel degenerative changes are noted throughout the cervical spine, most significant at the level of C5-C6 with loss of intervertebral disc height, endplate sclerosis, uncovertebral joint hypertrophy, and osteophytosis. There is a least mild canal narrowing and moderate to severe right foraminal narrowing at this level. Sclerosis with irregularity of endplates suggests degenerative changes potentially Schmorl's nodes at the inferior endplates of C5 and C6. A 3 mm, hypodense, right thyroid nodule is noted. No lymphadenopathy is present by CT size criteria. Incidentally noted is a 5 mm pulmonary nodule in the right lung apex. The visualized lung apices are otherwise clear. IMPRESSION: 1. No definitive evidence of acute fracture. 2. Mild anterolisthesis of C4 on C5 and retrolisthesis of C5 on C6, age indeterminate and likely degenerative. Recommend clinical correlation. 3. Moderate degenerative changes of the cervical spine, most notable at C5-C6. 4. Incidental, 5 mm right upper lobe solid pulmonary nodule. If the patient is at high risk for malignancy, recommend chest CT in ___ months. If at low risk, recommend chest CT in 12 months to establish stability. Radiology Report INDICATION: ___ with tib fib fracture s/p reduction // post reduction COMPARISON: Films from earlier the same day. TECHNIQUE: AP and lateral views of the proximal distal right tibia and fibula. FINDINGS: Overlying cast obscures fine bony detail. There has been interval reduction in the degree of displacement and angulation of the fractures of the mid right tibia and fibula. Known distal right fibular fracture is not clearly delineated. Radiology Report Images from the operating suite show fixation device scratch that EXAMINATION: TIB/FIB (AP AND LAT) RIGHT INDICATION: RT TIB FIB ORIF IN THE OR IMPRESSION: Fluoroscopic images from the operating suite shows placement of a intramedullary rod across a fracture of the midshaft of the tibia. Adjacent fibular fracture is seen. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: PED STRUCK Diagnosed with FX TIBIA W FIB NOS-OPEN, MV COLL W PEDEST-PEDEST, TETANUS-DIPHT. TD DT temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - touch down weight bearing in right lower extremity Physical Therapy: ACTIVITY AND WEIGHT BEARING: - touch down weight bearing in right lower extremity - ROMAT Treatments Frequency: WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / penicillin G / Erythromycin Base Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None this admission History of Present Illness: ___ F s/p lap hiatal hernia repair ___ gastroplasty by Dr ___ on ___ presented initially to ___ ___ with weakness, decreased appetite since surgery. She reports less PO intake but is tolerating what she eats. She experienced some nausea today but denies emesis. She is passing flatus and having formed regular bowel movements. Denies abd pain or drainage fro incsion. She is able to do activities around house but has experienced weakness since surgery. No fevers, chills, CP, SOB. On imaging at ___ was found to have a hemothorax and possible extravasatation from the left gastric artery. She was transferred to ___ for further work up and care. Past Medical History: PMH: Paraesophageal hernia, Pelvic floor dysfunction, Spinal stenosis Lumbar fracture PSH: Laparoscopic paraesophageal hernia repair with graft ___ gastroplasty, Fundoplication ___ ___ salpingo-oopherectomy; blader supension; hysterectomy; rotator cuff surgery Social History: ___ Family History: Notable for father with laryngeal cancer and a mother who died secondary to complications from a perforated appendix in her ___. Physical Exam: VS: 98.1, 85, 114/76, 18, 97% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, incisions CDI Ext: No ___ edema, ___ warm and well perfused Pertinent Results: CBC: ___ 12:50AM BLOOD WBC-5.7 RBC-3.50* Hgb-10.6* Hct-32.8* MCV-94 MCH-30.3 MCHC-32.4 RDW-13.5 Plt ___ ___ 04:20AM BLOOD Hct-31.8* ___ 12:50AM BLOOD Plt ___ Coags: ___ 01:00AM BLOOD ___ PTT-31.4 ___ Lytes: ___ 12:50AM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-136 K-4.1 Cl-101 HCO3-24 AnGap-15 ___ 09:00AM BLOOD Glucose-136* UreaN-12 Creat-1.0 Na-137 K-4.2 Cl-101 HCO3-26 AnGap-14 ___ 09:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4 LFTs: ___ 12:50AM BLOOD ALT-17 AST-16 AlkPhos-73 TotBili-0.2 ___ 12:50AM BLOOD Lipase-17 Other labs: ___ 12:50AM BLOOD Albumin-3.6 ___ 12:57AM BLOOD Lactate-1.1 U/A: ___ 01:20AM URINE Color-Straw Appear-Clear Sp ___ ___ 01:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Shoulder X-rays ___: IMPRESSION: No evidence of acute fracture or dislocation of the left shoulder. Medications on Admission: oxycodone 5' Q4H PRN, Acetaminophen 650' Q6H PRN, bupropion 150'', clonazepam 0.5'', fluticasone 50 2 sprays', omeprazole 20', ropinirole 1.5'' Discharge Medications: 1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. 3. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. ropinirole 1 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: s/p laparoscopic hiatal hernia repair with ___ gastroplasty Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report LEFT ___ No prior studies for comparison. FINDINGS: Radiographs of the left ___ demonstrate no evidence of acute fracture, dislocation, or soft tissue calcifications. Degenerative changes are seen at the glenohumeral joint and minimal degenerative changes were also present at the acromioclavicular joint. Left humeral head appears to be relatively high riding, a finding that can be associated with chronic rotator cuff degeneration. IMPRESSION: No evidence of acute fracture or dislocation of the left ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: WEAKNESS, R/O BLEEDING FROM GASTRIC ART Diagnosed with OTHER SPEC COMPL S/P SURGERY, OTHER MALAISE AND FATIGUE, ACCIDENT NOS temperature: 98.1 heartrate: 80.0 resprate: 16.0 o2sat: 100.0 sbp: 130.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were admitted to the ___ General Surgery Service for concerns that you had a bleed in your abdomen. At this time we do not believe this is the case and we are comfortable with you going home with some in-home services. Please follow up at your appointments with your primary Physician and your surgeon. Please resume all regular home medications as no changes were made to your medications during this admission. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Please follow up with your primary care Physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Thank you for letting us participate in your care. We wish you a speedy recovery.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: shortness of breath, large left hemothorax Major Surgical or Invasive Procedure: ___: Left VATS washout with chest tube placement History of Present Illness: Mr. ___ is a ___ male who had a motorcycle accident 2 days before presenting to an outside hospital. At the time of presentation he was having significant shortness of breath and was noted to have a large left hemothorax. Chest tube was emergency placed. Initial placement drained 2.2 L blood. He was transferred to BID for further management. On arrival he was hemodynamically unstable and felt responded to blood and resuscitation. A chest tube continued to have significant output, which then dropped off over the course of approximately 48 hours. Past Medical History: Hep C (no treatment), prior heroin abuse now on suboxone (clean since ___ PSH: orchiopexy for testicular torsion Social History: ___ Family History: noncontributory Physical Exam: VS 120/47 HR 92 O2 99% NRB RR 18 General: Appears anxious, alert and oriented x3 HEENT: PEERL Neck: Trachea midline CV: Regular Lungs: Diminished sounds on left side, mild crackles right base, CT left chest wall, draining dark red blood Abdomen: soft GU: foley draining clear yellow urine Ext: No edema Neuro: moves all extremities Skin: bruising over left ankle Discharge Physical Exam: VS: 98.2, 83, 138/46, 18, 97%ra Gen: A&O x3, calm, cooperative, NARD CV: HRR, sinus tachycardia to 110's with ambulation Pulm: Crackles throughout left lobe, diminished LS in base. No crepitus or hypoxia, O2 98% room air. VATS site CDI; CT sites covered with occlusive dressing Abd: Soft, NT/ND Ext: No edema Neuro: Intact Pertinent Results: Labs on admission: ___ 09:45PM BLOOD WBC-14.5* RBC-4.16* Hgb-11.5* Hct-33.8* MCV-81* MCH-27.6 MCHC-34.0 RDW-13.6 RDWSD-39.8 Plt ___ ___ 01:15AM BLOOD WBC-11.1* RBC-4.17* Hgb-11.6* Hct-34.1* MCV-82 MCH-27.8 MCHC-34.0 RDW-13.8 RDWSD-40.4 Plt ___ ___ 04:42AM BLOOD WBC-11.5* RBC-3.79* Hgb-10.5* Hct-31.0* MCV-82 MCH-27.7 MCHC-33.9 RDW-13.8 RDWSD-40.7 Plt ___ ___ 08:56AM BLOOD WBC-10.4* RBC-3.65* Hgb-10.1* Hct-30.3* MCV-83 MCH-27.7 MCHC-33.3 RDW-13.6 RDWSD-41.4 Plt ___ ___ 07:25AM BLOOD WBC-9.6 RBC-3.95* Hgb-11.0* Hct-32.7* MCV-83 MCH-27.8 MCHC-33.6 RDW-13.8 RDWSD-41.5 Plt ___ ___ 10:30AM BLOOD WBC-8.8 RBC-3.49* Hgb-9.6* Hct-29.5* MCV-85 MCH-27.5 MCHC-32.5 RDW-13.7 RDWSD-42.5 Plt ___ Labs on discharge: ___ 07:19AM BLOOD WBC-9.5 RBC-3.27* Hgb-8.9* Hct-26.7* MCV-82 MCH-27.2 MCHC-33.3 RDW-12.8 RDWSD-37.5 Plt ___ Radiology: ___ CXR: Left-sided chest tube terminates over the left hemi thorax. Moderate left-sided pleural effusion with adjacent compressive atelectasis of the left lung. ___ CXR: new small left apical pneumothorax. Left pleural effusion and adjacent atelectasis are not appreciably changed. ___ Chest CT: Moderate size left hemopneumohydrothorax. Complete atelectasis of the left lower lobe and lingular segments. The tip of the left-sided ICD is inseparable from the left lower lobe pulmonary parenchyma and repositioning is advised. Peribronchial opacity in the right lower lobe may represent aspiration or pneumonia. ___ CXR: There is no significant improvement in the left-sided effusion with adjacent airspace opacification in the left mid to lower lung zone. ___ CXR: Interval placement of a second left chest tube. No discernible pneumothorax is identified. ___ CXR: Unchanged left pleural effusion/hemothorax and left lower lobe ___ CT Chest: 1. Interval repositioning of a left-sided chest tube, with its tip terminating in the upper pleural space posteriorly. Near complete resolution of a left-sided hemothorax, with residual small left-sided hydropneumothorax. 2. Interval re- expansion of the left lower lobe, with residual subsegmental atelectasis noted. 3. Splenomegaly. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 2. ClonazePAM 1 mg PO BID 3. Citalopram 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*75 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 8.6 mg PO BID:PRN constipationj RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*20 Tablet Refills:*0 6. TraMADol 50 mg PO BID RX *tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 7. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 8. Citalopram 40 mg PO DAILY 9. ClonazePAM 1 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Left posterior rib fractures ___ Left hemothorax with trapped lung 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: ___ year old man with L hemothorax, increased resp distress // eval for interval change TECHNIQUE: Portable AP view COMPARISON: Reference chest CT on ___ at outside hospital. FINDINGS: A left-sided chest tube terminates over the left hemi thorax. The cardiomediastinal and hilar contours are within normal limits. The right lung appears clear. There is a moderate left pleural effusion and and adjacent compressive atelectasis. No pneumothorax is identified. No nondisplaced rib fractures are identified. IMPRESSION: Left-sided chest tube terminates over the left hemi thorax. Moderate left-sided pleural effusion with adjacent compressive atelectasis of the left lung. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with L hemothorax s/p Ct placement // eval for interval change IMPRESSION: In comparison to prior radiograph of 1 day earlier, a left-sided chest tube remains in place with persistent moderate to large left pleural effusion and adjacent atelectasis or consolidation in the lingula and left lower lobe. New linear atelectasis is present at the right lung base and there remains a persistent linear left perihilar focus of atelectasis. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT INDICATION: ___ year old man with motorcycle accident, bruising left ankle // ?left ankle fracture ?left ankle fracture TECHNIQUE: Frontal, oblique, and lateral view radiographs of left ankle none available FINDINGS: No definite acute fracture, dislocation, or degenerative change is detected. The mortise is congruent on this non stress view. A well corticated osseous density is present at the inferior aspect of the fibula and may reflect an accessory ossicle or the residua of old injury. Soft tissue swelling is mild and symmetrical in distribution. The Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p motorcycle crash ___ now presenting as transfer from osh with L hemothorax s/p chest tube placement // interval change of hemothorax IMPRESSION: In comparison to ___ radiograph, a left chest tube remains in place, with an apparently new small left apical pneumothorax. Left pleural effusion and adjacent atelectasis are not appreciably changed when consideration is given to technical differences between the studies. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with hemothorax // evaluate hemothorax, chest tube placement evaluate hemothorax, chest tube placement IMPRESSION: Compared to chest radiographs since ___, most recently ___. Combination of left lower lobe atelectasis and some left pleural effusion unchanged. Small left apical pneumothorax not appreciably changed since ___. Left pleural drainage tube unchanged in position in the left lower hemi thorax, precise location indeterminate. Chest CT on ___ one was equivocal regarding placement of the tube in the collapse left lower lobe. If repeat chest CT is performed for that determination,intravenous contrast agent should be administered. Right lung clear. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with hemothorax // Evaluate hemothorax, chest tube placement, pulmonary vasculature TECHNIQUE: Contrast enhanced multidetector CT performed of the entire volume of the thorax with multi planar reformations and MIP reconstructions. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 36.1 cm; CTDIvol = 19.6 mGy (Body) DLP = 707.2 mGy-cm. Total DLP (Body) = 707 mGy-cm. COMPARISON: ___ FINDINGS: FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: No thyroid lesions. No supraclavicular or axillary adenopathy. No gross breast lesions. UPPER ABDOMEN: This study was not tailored to evaluate the subdiaphragmatic organs. No hiatal hernia. No adrenal lesions. No intra-abdominal free fluid. MEDIASTINUM: Subcentimeter mediastinal lymph nodes. HILA: Subcentimeter left hilar lymph nodes. HEART and PERICARDIUM: Normal cardiac configuration. No pericardial effusion. A few subcentimeter pericardial lymph nodes. The thoracic aorta appears normal. PLEURA: Moderate sized left hemopneumohydrothorax. Left-sided IC drain in situ which terminates in close proximity to the left lower lobe pulmonary parenchyma. Loculated simple fluid (hydrothorax) component seen in the left pleural space (4, 76) LUNG: -PARENCHYMA: Complete collapse of the lingula and left lower lobe. The left upper lobe is aerated. Peribronchial opacification in the medial and posterior basal segments of the left lower lobe. -AIRWAYS: Patent to the subsegmental level. -VESSELS: The pulmonary arteries not enlarged. Suboptimal opacification of the pulmonary arterial system. CHEST CAGE: Spondylotic changes of the thoracic spine. No displaced rib fractures. IMPRESSION: Moderate size left hemopneumohydrothorax. Complete atelectasis of the left lower lobe and lingular segments. The tip of the left-sided ICD is inseparable from the left lower lobe pulmonary parenchyma and repositioning is advised. Peribronchial opacity in the right lower lobe may represent aspiration or pneumonia. Radiology Report INDICATION: ___ y/o M ___ s/p MCC, L hemothorax with CT placement // interval change TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Left-sided ICD in situ with its position unchanged. There is no significant improvement in the left-sided effusion with adjacent airspace opacification in the left mid to lower lung zone. Small left apical pneumothorax measuring 6 mm in diameter. The right lung is clear. IMPRESSION: As above. Radiology Report INDICATION: ___ year old man with hemothorax s/p VATS washout chest tube placement x2 // ?interval change TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: CT chest tubes project over the left hemithorax. There is a retrocardiac opacity noted likely a combination of atelectasis and pleural fluid. Mild atelectasis in the right lower lung zone. No discernible pneumothorax identified. The size of the cardiac silhouette is enlarged but overall unchanged. IMPRESSION: Interval placement of a second left chest tube. No discernible pneumothorax is identified. Persisting retrocardiac opacity likely reflects a combination of atelectasis and a pleural effusion. Radiology Report INDICATION: ___ year old man with hemothorax s/p VATS washout chest tube placement x2 // ?interval change TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The patient is status post left VATS. 2 left chest tubes are present. No definitive pneumothorax identified. Persisting retrocardiac opacity which may reflect post procedural changes/atelectasis. Mild atelectasis in the right lower lung zone. No right pleural effusion or pneumothorax. The size of the cardiac silhouette is enlarged but unchanged. IMPRESSION: No significant interval change since yesterday's radiograph given slight differences in technique. No discernible pneumothorax identified. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hemothorax s/p VATS washout chest tube placement x2 // ?interval change, please do at 7 am ?interval change, please do at 7 am IMPRESSION: Left chest tubes are in place. There is no interval increase in pleural effusion. Heart size and mediastinum are stable. There is no pneumothorax. There is no pulmonary edema Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hemothorax s/p VATS washout // evaluate hemothorax, chest tubes evaluate hemothorax, chest tubes IMPRESSION: 2 left chest tubes are in place. There is no pneumothorax. There is left pleural effusion, moderate, unchanged. Minimal atelectasis at the right lung base has not changed substantially. No pulmonary edema. Cardiomediastinal silhouette is stable. Radiology Report INDICATION: ___ s/p motorcycle crash ___ now presenting as transfer from osh with L hemothorax s/p VATS washout and chest tube placementx2 // ?interval change s/p anterior chest-tube DCd, please do at 0800 TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___ and CT from ___ FINDINGS: There has been interval removal of the left anterior chest tube. The left pleural effusion correlating to a hemothorax on recent CT and left lower lobe collapse are largely unchanged in the interval. Platelike atelectasis of the right lung base is stable. No new pleural effusions pneumothoraces. The cardiomediastinal and hilar contours are stable. Left chest tube terminates in left apex. IMPRESSION: Unchanged left pleural effusion/hemothorax and left lower lobe Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man s/p VATS, 1 Chest tube remain. Opacities seen on CXR. Chest tube low output past 2 days // ? Opacity, other etiology TECHNIQUE: Single phase contrast. MDCT axial images were acquired through the chest following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformats were performed and reviewed on PACs. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.4 s, 39.9 cm; CTDIvol = 16.5 mGy (Body) DLP = 632.2 mGy-cm. Total DLP (Body) = 644 mGy-cm. COMPARISON: CT chest from ___. FINDINGS: FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The left lateral chest musculature is enlarged, likely due to underlying hematoma. Again noted is small left-sided subcutaneous emphysema. There is no axillary lymphadenopathy. UPPER ABDOMEN: Limited evaluation of the upper abdomen shows no acute abnormality. There is splenomegaly measuring up to 16.2 cm in craniocaudal dimension. MEDIASTINUM: There are mildly prominent mediastinal lymph nodes, likely reactive. HILA: No hilar lymphadenopathy is noted. HEART and PERICARDIUM: There is no pericardial effusion. PLEURA: Left-sided chest tube has been repositioned and is now located in the superior aspect of the left pleural space. There has been near complete resolution of the left-sided hemothorax and decreased pneumothorax, with a residual small left-sided hydropneumothorax. The right lung is clear with interval resolution of the previously described opacity in the medial right lung base. LUNG: -PARENCHYMA: There has been re-expansion of the left lower lobe, with residual subsegmental atelectases. -AIRWAYS: The airway is patent to the subsegmental level. -VESSELS: There is poor opacification of the pulmonary vessels, however no large central pulmonary embolus is noted. IMPRESSION: 1. Interval repositioning of a left-sided chest tube, with its tip terminating in the upper pleural space posteriorly. Near complete resolution of a left-sided hemothorax, with residual small left-sided hydropneumothorax. 2. Interval re- expansion of the left lower lobe, with residual subsegmental atelectasis noted. 3. Splenomegaly. Radiology Report INDICATION: ___ y/o POD5-VATS s/p ___ CT removal // post-pull fim to eval for new ptx. *Pls obtain film at 1pm TECHNIQUE: Chest PA and lateral FINDINGS: There has been interval removal of the left chest tube. Interval increase in left mediastinal shift and decrease of left lung volume suggesting worsening atelectasis. The left pleural effusion correlating to a hemothorax on recent CT and largely unchanged. Improved platelike atelectasis of the right lung base. No new pleural effusions or pneumothoraces. The cardiomediastinal and hilar contours are stable. IMPRESSION: Worsening left lung atelectasis. Unchanged left pleural effusion/hemothorax. No evidence of pneumothorax. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Motorcycle accident, Transfer, HEMOTHORAX Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Traumatic hemothorax, initial encounter, Mtrcy driver injured pick-up truck, pk-up/van nontraf, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Mr. ___, You were transferred to ___ with a left lung injury after a motorcycle crash. There was blood trapped in the lining of your lung, causing part of the lung to collapse. This required a chest tube be placed to drain the blood and fluid. A repeat CT scan showed a large retained blood clot. You were taken to the operating room and underwent a VATS procedure to remove the retained blood clot. You tolerated this well. Both the chest tubes have now been removed and your chest X-Rays are stable. Your oxygen and vital signs are also stable. You are medically clear to be discharged home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cardizem CD Attending: ___ Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: Right CVL ___ History of Present Illness: HISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ with PMH of gout, HTN, ESRD s/p LRRT (___) c/b diabetes and CMV viremia, with multiple recent admissions for hypotension and c/f infection presents with fevers and hypotension. Patient recently discharged from ___ ___. On this admission, she was hypotensive, initially concerning for septic shock, covered empirically with antibiotics, but felt to be more consistent with adrenal insufficiency given all cultures negative (including CMV VL). Endocrinology consulted at the time, who recommended stress dose steroids, discharged on prednisone 10mg daily. Patient was doing well at home until the day of presentation. She reports feeling diffusely weak. She fell out of her bed and was unable to stand ___ weakness. Her husband called EMS and she was taken initially to ___. BP there 90/60 with T104. She was treated with 1.5L IVF and given IV vancomycin, meropenem and hydrocortisone. CXR without infiltrate, UA without pyuria. In ED initial VS: 98.1 75 91/57 16 97% 3L NC - Patient noted to be AAOX3, but somnolent particularly during CVL placement. - Labs significant for: Hgb 7.7, Plt 71, Cr 1.4, ALT 50, AST 51, AP 160, TB 2.4, lactate 1.2, pH 7.26, pCO2 36 - Patient was given: received in total 4L IVF (5.5L in total including OSH), NE at 0.12 gtt, valganciclovir 450mg, prednisone 5mg, metronidazole 500mg IV - Imaging notable for: CXR s/p R IJ - Consults: renal transplant, agree with IVF resuscitation, hold abx for now, continue home cyclosporine, hold AZA, continue stress dose steroids and continue valgancyclovir maintenance VS prior to transfer: 74 134/74 18 100% 2L NC On arrival to the MICU, patient is asking when she can eat and when she can go home. She denies any preceding infectious symptoms, only diffuse weakness. She wants to not have to keep coming back to the ICU. No changes to her medications since being discharged from the hospital several days ago. She missed her outpatient appointments and would like her renal doctors to be aware. REVIEW OF SYSTEMS: (+) per HPI, all other ROS otherwise negative Past Medical History: -End-stage renal disease of unclear etiology. Previously hemodialysis for ___ years, s/p living related renal transplant from herbrother in ___ -CMV viremia -Hypertension -History of post-posttransplant diabetes mellitus -History of cholecystectomy -Gout [no recent flares](onset ___ when Cr was up to 2.0) Social History: ___ Family History: gout Physical Exam: ADMISSION EXAM ============== VITALS: Reviewed in metavision GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD, right IJ in place LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Bilateral ___ fingers with swollen PIP joints SKIN: No rash noted NEURO: AOx3, moving all extremities, strength ___ in bilateral lower extremities but symmetric DISCHARGE EXAM ============== 24 HR Data (last updated ___ @ 858) Temp: 98.8 (Tm 98.8), BP: 101/73 (95-122/62-79), HR: 78 (77-84), RR: 18, O2 sat: 100% (95-100), O2 delivery: Ra GENERAL: no apparent distress HEENT: anicteric sclerae, oropharynx clear NECK: supple, JVP flat, no cervical LAD, RIJ dressing c/d/i LUNGS: unlabored, CTAB CV: RRR, S1/S2, no m/r/g ABD: soft, non-distended, non-tender EXT: warm, well perfused, 1+ pitting pretibial edema NEURO: non-focal Pertinent Results: ADMISSION LABS ============== ___ 01:06AM WBC-4.9 RBC-2.32* HGB-7.7* HCT-25.6* MCV-110* MCH-33.2* MCHC-30.1* RDW-22.0* RDWSD-85.4* ___ 01:06AM NEUTS-76* BANDS-1 LYMPHS-13* MONOS-8 EOS-0 BASOS-0 ___ METAS-1* MYELOS-1* AbsNeut-3.77 AbsLymp-0.64* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00* ___ 01:06AM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-OCCASIONAL MACROCYT-1+* MICROCYT-NORMAL POLYCHROM-1+* TEARDROP-OCCASIONAL ___ 01:06AM CORTISOL-104.7* ___ 01:06AM TRIGLYCER-552* ___ 01:06AM HAPTOGLOB-172 ___ 01:06AM ALBUMIN-1.9* CALCIUM-7.6* PHOSPHATE-3.2 MAGNESIUM-1.7 ___ 01:06AM cTropnT-<0.01 ___ 01:06AM LIPASE-52 MICRO ===== __________________________________________________________ ___ 1:41 pm STOOL CONSISTENCY: SOFT VIRAL CULTURE (Pending): __________________________________________________________ ___ 1:41 pm STOOL CONSISTENCY: SOFT FECAL CULTURE (Preliminary): CAMPYLOBACTER CULTURE (Preliminary): OVA + PARASITES (Final ___: CANCELLED. Three separate stool specimens collected EVERY OTHER DAY are recommended for optimum sensitivity. Duplicate specimens collected on the same day will not be processed, since this does not increase diagnostic yield. Make sure to label date and time of collection on each stool specimen submitted to ensure appropriate processing. __________________________________________________________ ___ 1:41 pm STOOL CONSISTENCY: SOFT **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). __________________________________________________________ ___ 1:41 pm STOOL CONSISTENCY: FORMED Source: Stool. OVA + PARASITES (Pending): __________________________________________________________ ___ 3:22 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 2:47 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 1:06 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 3:09 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Line-central. BLOOD/FUNGAL CULTURE (Pending): No growth to date. BLOOD/AFB CULTURE (Pending): No growth to date. __________________________________________________________ ___ 3:00 am BLOOD CULTURE Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:50 am BLOOD CULTURE Blood Culture, Routine (Final ___: NO GROWTH. STUDIES ======= CT A/P IMPRESSION: 1. No acute process in the abdomen or pelvis. 2. Diffuse anasarca. The previously described area of induration in the soft tissues of the right flank is less conspicuous, is felt to represent sequela of volume overload. 3. Diverticulosis, without evidence of diverticulitis. CT Chest IMPRESSION: 1. Patchy areas of ground-glass opacity in bilateral lung apices, slightly worse on the right worrisome for a multifocal infectious or inflammatory process. 2. Similar appearance of the asymmetrically enlarged left breast with skin thickening, previously evaluated by diagnostic mammography. 3. Small nonhemorrhagic pleural effusions bilaterally. DISCHARGE LABS ============== ___ 04:31AM BLOOD WBC-8.0 RBC-2.25* Hgb-7.5* Hct-24.0* MCV-107* MCH-33.3* MCHC-31.3* RDW-22.2* RDWSD-80.5* Plt Ct-87* ___ 04:31AM BLOOD Plt Ct-87* ___ 04:31AM BLOOD ___ PTT-25.6 ___ ___ 04:31AM BLOOD Glucose-180* UreaN-37* Creat-1.5* Na-134* K-3.6 Cl-105 HCO3-23 AnGap-6* ___ 02:01AM BLOOD ALT-45* AST-27 LD(LDH)-454* AlkPhos-198* TotBili-0.9 ___ 04:31AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1500 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Ranitidine 150 mg PO DAILY 4. pen needle, diabetic 33 gauge x ___ miscellaneous QID 5. Furosemide 20 mg PO BID 6. PredniSONE 5 mg PO DAILY 7. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 8. ValGANCIclovir 450 mg PO Q24H 9. AzaTHIOprine 50 mg PO DAILY Discharge Medications: 1. Humalog 7 Units Breakfast Humalog 9 Units Lunch Humalog 10 Units Dinner NPH 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. Levofloxacin 750 mg PO Q48H RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 3. Sodium Bicarbonate 650 mg PO TID RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 4. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. PredniSONE 15 mg PO DAILY RX *prednisone 10 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*0 6. ValGANCIclovir 450 mg PO EVERY OTHER DAY 7. Calcium Carbonate 1500 mg PO BID 8. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 9. Multivitamins 1 TAB PO DAILY 10. pen needle, diabetic 33 gauge x ___ miscellaneous QID 11. Ranitidine 150 mg PO DAILY 12. HELD- AzaTHIOprine 50 mg PO DAILY This medication was held. Do not restart AzaTHIOprine until cleared by your kidney doctors. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypotension Insulin dependent Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with s/p CVL placement// cvl placement COMPARISON: Multiple prior chest radiographs the most recent dated ___ FINDINGS: Portable semi-upright view of the chest provided. Patient is status post placement of right IJ central venous catheter with the catheter tip terminating at the cavoatrial junction. Persistent streaky right basilar opacity is unchanged likely reflecting atelectasis. There is pleural effusion or pneumothorax. The cardiomediastinal silhouette is unchanged. IMPRESSION: Status post placement of right IJ central venous catheter which terminates at the cavoatrial junction. Radiology Report EXAMINATION: CT abdomen and pelvis without contrast INDICATION: ___ year old woman with LRRT ___ on immunosuppression, representing with fever and hypotension. No localizing infectious symptoms.// Evaluate for any abscess, PNA other infectious sources TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 996 mGy-cm. COMPARISON: CT abdomen pelvis dated ___ FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. 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 bilateral native kidneys are shrunken and atrophic, and contain multiple calcified foci. A right lower quadrant renal transplant is present, with an unremarkable, unenhanced appearance. No evidence of hydronephrosis within the renal transplant. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Diverticulosis of the 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 a small amount of free fluid. REPRODUCTIVE ORGANS: There is a fibroid uterus. No adnexal abnormalities are present. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There is diffuse anasarca. The previously described soft tissue induration in the right flank is less conspicuous. IMPRESSION: 1. No acute process in the abdomen or pelvis. 2. Diffuse anasarca. The previously described area of induration in the soft tissues of the right flank is less conspicuous, is felt to represent sequela of volume overload. 3. Diverticulosis, without evidence of diverticulitis. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ woman status post renal transplant on immunosuppression fever and hypotension, evaluate for infection. TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous 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) Spiral Acquisition 15.9 s, 61.1 cm; CTDIvol = 16.5 mGy (Body) DLP = 979.9 mGy-cm. Total DLP (Body) = 996 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS W/O CONTRAST) COMPARISON: Prior chest CT dated ___. FINDINGS: NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal. Supraclavicular and axillary lymph nodes are not enlarged. MEDIASTINUM: Mildly enlarged subcarinal lymph node measuring up to 11 mm in short axis is likely reactive (4:124). HILA: Hilar lymph nodes are not enlarged. HEART: The heart is not enlarged and there is no coronary arterial calcification. There is no pericardial effusion. VESSELS: A retroesophageal right subclavian artery is noted, a normal anatomic variant. A right IJ central venous catheter terminates the cavoatrial junction. Aortic caliber is normal. The main, right, and left pulmonary arteries are normal caliber. PULMONARY PARENCHYMA: Patchy areas of ground-glass opacity in bilateral lung apices, right slightly worse than left, and the right lower lobe is worrisome for an infectious process. There is no lobar consolidation. There is no interlobular septal thickening. There is no emphysema. AIRWAYS: The airways are patent to the subsegmental level bilaterally. PLEURA: Small nonhemorrhagic pleural effusions are present bilaterally. CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion. Multilevel degenerative changes are mild. Similar to the immediate prior study there is asymmetric enlargement of the left breast with extensive edema and skin thickening in UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen. Allowing for this, the partially visualized upper abdomen is notable for cholecystectomy clips.. IMPRESSION: 1. Patchy areas of ground-glass opacity in bilateral lung apices, slightly worse on the right worrisome for a multifocal infectious or inflammatory process. 2. Similar appearance of the asymmetrically enlarged left breast with skin thickening, previously evaluated by diagnostic mammography. 3. Small nonhemorrhagic pleural effusions bilaterally. Gender: F Race: ASIAN Arrive by AMBULANCE Chief complaint: Fever, Hypotension Diagnosed with Sepsis, unspecified organism, Hypotension, unspecified, Other cytomegaloviral diseases, Anemia, unspecified, Nonspec elev of levels of transamns & lactic acid dehydrgnse temperature: 98.1 heartrate: 75.0 resprate: 16.0 o2sat: 97.0 sbp: 91.0 dbp: 57.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, ___ were admitted to ___ with low blood pressures. ___ improved with antibiotics and high doses of steroids. We better controlled your blood sugars with insulin with the help of our diabetes doctors. ___ left against medical advice while we were still trying to figure out the cause of your blood pressures. It was a pleasure caring for ___. Wishing ___ the best, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Keflex / Latex / Lipitor / Zosyn Attending: ___. Chief Complaint: febrile x 2 days, acute onset of SOB and mental status changes Major Surgical or Invasive Procedure: NONE History of Present Illness: Mrs ___ is well known to the cardiac surgery service. She originally underwent CABG x3 on ___. She was readmitted on ___ for sternal wound dehisence and on ___ underwent bilaterl pectoral flaps and plating with Dr. ___. She was discharged to rehab on ___ on a 6 week course of Vanco and Cipro despite negative OR cultures. Sternal drains placed by plastics remained in place. She was due to f/u with Dr. ___ week to have them removed. Over the past 48hrs she spiked fever and zosyn was added. Today she became acutely SOB and lethargic. She was brought to the ER and was intubated. Head CT was negative (recent hx of stroke after CABG), CTA of chest suggestive OF PE. ALabs, EKG and bedside Echo was unremarkable. During her ER stay she became mildly hypotensive. Central line was placed and she was started on levo. She was admitted cardiac surgery service for further evaluation Past Medical History: Coronary Artery Disease s/p Coronary artery bypass grafting x 3 ___ Hypertension insulin dependent Diabetes peripheral vascular disease Hypercholesterolemia Right Breast CA in ___ s/p lumpectomy and radiation therapy with recurrence in ___ s/p right breast mastectomy and reconstruction Left great toe to left shin cellulitis s Depression Restless leg syndrome Hypothyroidism h/o deep vein thrombophlebitis s/p appendectomy Social History: ___ Family History: non-contributory Physical Exam: Pulse: 80 SR Resp: 24 O2 sat:100 vented B/P Right:120/89 Left: Height: Weight: Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [] hyperactive bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [x] _+1____ Varicosities: None [x] Neuro: Intubated and sedated Pulses: Femoral Right:+2 Left:+2 DP Right:+1 Left:+1 ___ Right:+1 Left:+1 Radial Right: +2 Left:+2 Carotid Bruit Right: None Left:None Pertinent Results: ECHO: ___ The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is at least 15 mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%) with abnormal septal motion and septal hypokinesis. The right ventricular cavity is mildly dilated 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. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal study. Low-normal global left ventricular systolic function and hypokinesis of the septum. Mildly dilated right ventricle with mild free wall hypokinesis. ___ 05:45AM BLOOD WBC-11.0 RBC-3.41* Hgb-9.3* Hct-28.8* MCV-85 MCH-27.2 MCHC-32.1 RDW-15.4 Plt ___ ___ 06:01AM BLOOD WBC-10.0 RBC-3.24* Hgb-9.0* Hct-27.8* MCV-86 MCH-27.7 MCHC-32.2 RDW-15.2 Plt ___ ___ 07:20PM BLOOD WBC-13.5* RBC-3.94* Hgb-10.9* Hct-32.9* MCV-84 MCH-27.6 MCHC-33.0 RDW-15.2 Plt ___ ___ 05:45AM BLOOD Glucose-76 UreaN-22* Creat-1.0 Na-145 K-4.2 Cl-111* HCO3-29 AnGap-9 ___ 06:01AM BLOOD Glucose-99 UreaN-29* Creat-1.1 Na-146* K-3.9 Cl-112* HCO3-27 AnGap-11 Medications on Admission: ciprofloxacin 500 mg q 12hrs, vancomycin 750mg q 24hrs, 81 mg daily, pravastatin 20 mmg DAILY, pantoprazole 40 mg daily, ergocalciferol weekly, levothyroxine 50 mcg daily, heparin sc tid,clopidogrel 75 mg daily, citalopram 20 mg daily, metoprolol 25mg TID, tramadol 50 mg prn,Imdur 60 mg q 24hrs, hydralazine 50 mg q 6hrs, Norvasc 5 mg daily,lomotil prn, lantus 80 units q am Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 12. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for loose stools. 13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. glargine ___very morning at breakfast 15. novolin -R dose based on sliding scale fingerstick before meals and at bedtime Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: mental status changes s/p sternal dehiscence, debridement, sternal plating Coronary artery disease s/p coronary artery bypass grafts hypertension insulin dependent Diabetes peripheral vascular disease hyperlipidemia Breast CA in ___ s/p lumpectomy (radiation therapy with recurrence in ___ s/p right breast mastectomy and reconstruction Left great toe to left shin cellulitis problem Depression Hypothyroidism s/p appendectomy Obesity Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait and assist of onw Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Edema 1+ bilateral lower extremities Followup Instructions: ___ Radiology Report EXAM: Chest, single AP portable view. CLINICAL INFORMATION: ___ female with history of shortness of breath and pneumonia. ___. FINDINGS: Single AP portable view of the chest was obtained. The patient is status post median sternotomy hardware/sternal fixation devices are again seen. There has been interval placement of a left subclavian central venous catheter, possibly a PICC, terminating in the distal SVC. Cardiac and mediastinal silhouettes are stable. There is moderate pulmonary vascular congestion. Minimal blunting of the right costophrenic angle may be due to a trace effusion. Left base retrocardiac opacity most likely represents atelectasis, less likely consolidation. Otherwise, no definite focal consolidation is seen. There is no pneumothorax. Radiology Report EXAM: Chest, single supine AP portable view. CLINICAL INFORMATION: ___ female status post intubation with increased work of breathing: ___. FINDINGS: Supine AP portable view of the chest was obtained. There is interval placement of an endotracheal tube terminating just above the level of the clavicles. The exact level of the carina is difficult to determine due to patient's overlying sternotomy hardware. An orogastric tube is seen coursing below the level of the diaphragm, inferior aspect not included on the images. Left subclavian central venous catheter terminates at the distal SVC/cavoatrial junction. Mild pulmonary vascular congestion appears improved. There is mild bibasilar atelectasis. Radiology Report INDICATION: Mental status change. COMPARISON: CT available from ___. TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without the use of IV contrast. Coronal and sagittal reformations were performed at 2-mm slice thickness. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. The ventricles and sulci are mildly prominent, reflective of diffuse cortical atrophy. There is relative hypoattenuation of the periventricular white matter, compatible with chronic microvascular ischemic disease. Mild mucosal thickening within the ethmoid and left maxillary sinus is again seen (2:8). The middle ear cavities and mastoid air cells are clear. Oropharyngeal secretions are seen likely secondary to intubation. IMPRESSION: No acute intracranial process. Radiology Report INDICATION: Hypoxia. COMPARISON: CT available from ___. TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained prior to and following the uneventful administration of 100 cc of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. Additional right and left oblique reconstructions were also obtained for further evaluation of the pulmonary vessels. FINDINGS: The patient is status post median sternotomy and CABG, with broken sternal wires and multiple metallic sternal plates denoting sternal dehiscence repair. Partially calcified 2-cm circumscribed subcutaneous structure anterior to the sternum (3:28) is unchanged, likely reflecting a focus of fat necrosis. No adjacent fluid collections are detected. The heart size is top normal. The great vessels are normal in caliber. No aortic dissection is detected. Apparent filling defects are seen at the lateral edge of the right distal main pulmonary artery (3:25). However, there is marked patient motion throughout the study, and this may represent a false positive from motion-related artifact. On the oblique reconstructions, there is an apparent right posterior segmental filling defect (___), however, this is also incompletely assessed due to motion. No other filling defects are appreciated. There are trace bilateral pleural effusions (3:51). There is mild central venous congestion with minimal interstitial edema. An endotracheal tube terminates within the distal trachea (2:10). An orogastric tube terminates within the lumen of the stomach. Included views of the spleen, adrenal glands, liver, pancreas, stomach, and kidneys are normal. OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or lytic lesions are identified. IMPRESSION: 1. Equivocal linear filling defects within the right lower lobar and segmental pulmonary arterial branches may represent artifact from severe patient motion vs pulmonary embolism. Consilder followup examination in 24 hours for further assessment. 2. Trace bilateral pleural effusions. 3. Post-CABG and sternal dehiscence repair surgeries. Radiology Report INDICATION: Evaluate for effusions. COMPARISONS: Chest radiograph ___. CTA chest ___. FINDINGS: Since the prior radiograph, a right internal jugular central line has been placed and ends in the upper SVC. There is no pneumothorax. A left PICC ends in the mid SVC. An endotracheal tube is approximately 5.5 cm from the carina and unchanged in appearance. A feeding tube is seen within the stomach. Sternal hardware is intact and unchanged. The cardiomediastinal silhouette is stable and has a normal postoperative expected appearance. There is mild pulmonary vascular congestion but no pulmonary edema. Bibasilar atelectasis is unchanged. There are no definite pleural effusions. There is no new consolidation. IMPRESSION: 1. New right internal jugular central line ends in the upper SVC. No pneumothorax. 2. Stable bibasilar atelectasis. Radiology Report INDICATION: ___ female with sepsis and acidosis, status post CABG and sternal wound re-plating, here to assess for ___ source of infection. COMPARISON: No prior studies available. TECHNIQUE: CTA of the abdomen and pelvis was performed prior to and after the uneventful administration of 100 cc of Visipaque intravenous contrast. Coronally and sagittally reformatted images were generated and reviewed. FINDINGS: CTA OF THE ABDOMEN: Limited supradiaphragmatic evaluation shows the patient is status post median sternotomy and CABG, now with metallic sternal plate denoting sternal dehiscence repair. No adjacent fluid collections are detected anterior to the pericardium. Two mediastinal drains are in place. Limited evaluation of the heart shows top normal size but no pericardial effusion. Trace bilateral pleural effusions with associated compressive atelectasis are present in the lung bases. No pulmonary nodule, opacity, or focal consolidation is seen. The liver enhances homogeneously without focal liver lesions. The hepatic arterial anatomy is conventional. No intra- or extra-hepatic biliary dilation is seen. The gallbladder, spleen, pancreas, and bilateral adrenal glands are unremarkable. Both kidneys demonstrate striated nephrograms which is more pronounced on the right than the left, but excrete contrast normally. No perinephric stranding is appreciated. No intrarenal stones, hydronephrosis, or solid renal masses are appreciated. A small exophytic hypodensity in the right kidney measures 1 cm and cannot be accurately characterized by CT, but likely represents a renal cyst. A nasogastric tube is seen terminating in the stomach. The ___ loops of small and large bowel are unremarkable without evidence of wall thickening or obstruction. No free air or ascites is present. No pathologically enlarged lymph nodes are identified in the retroperitoneal or mesenteric regions. There is calcified atherosclerosis of the infrarenal abdominal aorta extending into the iliac arteries bilaterally. CTA OF THE PELVIS: The rectum, sigmoid colon, uterus, and bilateral adnexa are unremarkable. The urinary bladder is almost completely decompressed by a Foley catheter in appropriate position. There is no free pelvic fluid or inguinal lymphadenopathy. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. Evidence of bilateral pyelonephritis more pronounced on the right than the left without associated nephrolithiasis or hydronephrosis. 2. No other findings to suggest ___ infection. Radiology Report PA AND LATERAL CHEST COMPARISON: ___, chest radiograph. FINDINGS: Left PICC and endotracheal tube have been removed as well as midline drains and nasogastric tube. Right internal jugular vascular catheter remains in standard position. Cardiomediastinal contours are stable in the postoperative period in this patient, status post prior cardiovascular surgery and sternal closure procedure. No confluent areas of consolidation are present in either lung. Scattered areas of linear atelectasis are present bilaterally, and note is also made of small pleural effusions bilaterally. IMPRESSION: Small bilateral pleural effusions. No evidence of pneumonia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: SOB Diagnosed with RESPIRATORY ABNORM NEC, FEVER, UNSPECIFIED, HYPOTENSION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ year old man with dementia, TIA, pulmonary fibrosis, ataxia with prior falls (most recently ___ who presented from his assisted living facility after a fall. He is very demented at baseline and does not recall any of the circumstances surrounding the fall. The staff at the nursing home noted scrapes on his knees and they were concerned that his mental status was "not normal." In speaking with his health care proxy, he was not as interactive as he usually is and it was difficult to get him to respond to any questions, so he was sent into the the hospital. No other trauma was noted aside from the scraped knees. In the ED, initial vitals were 97.8 95 151/120 18 98%. Exam was notable for his baseline dementia, with knee abrasions bilaterally. His labs were notable for creatinine of 1.2 (from baseline of 1.0) and BUN of 28. His WBC count was 11.5 with 92% PMNs (prior hospitalization 10.4 - 11.5). He had a CT head and C-spine which were unremarkable, CXR without pneumonia, and hip and pelvis x-rays which were unremarkable as well. He was noted to be in atrial fibrillation with RVR with rates in the 130s for approximately one hour. This resolved with 2L NS without the need for rate control medications. He also received 500 mg acetaminophen before being admitted to medicine for monitoring for a complaint of back pain. On arrival to the floor, vital signs were 98.1 119/73 82 18 95%RA. He has no specific complaints and clearly reports that he is not in any pain. In speaking with his neice who is his health care proxy, the circumstances surrounding the fall are unclear. She was worried in the Emergency Department because the patient was not speaking as much as he normally does. She also noted that they recently discontinued many of his medications in an effort to simplify his medication regimen. On review of systems, denies fever, chills, headache, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: - Dementia - Prior TIAs - Hyperlipidemia - Paroxysmal atrial fibrillation (CHADS2 of 4, not anticoagulated due subarachnoid hemorrhage and frequent falls) - Pulmonary fibrosis ___ syndrome) - Ataxia - Positive for hepatitis A and hepatitis B - BPH s/p laser surgery - Glaucoma - Chronic constipation - Depression Social History: ___ Family History: Father- myocardial infarction Mother- dementia Brother- healthy Physical Exam: ADMISSION PHYSICAL EXAM: VS 98.1 119/73 82 18 95%RA GEN - altert, oriented x1, follows commands HEENT - NC/AT, dry MMM, EOMI, right pupil 3mm with surgical scar, left 2mm, both reactive, sclera anicteric, OC/OP clear. NECK - thin, no JVD, no LAD PULM - adequate air entry/chest expansion, fine rales at right base CV - Irregularly irregular, normal rate, S1/S2, no m/r/g ABD - soft, NT/ND, normoactive bowel sounds, no guarding or rebound EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally NEURO - CN II-XII intact, slight left sided facial droop most prominent at the corner of his mouth, motor function grossly normal, no pronator drift SKIN - abrasions on his knees bilaterally DISCHARGE PHYSICAL EXAM: VS - 97.___/98.1 134/68 60-112 18 95%RA GEN - altert, oriented to self, follows commands HEENT - NC/AT, dry MMM, EOMI, right pupil 3mm with surgical scar, left 2mm, both reactive, sclera anicteric, OC/OP clear. NECK - thin, no JVD, no LAD PULM - adequate air entry/chest expansion, no wheezes, rales, rhonchi CV - Regular rate and rhythm, normal S1/S2, no m/r/g ABD - soft, NT/ND, normoactive bowel sounds, no guarding or rebound EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally NEURO - CN II-XII intact, slight left sided facial droop most prominent at the corner of his mouth with ? right sided ptosis, motor function grossly normal, no pronator drift SKIN - abrasions on his knees bilaterally Pertinent Results: On admission: ___ 09:55AM BLOOD WBC-11.5* RBC-4.21* Hgb-13.1* Hct-40.7 MCV-97 MCH-31.2 MCHC-32.2 RDW-12.7 Plt ___ ___ 09:55AM BLOOD Neuts-92.9* Lymphs-2.2* Monos-3.8 Eos-0.6 Baso-0.5 ___ 09:55AM BLOOD Glucose-96 UreaN-28* Creat-1.2 Na-137 K-4.2 Cl-100 HCO3-25 AnGap-16 ___ 02:57PM BLOOD Lactate-1.5 On discharge: ___ 06:50AM BLOOD WBC-8.9 RBC-3.68* Hgb-11.4* Hct-35.9* MCV-98 MCH-30.9 MCHC-31.6 RDW-12.8 Plt ___ ___ 06:50AM BLOOD Glucose-69* UreaN-26* Creat-1.1 Na-138 K-3.7 Cl-103 HCO3-25 AnGap-14 Micro: ___ Urine culture: pending ___ Blood culture: pending Studies: ___ CT head: There is no evidence of acute hemorrhage, edema, mass effect, or infarction. The previously seen foci of subarachnoid hemorrhage and intraparenchymal hemorrhage have resolved. The ventricles and sulci are widened which suggests age-related involutional changes. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. No fracture is seen. Again seen is a diastasis of a suture in the right occipital region. There is partial opacification of the right mastoid air cells, as well as secretions in the right ethmoid air cells. IMPRESSION: No evidence of acute intracranial process. ___ CT C-spine: 1. No fracture or traumatic malalignment of the cervical spine. Stable multilevel degenerative changes present. 2. Chronic fibrotic biapical opacities with small nodular opacities and bronchial wall thickening, bronchiectasis. This is concerning for small airways infection versus inflammation superimposed on a background of chronic interstitial lung disease. Chest x-ray is recommended for further evaluation. ___ CXR: Similar appearance of the chest with chronic fibrotic interstitial changes most pronounced in the lung apices. These findings could reflect sarcoidosis, but considerations for ___ pneumocosis or silicosis should be considered with the appropriate clinical history. ___ Hip and pelvis x-ray: No acute fracture or dislocation is seen. Mild degenerative changes of both hips are noted with joint space narrowing. There is no diastasis of the pubic symphysis or sacroiliac joints. No suspicious lytic or sclerotic osseous abnormalities are detected. IMPRESSION: No acute fracture or dislocation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 500 mg PO BID 2. Memantine 10 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY 4. timolol maleate *NF* 0.25 % ___ BID 5. travoprost *NF* 0.004 % ___ BID 6. Senna 1 TAB PO BID 7. Docusate Sodium 100 mg PO BID 8. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Calcium Carbonate 500 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Memantine 10 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 1 TAB PO BID 7. timolol maleate *NF* 0.25 % ___ BID 8. travoprost *NF* 0.004 % ___ BID 9. Metoprolol Succinate XL 25 mg PO DAILY Hold for systolic BP less than 100 or heart rate less than 55 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: - Syncope with fall - Advanced dementia - Paroxysmal atrial fibrillation Secondary diagnoses: - Prior TIAs - Hyperlipidemia - Pulmonary fibrosis ___ syndrome) - Ataxia - Glaucoma - Chronic constipation - Depression Discharge Condition: Mental Status: Confused - always. Alert and oriented to self only. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Unwitnessed fall. TECHNIQUE: Upright AP view of the chest. COMPARISON: ___. FINDINGS: Cardiac and mediastinal contours are unchanged with the heart size within normal limits. The aortic knob is calcified. Again demonstrated are upper lobe predominant parenchymal opacities with architectural distortion, bronchiectasis and slight superior hilar retraction. Additionally, patchy opacities are also noted within the right lung base. No new focal consolidation is seen. There is no pleural effusion or pneumothorax. No acute osseous abnormalities are demonstrated. IMPRESSION: Similar appearance of the chest with chronic fibrotic interstitial changes most pronounced in the lung apices. These findings could reflect sarcoidosis, but considerations for coalworkers pneumocosis or silicosis should be considered with the appropriate clinical history. Radiology Report HISTORY: Right hip pain after fall. TECHNIQUE: AP view of the pelvis, 2 views of the right hip. COMPARISON: None. FINDINGS: No acute fracture or dislocation is seen. Mild degenerative changes of both hips are noted with joint space narrowing. There is no diastasis of the pubic symphysis or sacroiliac joints. No suspicious lytic or sclerotic osseous abnormalities are detected. IMPRESSION: No acute fracture or dislocation. Radiology Report HISTORY: Unwitnessed fall, altered mental status. TECHNIQUE: Contiguous axial CT images were obtained through the brain without the administration of IV contrast. Coronal and sagittal reformats were also obtained. DLP: 1025.72 mGy-cm. COMPARISON: CT head ___. FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or infarction. The previously seen foci of subarachnoid hemorrhage and intraparenchymal hemorrhage have resolved. The ventricles and sulci are widened which suggests age-related involutional changes. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. No fracture is seen. Again seen is a diastasis of a suture in the right occipital region. There is partial opacification of the right mastoid air cells, as well as secretions in the right ethmoid air cells. IMPRESSION: No evidence of acute intracranial process. Radiology Report HISTORY: Fall, altered mental status. TECHNIQUE: Contiguous axial MDCT images were taken from the skull base through the T2 level. Coronal and sagittal reformats were also examined. DLP: 787.37 mGy-cm. COMPARISON: CT cervical spine ___. FINDINGS: There is no fracture, traumatic malalignment, or prevertebral soft tissue swelling. Again seen is a stable grade 1 anterolisthesis of C7 on T1, likely degenerative. There are stable multilevel degenerative changes with posterior disc osteophyte complexes in mild contact with the ventral thecal sac, worse at C2-3. Fibrotic changes are again seen at the right lung apex. Small ___ nodular opacities at both lung apices, right greater than left, with increased bronchiectasis and bronchial wall thickening is noted. IMPRESSION: 1. No fracture or traumatic malalignment of the cervical spine. Stable multilevel degenerative changes present. 2. Chronic fibrotic biapical opacities with small nodular opacities and bronchial wall thickening, bronchiectasis. This is concerning for small airways infection versus inflammation superimposed on a background of chronic interstitial lung disease. Chest x-ray is recommended for further evaluation. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: S/P FALL, ALT MS Diagnosed with ATRIAL FIBRILLATION, ABRASION HIP & LEG, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE temperature: 97.8 heartrate: 95.0 resprate: 18.0 o2sat: 98.0 sbp: 151.0 dbp: 120.0 level of pain: it hurts level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at the ___. You were admitted to the hospital because you fell at your assisted living facility. Nobody saw you fall, so we don't know exactly why this happened, but you were dehydrated when you arrived and your heart rate was fast, so these may be contributing. It is also likely that your underlying dementia and your balance problems put you at a higher risk for a fall. We recommend that your facility takes measures to help prevent you from falling such as lowering the height of your bed, putting soft mats on the floor near your bed, and helping you when you need to walk somewhere. Because you were in a heart rate called atrial fibrillation, we discussed starting blood thinners with your health care proxy. Because of your frequent falls and recent bleeding in your brain, there is substantial risk with blood thinners, so they were not started. We did start you on a medication to slow your heart called metoprolol. Please discuss this with your primary care doctor.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: regurgitation, SOB Major Surgical or Invasive Procedure: conservative management History of Present Illness: ___ with a history of esophageal adenocarcinoma s/p neoadjuvant treatment and then minimally invasive esophagectomy on ___, who presents with 3 weeks of regurgitation of solids and SOB. For the past 3 weeks, she has been unable to keep down any solid food; she can swallow, but a few minutes later feels as though the food is stuck, feels nauseated, she begins coughing, and will cough the food back up. No trouble with liquids. She has also felt SOB intermittently, usually when walking or working, but also occasionally at rest. The patient was seen by her PCP ___ 3 weeks ago when this started, and has since taken courses of azithromycin and levofloxacin, with subjective improvement in SOB when on antibiotics; SOB returned after completing the anitbiotics. No chest pain. No fevers, but occasional chills. Some diarrhea about a week ago. Her postoperative course in last ___ was complicated by development of gastric outlet obstruction and recurrent aspiration pneumonia, treated with balloon dilation and botox injection at the pylorus in ___. In ___, she noted nausea and abdominal pain with eating; this was evaluated with a barium swallow which did not demonstrate obstruction. She has been relatively well since then. Past Medical History: PMH: esophageal adenocarcinoma s/p MIE ___, asthma Social History: ___ Family History: Mother - rectal cancer Father - oral cancer Physical Exam: GEN: NAD, A&Ox3 CV: RRR, no MRG, nl s1/s2 PULM: CTAB, tachypneic ABD: s/nt/nd; well-healed scars EXT: WWP Pertinent Results: ___ 09:55PM BLOOD WBC-7.6 RBC-3.52* Hgb-11.2* Hct-32.7* MCV-93 MCH-31.9 MCHC-34.4 RDW-13.0 Plt ___ ___ 09:55PM BLOOD Glucose-108* UreaN-14 Creat-0.6 Na-140 K-4.1 Cl-103 HCO3-27 AnGap-14 ___ 09:55PM BLOOD Calcium-9.6 Phos-4.9*# Mg-1.8 CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___ 10:17 ___ 1. No evidence of pulmonary embolism. 2. Status post partial esophagectomy with gastric pull-through. The remaining esophagus is distended and contains ingested material. 3. Bronchial wall thickening at right base could represent bronchitis, possible from chronic aspiration given patient history. UGI SGL CONTRAST W/ KUB Study Date of ___ 9:34 AM IMPRESSION: Status post esophagectomy with gastric pull-through with no evidence of obstruction. Medications on Admission: protonix 20', ativan 0.5" prn Discharge Medications: 1. Protonix 40 mg Susp,Delayed Release for Recon Sig: One (1) 40 mg PO once a day. Disp:*45 dose* Refills:*2* 2. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: -Esophageal adenocarcinoma s/p MIE ___ -Dysphagia -Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female status post esophagectomy (___), now presenting with regurgitation. Evaluate for gastric outlet obstruction. EXAMINATION: Fluoroscopic upper GI series. COMPARISONS: ___ and CTs from ___. PROCEDURE AND FINDINGS: The patient was brought to the fluoroscopic suite and placed upright on an imaging platform. The patient under fluoroscopic surveillance self-administered thin barium. Contrast was administered orally. Initial scout radiographs demonstrate the patient to be status post esophagectomy with gastric pull-through with relatively high anastomosis. The lungs are clear. There is no pleural effusion or pneumothorax. The cardiomediastinal and hilar contours are otherwise unremarkable. Pulmonary vascularity is not increased. Contrast flows freely through both the anastomosis and also the distal stomach through the pylorus. There is no evidence of outlet obstruction. IMPRESSION: Status post esophagectomy with gastric pull-through with no evidence of obstruction. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SOB Diagnosed with RESPIRATORY ABNORM NEC, VOMITING, MAL NEO ESOPHAGUS NOS temperature: 99.8 heartrate: 109.0 resprate: 24.0 o2sat: 100.0 sbp: 139.0 dbp: 76.0 level of pain: 4 level of acuity: 2.0

Please call Dr. ___ office ___ if you experience: -Fevers > 101 or chills -Difficult or painful swallowing. -Chest or back discomfort. -Abdominal pain

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with H/O breast cancer S/P breast reconstructive surgery, insomnia, depression, and recent hospital admission (___) for hyponatremia thought due to Effexor presenting with chest pain. Patient noticed onset of sudden, sharp left sided chest pain that radiated to the back and left arm the night prior to admission. She had just finished walking home from the ___ in her ___ building and had sat down in her residence when she noticed onset of sharp left sided chest pain. The pain occurred at rest and was not associated with exertion. She denied any nausea, vomiting, diaphoresis, palpitations, shortness of breath or lightheadedness. She took a baby aspirin but the pain persisted so she presented to the ___ emergency department. At the ___, exam was notable for left chostochondral junction tenderness. CTA was done which was originally read as no pulmonary embolus and no dissection. She was placed in observation status for 2 sets of cardiac biomarkers and was going to be discharged, but radiology reread the CTA as possible small focal type B dissection. She was transferred to ___ ___ for further monitoring and workup. At ___, she received ASA 324 mg, morphine, and Zofran 5 mg. In the ___ ___, initial vitals were T 98.6 HR 96 BP 123/64 RR 18 SaO2 98% on RA. Labs were notable for a normal troponin, CK and CK-MB. EKG showed sinus rhythmn with left axis deviation and left ventricular hypertrophy. Vascular surgery was consulted regarding the possible aortic dissection. After their review of the images, they felt a dissection was not present and recommended admission to medicine to complete the biomarker series to exclude myocardial infarction, BP control, and repeat aortic imaging. Patient was given morphine 2 mg and Dilaudid 1 mg IV for pain control and admitted to cardiology. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. On arrival to the floor, patient stated that she feels well and that her pain is well controlled. On further questioning, patient reports that she exercises regularly and is active in water aerobics. She never has this kind of pain while doing aerobics and says she can walk 'quite a distance' without getting short of breath, has not been limited in her activities by shortness of breath. Past Medical History: 1. CAD RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None PMH 1. Hot flashes. 2. Insomnia. 3. breast cancer in ___, now on hormonal therapy, S/P left mastectomy with reconstruction from abdominal flap (multiple node-positive breast cancer, ER positive, HER-2/neu negative; T2, N1 lesion with ___ positive nodes with extranodal extension; treated with left modified radical mastectomy, reconstruction, Cytoxan and Adriamycin, followed by Taxol as adjuvant chemotherapy followed by ___ years of tamoxifen and ___ years of letrozole) 4. Osteopenia. 5. Hyponatremia PAST SURGICAL HISTORY: Significant for bilateral cataracts and mastectomy on the left with surgical reconstruction using a right rectus flap. Social History: ___ Family History: Her father died at age ___ he had diabetes ___ esophagus, and esophageal cancer. Her mother died at age ___ she had a central tremor and anxiety. She has two sisters who are healthy. Physical Exam: ADMISSION EXAM GENERAL: awake, alert, pleasant elderly Caucasian woman in NAD VS: Tc 98.5 BP 110/52 HR 91 RR 16 SaO2 95% on RA. left arm BP: 115/65 right arm BP: 124/72 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Oral mucosa moist, no lesions NECK: Supple, no appreciable JVP CARDIAC: RRR, S1, S2; no murmurs, rubs or gallops appreciated LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. CHEST: has pain to palpation over ___ left costochondral junction ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: distal radial and dorsalis pedis pulses 2+ and equal bilaterally NEURO: CN II-XII intact, no asymmetry, UE and ___ strength ___ with no focal defecits, sensory grossly intact DISCHARGE EXAM GENERAL: awake, alert, pleasant woman in NAD VS: Tc 97.8 Tm 98.8 BP 122/58 (110-126/52-62) HR 75 (75-91) RR 18 SaO2 97% on RA NECK: Supple, no appreciable JVP CARDIAC: RRR, S1, S2; no murmurs, rubs or gallops appreciated LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. CHEST: has pain to palpation over ___ left costochondral junction, chronic changes of left breast reconstruction without erythema or swelling ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No clubbing, cyanosis or edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: distal radial and dorsalis pedis pulses 2+ and equal bilaterally NEURO: CN II-XII intact, no asymmetry, UE and ___ strength ___ with no focal defecits, sensory grossly intact Pertinent Results: ADMISSION LABS ___ 11:25AM WBC-7.1 RBC-4.48 HGB-13.8 HCT-40.7 MCV-91 MCH-30.8 MCHC-33.9 RDW-12.6 ___ 11:25AM NEUTS-72.6* ___ MONOS-8.4 EOS-0.4 BASOS-0.1 ___ 11:25AM ___ PTT-28.1 ___ ___ 11:25AM GLUCOSE-129* UREA N-20 CREAT-0.7 SODIUM-137 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 ___ 11:25AM CK(CPK)-62 ___ 11:25AM CK-MB-3 cTropnT-<0.01 DISCHARGE LABS ___ 07:45AM BLOOD WBC-5.4 RBC-4.22 Hgb-12.6 Hct-38.1 MCV-90 MCH-29.9 MCHC-33.1 RDW-12.2 Plt ___ ___ 07:45AM BLOOD Glucose-93 UreaN-16 Creat-0.7 Na-142 K-4.3 Cl-105 HCO3-30 AnGap-11 ECG ___ 11:17:04 AM Sinus rhythm. Left ventricular hypertrophy. No significant change compared with previous tracing of ___. ___ - CT/CT TORSO WITH CONTRAST ___ - PRELIM 1. NO EVIDENCE OF PULMONARY EMBOLISM. QUESTIONABLE FOCAL LINEAR AREA IN THE AORTIC ARCH THAT MIGHT POTENTIALLY REFLECT SMALL FOCAL DISSECTION. ATTENTION TO THIS AREA IN THE SUBSEQUENT STUDIES SHOULD BE OBTAINED IN 24 HOURS IS RECOMMENDED. 2. STATUS POST LEFT BREAST SURGERY AND RADIATION WITH UNCHANGED APPEARANCE OF THE CALCIFIED NODULE IN THE LEFT LATERAL BREAST. 3. FOCAL HYPODENSITY IN THE UNCINATE PROCESS OF THE PANCREAS THAT SHOULD BE FURTHER ASSESSED WITH ___. THESE FINDINGS WERE ALSO DISCUSSED WITH THE RESIDENT TAKING CARE OF THE PATIENT, ___. ___. 4. LIVER HYPODENSITY AND LEFT KIDNEY HYPODENSITY, TOO SMALL TO CHARACTERIZED MAY BE ASSESSED ON ULTRASOUND. 5. SMALL UMBILICAL HERNIA. ATROPHY OF THE RIGHT RECTUS ABDOMINUS MUSCLE, UNCLEAR IF PRIOR SURGERY OR CONGENITAL. LARGE LEFT ILIOPSOAS LIPOMA 6. CALCIFIED FIBROID. ___ - CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___ 11:26 AM No lower cervical adenopathy. 3 vessel aortic arch. The great vessels are patent without evidence of dissection. Scattered sub cm prevascular, peritracheal and subcarinal lymph nodes lymph nodes are noted as well as sub cm bilateral hilar nodes which do not meet CT criteria for adenopathy. The ascending aorta, arch and descending aorta are normal in caliber. There are minimal atherosclerotic vascular calcifications. There is no evidence of aortic these dissection to the level of the diaphragmatic crus. Limited evaluation of the upper abdomen demonstrates a sub cm cystic lesion in the hepatic dome which is too small to characterize but likely represents a simple cyst. There is a small hiatal hernia. There is diffuse thickening of the left adrenal gland without discrete nodule or mass. Incidental note of anomalous origin of the left portal vein from the anterior right portal vein. The remainder is unremarkable. Lungs demonstrate normal background parenchymal pattern without mildly volume loss on the left as well as an area of ground-glass opacity of the left upper lung and scarring in the lingula which likely represents radiation changes related to breast cancer treatment. Bilateral mild dependent atelectasis is present. The central airways are patent. The central pulmonary arteries are also patent without evidence of filling defects. Patient is status post left mastectomy. There is a calcified partially calcified collection in the left axilla which likely represents a postoperative seroma. The no suspicious or acute osseous abnormalities are seen. IMPRESSION: 1. No evidence of aortic dissection. 2. Postsurgical changes in the left breast and likely postradiation changes involving the lingula and left upper lobe lung apex. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. Aspirin 81 mg PO DAILY 3. Vitamin D 800 UNIT PO DAILY 4. letrozole *NF* 2.5 mg Oral daily Discharge Medications: 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. Vitamin D 800 UNIT PO DAILY 3. Aspirin 81 mg PO DAILY 4. letrozole *NF* 2.5 mg Oral daily 5. Acetaminophen 1000 mg PO Q6H:PRN pain RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: costochondritis Secondary: -aortic atherosclerosis -insomnia -depression -breast cancer -radiographic pancreatic lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: History of breast cancer presenting with the tip chest pain. Transferred to both ___ when the CT chest angiogram suggested a possible small dissection of the descending aorta. TECHNIQUE: Helical CT acquisition through the chest following uneventful administration of 100 cc Omnipaque IV contrast. Coronal and sagittal reformats provided by technologist. 3 d curved planar reformats were performed on an independent 3D workstation. DLP: 381 mGy-cm. COMPARISON: CT torso ___. FINDINGS: No lower cervical adenopathy. 3 vessel aortic arch. The great vessels are patent without evidence of dissection. Scattered sub cm prevascular, peritracheal and subcarinal lymph nodes lymph nodes are noted as well as sub cm bilateral hilar nodes which do not meet CT criteria for adenopathy. The ascending aorta, arch and descending aorta are normal in caliber. There are minimal atherosclerotic vascular calcifications. There is no evidence of aortic these dissection to the level of the diaphragmatic crus. Limited evaluation of the upper abdomen demonstrates a sub cm cystic lesion in the hepatic dome which is too small to characterize but likely represents a simple cyst. There is a small hiatal hernia. There is diffuse thickening of the left adrenal gland without discrete nodule or mass. Incidental note of anomalous origin of the left portal vein from the anterior right portal vein. The remainder is unremarkable. Lungs demonstrate normal background parenchymal pattern without mildly volume loss on the left as well as an area of ground-glass opacity of the left upper lung and scarring in the lingula which likely represents radiation changes related to breast cancer treatment. Bilateral mild dependent atelectasis is present. The central airways are patent. The central pulmonary arteries are also patent without evidence of filling defects. Patient is status post left mastectomy. There is a calcified partially calcified collection in the left axilla which likely represents a postoperative seroma. The no suspicious or acute osseous abnormalities are seen. IMPRESSION: 1. No evidence of aortic dissection. 2. Postsurgical changes in the left breast and likely postradiation changes involving the lingula and left upper lobe lung apex. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST PAIN (CARDIAC FEATURES) Diagnosed with CHEST PAIN NOS, HX OF BREAST MALIGNANCY temperature: 98.6 heartrate: 96.0 resprate: 18.0 o2sat: 98.0 sbp: 123.0 dbp: 64.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure to take care of you at ___. You were admitted for chest pain and underwent several studies that did not indicate any serious disease was occuring with your heart or blood vessels. You were treated with tylenol and are feeling better. There were no changes made to your medications. Please continue to take them as prescribed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Zestril Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o F with PMHx of DM, HTN, HLD, hypothyroidism, essential tremor, who presents with an unwitnessed fall. She reports that she has had two falls in the last week. She was found by her neighbor on the ground this morning when the neighbor came over to check on her. She denied any headache, dizziness, chest pain, shortness of breath, neck, back, or extremity pain at this time. Of note, the patient has been having increased tremors and has been started on carbidopa levodopa recently. She reports that since starting this medication, her tremors have improved, but she reports some mental fogginess or confusion since beginning this medication. In the ED, initial VS were 98.5 81 140/71 18 97% RA. Labs significant for WBC of 18.0, H/H of 10.6/34.1, Plt 307. CK elevated at 1072. BMP WNL with BUN/Cr of ___. Anion gap was elevated at 19 and lactate 2.1. UA grossly positive. CT head negative for acute intracranial process. CT c-spine without acute fracture. She received PO carbidopa-levodopa ___ .5 tablet, 10 mg propranolol, 4 units subQ insulin, 1 g ceftriaxone. Upon my arrival, the patient is at the bedside with her son. She reports that she fell first on ___ afternoon when standing up from bed. She remembers the fall and denies headstrike or loss of consciousness. On the day of admission, she fell again. She reports she was using her walker to rise to standing when she had some lightheadedness or "fogginess" and fell down. She denies loss of consciousness and reports she remembers the event. She denies chest pain or palpitations at the time of the fall. She reports after falling that she felt a wave of nausea. She felt very weak and was unable to get up again and did not want to try again because she was worried she would fall. She stayed on the ground until her neighbor arrived. She denies recents fevers, chills, shortness of breath, chest pain, exertional chest pain or shortness of breath. She does endorse a chronic mild cough. She reports some dysuria occurring over the past month with a significant increase in urinary frequency. She denies abdominal pain. She denies blood in urine or blood in her stools. She endorses chronic stable neuropathic pain which she associates with her diabetes, but denies new numbness or tingling. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: IDDM2 with neuropathy, hypothyroidism, essential tremor, HTN, HLD Macular degeneration Osteoporosis Lumbar stenosis Anemia Social History: ___ Family History: Brother with CAD/PVD, DM2 Two grandchildren with UC 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. CV: Heart regular, systolic ___ murmur RESP: Lungs diminished at bases. 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, with minimal <4 Hz truncal/head/neck/arm tremor improved further than on admission. SKIN: No rashes or ulcerations noted PSYCH: pleasant, appropriate affect NEUROLOGIC: MENTATION: alert and cooperative. Oriented to person and place and time. Pertinent Results: ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL EMERGENCY WARD ___ URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} EMERGENCY WARD ___ 1:15 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 06:15 7.4 3.54* 9.3* 29.8* 84 26.3 31.2* 16.8* 52.0* 246 ___ 06:15 11.4* 3.67* 10.0* 31.1* 85 27.2 32.2 17.1* 53.3* 261 ___ 11:45 18.0* 4.03 10.6* 34.1 85 26.3 31.1* 16.6* 50.8* 307 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:15 ___ 139 3.4 98 27 142 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili ___ 06:15 12 34 50 0.3 CARDIAC MARKERS cTropnT ___ 06:15 <0.011 ___ 15:10 <0.011 WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate ___ 07:20 1.71 ___ 12:16 2.1*2 GENERAL URINE INFORMATION Type Color ___ ___ 11:30 Straw Hazy* 1.015 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks ___ 11:30 SM* POS* 30* 300* 40* NEG NEG 6.0 LG MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp ___ 11:30 3* >182* FEW* NONE 0 <1 OTHER URINE FINDINGS WBC Clm Mucous ___ 11:30 MANY* OCC* ===================== ___ Imaging CT HEAD W/O CONTRAST FINDINGS: There is no evidence of large territorial infarction,hemorrhage,edema,or mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. Bilateral periventricular white matter hypodensities are nonspecific but most likely reflect sequela of chronic small vessel ischemic changes. There is no evidence of fracture. There is mild mucosal thickening of ethmoid air cells. There is minimal opacification of the dependent portion of the right mastoid air cells. The remaining paranasal sinuses and middle ear cavities are clear. Patient is status post bilateral lens replacement. IMPRESSION: 1. No acute intracranial process. Specifically no intracranial hemorrhage. 2. No fracture. ===================== ___-SPINE W/O CONTRAST FINDINGS: There is mild retrolisthesis of C3 over C4 and anterolisthesis of C4 over C5, most likely degenerative changes.No acute fractures are identified.There is anterior posterior bridging osteophytes throughout the cervical spine, most severe at C6-7, C7-T1. There is moderate to severe loss of disc heights at C6-7 and C7-T1. There is no spinal canal stenosis. Uncovertebral and facet osteophytes cause moderate left neural foraminal narrowing at C2-3 and C4-5, moderate bilateral neural foraminal narrowing at C5-6 and C6-7..There is no prevertebral soft tissue swelling. Visualized thyroid and bilateral lung apices are unremarkable. IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes of the cervical spine most severe at C6-7 and C7-T1. ================= ___ Imaging CHEST (PA & LAT) FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. The aorta is calcified and tortuous. The cardiac silhouette size is top normal to mildly enlarged. Mitral annulus calcification is seen. IMPRESSION: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carbidopa-Levodopa (___) ODT 0.5 TAB PO BID 2. Glargine 18 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. amLODIPine 5 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Levothyroxine Sodium 112 mcg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Propranolol 10 mg PO BID 11. Acetaminophen 1000 mg PO BID:PRN Pain - Mild Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days Last day to take is on ___ 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 3. amLODIPine 10 mg PO DAILY 4. Carbidopa-Levodopa (___) 1 TAB PO BID 5. Glargine 18 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Citalopram 20 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Propranolol 10 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: E coli UTI E coli bacteremia Sepsis 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 fall, doesn't recall event but found down on floor// r/o SDHr/o cspine fxr/o PNA TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. The aorta is calcified and tortuous. The cardiac silhouette size is top normal to mildly enlarged. Mitral annulus calcification is seen. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with fall, doesn't recall event but found down on floor//rule out subdural hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None available. FINDINGS: There is no evidence of large territorial infarction,hemorrhage,edema,or mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. Bilateral periventricular white matter hypodensities are nonspecific but most likely reflect sequela of chronic small vessel ischemic changes. There is no evidence of fracture. There is mild mucosal thickening of ethmoid air cells. There is minimal opacification of the dependent portion of the right mastoid air cells. The remaining paranasal sinuses and middle ear cavities are clear. Patient is status post bilateral lens replacement. IMPRESSION: 1. No acute intracranial process. Specifically no intracranial hemorrhage. 2. No fracture. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with fall, doesn't recall event but found down on floor//rule out C-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 5.4 s, 21.3 cm; CTDIvol = 22.6 mGy (Body) DLP = 481.1 mGy-cm. Total DLP (Body) = 481 mGy-cm. COMPARISON: None available. FINDINGS: There is mild retrolisthesis of C3 over C4 and anterolisthesis of C4 over C5, most likely degenerative changes.No acute fractures are identified.There is anterior posterior bridging osteophytes throughout the cervical spine, most severe at C6-7, C7-T1. There is moderate to severe loss of disc heights at C6-7 and C7-T1. There is no spinal canal stenosis. Uncovertebral and facet osteophytes cause moderate left neural foraminal narrowing at C2-3 and C4-5, moderate bilateral neural foraminal narrowing at C5-6 and C6-7..There is no prevertebral soft tissue swelling. Visualized thyroid and bilateral lung apices are unremarkable. IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes of the cervical spine most severe at C6-7 and C7-T1. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with Weakness, Urinary tract infection, site not specified, Fall on same level, unspecified, initial encounter temperature: 98.5 heartrate: 81.0 resprate: 18.0 o2sat: 97.0 sbp: 140.0 dbp: 71.0 level of pain: 0 level of acuity: 2.0

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 a fall at home. ==================================== What happened at the hospital? ==================================== -The fall was due to general weakness caused by an infection. You were diagnosed with a bloodstream infection caused by a urinary tract infection. You were treated with appropriate antibiotics. ================================================== What needs to happen when you leave the hospital? ================================================== -Take your medications every day and as directed by your doctors -___ attend all of your doctor appointments, this is especially important to help with your essential tremor managed by your PCP. 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: F Service: MEDICINE Allergies: Vicodin / Ciprofloxacin / Coumadin Attending: ___. Chief Complaint: Arm Pain, Shortness of Breath Major Surgical or Invasive Procedure: None. History of Present Illness: Ms ___ is a very pleasant ___ year old female with hx CHF w/preserved EF, and pAFib on Xarelto who presents with arm pain. Pt states she had L arm pain starting at the shoulder and radiating down the hand, which she states is worse with urination. The pain resolved in the ED however she was noted to be hypoxic to the low ___ on RA which is new for her. Of note she recently also had dysuria and was treated with fosfomycin on ___, however her dysuria symptoms have persisted x2 days. On further questioning about her respiratory status, pt states that she has had SOB and nighttime cough, which she attributes to PND, for ___ years. She notes that she used to be able to walk 3 miles but now she is only able to walk 10 min before getting SOB. She also tells me that she sleeps on 2 pillows at night. Denies CP/n/v/d/f/c/ wheezing. She states that she is currently thirsty, denies recent dietary indiscretion or increased salt intake, has been taking all her meds as prescribed. In the ED, initial vitals were: 98.5 72 143/68 16 RA. Labs were unremarkable except for proBNP of 1773 and UA with large leuks, trace blood. CXR showed no pleural effusions, increased interstitial markings are similar to slightly increased compared the prior study which may be due to chronic lung disease or/and interstitial edema. Pt was given Lasix, ceftriaxone, and aspirin. On the floor, pt has no new complaints however endorses constipation and arthritis pain in her lower back. She denies arm pain or SOB currently. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, or abdominal pain. 10 pt ros otherwise negative. Past Medical History: - Heart failure with preserved ejection fraction. - Paroxismal atrial fibrillation - Hypertension. - Dyslipidemia. - Osteoarthritis s/p R knee arthroscopy - Osteopenia - Sciatica - Recurrent UTIs - ___ cataracts - Thyroid nodule - R auricular perichondritis - Hx falls w/ T12 compression fracture in ___ - HTN - essential tremor Social History: ___ Family History: Father with heart problems, mother with arthritis. Both were killed in the ___. Physical Exam: ADMISSION EXAM: Vitals: 97.9 PO 149 / 74R Lying 80 20 90 RA Constitutional: Alert, oriented x3, no acute distress EYES: Sclera anicteric, EOMI, PERRL ENT: MMM, oropharynx clear Neck: JVP at 8 cm CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Bibasilar crackles GI: Soft, non-tender, mildly distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, 1+ bilat edema to mid shin, no calf tenderness NEURO: aaox3 CNII-XII and strength grossly intact SKIN: no rashes or lesions 98 135/74 88 20 97 2L NC aox3, calm, becomes anxious talking about her memories of the holocaust jvp lower ___ of neck irregular s1 and s2, slight murmur RUSB faint early insp crackles at bases trace ___ edema to lower leg just above ankle Pertinent Results: ADMISSION LABS: ___ 06:00PM BLOOD WBC-5.8 RBC-3.83* Hgb-11.8 Hct-34.0 MCV-89 MCH-30.8 MCHC-34.7 RDW-13.4 RDWSD-43.2 Plt ___ ___ 06:00PM BLOOD Neuts-54.4 ___ Monos-10.3 Eos-1.5 Baso-0.5 Im ___ AbsNeut-3.16 AbsLymp-1.92 AbsMono-0.60 AbsEos-0.09 AbsBaso-0.03 ___ 06:00PM BLOOD Glucose-109* UreaN-18 Creat-1.1 Na-133 K-5.8* Cl-95* HCO3-24 AnGap-20 ___ 06:00PM BLOOD proBNP-1773* ___ 06:00PM BLOOD cTropnT-<0.01 ___ 06:10AM BLOOD cTropnT-<0.01 ___ 02:30PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 02:30PM URINE RBC-6* WBC->182* Bacteri-NONE Yeast-NONE Epi-0 ___ 02:30PM URINE Color-Yellow Appear-Hazy Sp ___ CXR - IMPRESSION: Hyperinflated lungs. Increased interstitial markings are similar to slightly increased compared to the prior study from ___, concerning for moderate interstitial edema and/or chronic lung disease. TTE - The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>65%). 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 valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild pulmonary artery systolic hypertension. Mild mitral regurgitation. Increased PCWP. Compared with the prior study (images reviewed) of ___, the estimated PA systolic pressure is now lower. The other findings are similar. ___ 06:25AM BLOOD WBC-5.4 RBC-3.81* Hgb-11.5 Hct-34.3 MCV-90 MCH-30.2 MCHC-33.5 RDW-13.2 RDWSD-43.6 Plt ___ ___ 06:00AM BLOOD Glucose-94 UreaN-25* Creat-1.2* Na-137 K-4.0 Cl-96 HCO3-26 AnGap-19 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 10 mg PO EVERY OTHER DAY 4. Propranolol 10 mg PO TID 5. Rivaroxaban 15 mg PO DAILY 6. Furosemide 40 mg PO QAM 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral BID 9. Multivitamins 1 tab Other DAILY 10. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Furosemide 40 mg PO DAILY Duration: 2 Days in ___, no later than 3;30pm, then resume 20mg ___ dose 2. Furosemide 20 mg PO QPM start on ___. Acetaminophen 650 mg PO Q6H:PRN pain 4. Amiodarone 200 mg PO DAILY 5. Amlodipine 10 mg PO DAILY 6. Ascorbic Acid ___ mg PO DAILY 7. Atorvastatin 10 mg PO EVERY OTHER DAY 8. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral BID 9. Furosemide 40 mg PO QAM 10. Losartan Potassium 100 mg PO DAILY 11. Multivitamins 1 tab Other DAILY 12. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 13. Propranolol 10 mg PO TID 14. Rivaroxaban 15 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute on Chronic Diastolic Heart Failure Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with a history of CHF, presents emergency room today with hypoxia.// ? CHF ? pneumonia TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: The lungs are hyperinflated. No pleural effusion is seen. Increased interstitial markings are similar to slightly increased compared the prior study which may be due to chronic lung disease or/and interstitial edema. Cardiac and mediastinal silhouettes are stable with the cardiac silhouette enlarged. The aorta is calcified. IMPRESSION: Hyperinflated lungs. Increased interstitial markings are similar to slightly increased compared to the prior study from ___, concerning for moderate interstitial edema and/or chronic lung disease. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Arm pain Diagnosed with Urinary tract infection, site not specified temperature: 98.5 heartrate: 72.0 resprate: 16.0 o2sat: nan sbp: 143.0 dbp: 68.0 level of pain: 0 level of acuity: 3.0

You presented to the hospital with arm pain and shortness of breath. You were treated with IV antibiotics for possible ongoing urinary tract infection and well as IV diuretics for fluid overload. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: tachypnea Major Surgical or Invasive Procedure: arterial line- ___ CVL placement- ___ History of Present Illness: ___ with AF on Coumadin, history of digoxin use, who presented with tachypnea. In the ED, pt initially triggered for hypotension, tachypnea and tachycardia. Trachycardic to 130 in afib with RVR and was intubated shortly after. Labs were notable for severe lactic metabolic acidosis, hyperkalemia, ___ from unknown baseline, a positive UA, and a CXR concerning for layering effusion vs pneumonia. Renal was consulted given his severe acidosis and hyperkalemia. They recommended serial EKGs, beginning IV bicarbonate and an isotonic bicarbonate gtt, insulin/dextrose, 40mg IV Lasix. The patient was additionally given an calcium gluconate, 3L NS bolus, 2g cefepime, 1000mg vancomycin, 750mg of levofloxacin, and started on norepinephrine for hypotension. On arrival to the MICU, the patient is intubated and sedated. Review of systems: unable to obtain ___ pt being intubated Past Medical History: -AF on Coumadin (on dig) - hypothyroidism - G6PD def - nephrolithiasis - nightly clonazepam (weaned recently over the last week) - urinary incontinence Social History: ___ Family History: No family history of nephrolithiasis or CKD. Physical Exam: PHYSICAL EXAM: Vitals: Reviewed in MetaVision GENERAL: Intubated and sedated HEENT: Sclera anicteric, PERRL, ETT in place NECK: supple, JVP not elevated, no LAD LUNGS: Rhonchi anteriorly CV: Tachycardic, irregularly irregular, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Cool, 2+ pulses, no clubbing, cyanosis, trace edema SKIN: scattered ecchymoses NEURO: intubated and sedated DISCHARGE PHYSICAL EXAM: Reviewed in MetaVision NAD, breathing comfortably RRR CTAB S/nt/nd 1+ pitting edema A&Ox3 Pertinent Results: ADMISSION LABS: ___ 10:05PM ___ ___ 10:05PM PLT COUNT-106* ___ 10:05PM ___ PTT-36.3 ___ ___ 10:05PM WBC-19.0* RBC-3.48* HGB-13.0* HCT-41.1 MCV-118* MCH-37.4* MCHC-31.6* RDW-17.1* RDWSD-74.4* ___ 10:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10:05PM LIPASE-69* ___ 10:05PM UREA N-93* CREAT-2.9* ___ 10:11PM freeCa-1.05* ___ 10:11PM HGB-14.2 calcHCT-43 O2 SAT-68 CARBOXYHB-3 MET HGB-0 ___ 10:11PM GLUCOSE-139* LACTATE-7.5* NA+-137 K+-7.2* CL--112* TCO2-9* ___ 10:11PM PO2-51* PCO2-18* PH-7.27* TOTAL CO2-9* BASE XS--16 ___ 10:20PM URINE RBC-176* WBC->182* BACTERIA-MANY YEAST-NONE EPI-0 ___ 10:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-600 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 10:20PM URINE COLOR-YELLO APPEAR-Cloudy SP ___ ___ 10:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 10:21PM PLT COUNT-102* ___ 10:21PM ___ PTT-30.1 ___ ___ 10:21PM NEUTS-85.0* LYMPHS-4.4* MONOS-9.5 EOS-0.0* BASOS-0.1 NUC RBCS-1.4* IM ___ AbsNeut-14.30* AbsLymp-0.74* AbsMono-1.59* AbsEos-0.00* AbsBaso-0.02 ___ 10:21PM WBC-16.8* RBC-3.27* HGB-12.0* HCT-39.4* MCV-121* MCH-36.7* MCHC-30.5* RDW-16.6* RDWSD-75.0* ___ 10:21PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10:21PM DIGOXIN-<0.2* ___ 10:21PM ALBUMIN-3.4* CALCIUM-8.6 PHOSPHATE-6.7* MAGNESIUM-2.8* ___ 10:21PM cTropnT-0.01 ___ ___ 10:21PM LIPASE-67* ___ 10:21PM ALT(SGPT)-127* AST(SGOT)-94* ALK PHOS-208* TOT BILI-1.8* ___ 10:21PM GLUCOSE-145* UREA N-91* CREAT-2.9* SODIUM-134 POTASSIUM-7.7* CHLORIDE-100 TOTAL CO2-9* ANION GAP-33* ___ 10:31PM HGB-12.6* calcHCT-38 ___ 10:31PM GLUCOSE-132* LACTATE-7.2* NA+-133 K+-7.3* CL--111* TCO2-11* IMAGING: ECHO ___ The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated with moderate to severe global hypokinesis (LVEF = ___ %). Left ventricular cardiac index is markedly depressed (<2.0L/min/m2). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Left ventricular cavity dilation with severe global hypokinesis most c/w diffuse process. Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild aortic regurgitation. Dilated ascending aorta. CT CHEST w/out CONTRAST ___ 1. Right middle lobe wedge-shaped peripheral consolidation. Infarct could be considered in the appropriate clinical setting. Follow-up in 3 months is recommended to ensure resolution. 2. Bilateral pleural effusions with overlying compressive atelectasis. 3. Extensive vascular calcifications, compatible with atherosclerotic change. 4. Please see CT abdomen pelvis that was performed concurrently for detailed intra-abdominal findings. CT ABD/PELVIS w/out CONTRAST ___ 1. Circumferential thickening of the urinary bladder and stranding is concerning for cystitis. Correlation with UA is recommended. 2. Bladder diverticulum containing a 12 mm stone. Non-urgent urology consultation recommended. 3. Small volume intraperitoneal ascites. 4. Left nonobstructing renal calculi. No hydronephrosis. 5. Please see CT chest performed concurrently for detailed intrathoracic findings. Micro: **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefepime sensitivity testing performed by Microscan. ESCHERICHIA COLI. >100,000 CFU/mL. SECOND MORPHOLOGY. Cefepime sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 8 S 8 S CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- 16 R 16 R CEFTAZIDIME----------- 4 S 2 S CEFTRIAXONE----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ___ 10:05 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. DISCHARGE LABS: ___ 04:11AM BLOOD WBC-10.4* RBC-2.99* Hgb-10.9* Hct-33.1* MCV-111* MCH-36.5* MCHC-32.9 RDW-16.7* RDWSD-68.1* Plt Ct-80* ___ 10:21PM BLOOD WBC-16.8* RBC-3.27* Hgb-12.0* Hct-39.4* MCV-121* MCH-36.7* MCHC-30.5* RDW-16.6* RDWSD-75.0* Plt ___ ___ 03:14AM BLOOD Neuts-83.9* Lymphs-6.5* Monos-8.9 Eos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-12.47* AbsLymp-0.96* AbsMono-1.32* AbsEos-0.01* AbsBaso-0.02 ___ 04:11AM BLOOD ___ PTT-34.5 ___ ___ 11:26AM BLOOD Glucose-108* UreaN-38* Creat-1.4* Na-146* K-3.2* Cl-113* HCO3-20* AnGap-16 ___ 04:01AM BLOOD ALT-62* AST-36 LD(LDH)-162 AlkPhos-105 TotBili-2.0* ___ 11:26AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.0 ___ 04:01AM BLOOD ___ 04:01AM BLOOD 25VitD-48 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Warfarin 2.5 mg PO DAILY16 3. Tamsulosin 0.4 mg PO QHS 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Digoxin 0.25 mg PO DAILY Discharge Medications: 1. Ampicillin-Sulbactam 3 g IV Q6H End date ___. Docusate Sodium 100 mg PO BID 3. Metoprolol Tartrate 25 mg PO TID 4. OLANZapine 5 mg PO DAILY 5. Senna 8.6 mg PO BID 6. ___ MD to order daily dose PO DAILY16 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Septic shock secondary to urinary tract infection Hypoxic respiratory failure Severe metabolic acidosis ___ secondary to acute tubular necrosis Acute HFrEF Hyperkalemia Atrial fibrillation 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 INDICATION: ___ with intubated // intubated COMPARISON: No priors FINDINGS: Supine AP portable view the chest provided. The endotracheal tube is seen with its tip projecting approximately 6 cm above the carina. The nasogastric tube descends below the left hemidiaphragm. Tapering opacity is noted in the right mid to lower lung likely representing layering effusion. Which could represent a layering right pleural effusion. The heart appears moderately enlarged. Left lung appears relatively clear. Aortic calcifications noted. Bony structures are intact. IMPRESSION: As above. ETT somewhat high-riding and may benefit from slight advancement. Radiology Report EXAMINATION: CT abdomen pelvis without contrast. INDICATION: ___ year old man with septic shock, likely urinary vs pulmonary source, with initial lactate of 7 and history of abdominal discomfort and lethargy, now intubated in the MICU with ongoing pressor requirement // please eval acute intra-abdominal process, RML/RLL layering effusion 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: Total DLP (Body) = 595 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Please see CT chest performed concurrently for detailed intrathoracic 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. Multiple hyperdense stones are identified within the dependent portion of the gallbladder. No pericholecystic fluid 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, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is bilateral renal cortical atrophy, with bilateral parapelvic cysts, largest of which measures up to 5.4 cm on the right. Multiple nonobstructing renal calculi are identified at the lower pole of the left kidney. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Enteric tube is identified with its tip in the proximal stomach. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. There is colonic diverticulosis without inflammatory changes to suggest diverticulitis. Appendix is not well visualized appear PELVIS: There is diffuse circumferential thickening of the urinary bladder with adjacent stranding, containing a Foley catheter. There is a diverticulum at the right lateral aspect of the urinary bladder containing a 12 mm hyperdense stone (series 3, image 106). Small volume perihepatic and perisplenic ascites. 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. Moderate to severe atherosclerotic disease is noted. Partially visualized right femoral l catheter. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Moderate multilevel degenerative changes of the visualized spine. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Circumferential thickening of the urinary bladder and stranding is concerning for cystitis. Correlation with UA is recommended. 2. Bladder diverticulum containing a 12 mm stone. Non-urgent urology consultation recommended. 3. Small volume intraperitoneal ascites. 4. Left nonobstructing renal calculi. No hydronephrosis. 5. Please see CT chest performed concurrently for detailed intrathoracic findings. Radiology Report EXAMINATION: CT chest without contrast. INDICATION: ___ man with septic shock, likely urinary versus pulmonary source with initial lactating 7 history are abdominal discomfort, at the GE. An to be in the MICU with ongoing pressor requirement. Evaluate for acute intra-abdominal process. TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: None. FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart, pericardium, and great vessels are within normal limits based on an unenhanced scan. No pericardial effusion is seen. Mild coronary artery calcifications. There are extensive vascular calcifications, compatible with atherosclerotic change. AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: Small bilateral pleural effusions. No pneumothorax. LUNGS/AIRWAYS: An endotracheal tube is noted with the tip 3.6 cm above the carina. A wedge-shaped opacity abutting the pleura anteriorly within the right middle lobe may represent consolidation or infarct. Bilateral lower lobe compressive atelectasis. 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: Please see CT abdomen pelvis that was performed concurrently for detailed intra-abdominal findings. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. Moderate multilevel degenerative changes of the visualized spine. IMPRESSION: 1. Right middle lobe wedge-shaped peripheral consolidation. Infarct could be considered in the appropriate clinical setting. Follow-up in 3 months is recommended to ensure resolution. 2. Bilateral pleural effusions with overlying compressive atelectasis. 3. Extensive vascular calcifications, compatible with atherosclerotic change. 4. Please see CT abdomen pelvis that was performed concurrently for detailed intra-abdominal findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with AF on Coumadin, history of digoxin use, who presented with tachypnea. // eval extent of opacities, edema eval extent of opacities, edema IMPRESSION: NG tube tip is in the stomach. ET tube tip is 5.5 cm above the carinal. Heart size and mediastinum are unchanged including cardiomegaly. Bilateral pleural effusions, right more than left are substantial. Right basal more nodular opacity represents a right middle lobe lesion, better characterized on ___ chest CT. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with septic shock, hypoxic resp failure. // ? pulm edema, infiltrate ? pulm edema, infiltrate IMPRESSION: Comparison to ___. The effusion on the right. Is still moderate in extent and has not substantially changed. A minimal left effusion and a left retrocardiac atelectasis is also stable. Moderate cardiomegaly persists. In the interval, the patient has been extubated. No pulmonary edema. No pneumothorax. Radiology Report EXAMINATION: Video oropharyngeal swallow INDICATION: ___ year old man w/ AF on Coumadin, history of digoxin use (stopped 1 mon prior), hx nephrolithiasis, hypothyroidism, urinary incontinence and G6PD def who presented to ED with tachypnea ___ and was found to have ___ (baseline Cr 1.0), metabolic acidosis, hyperkalemia and septic shock. // eval for aspiration risk, quality of swallow TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 2 minutes and 53 seconds . COMPARISON: None FINDINGS: There is gross aspiration with thin and nectar thick liquids. There is abundant amount of residue within the valleculae. Barium passes freely through the oropharynx and esophagus without evidence of obstruction. IMPRESSION: 1. Gross aspiration with thin and nectar thick liquids. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report INDICATION: ___ year old man with septic shock now requiring IV abx therapy for bacteremia // insertion of PICC line 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: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.6 min, 5 mGy PROCEDURE: 1. Double lumen PICC placement through the left brachial vein. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the left brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava using fluoroscopic guidance. A double lumen PIC line measuring 47 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. The accessed vein was patent and compressible. 2. Brachialvein approach double lumen left PICC with tip in the distal SVC. IMPRESSION: Successful placement of a left 47 cm basilic approach double lumen PowerPICC with tip in the distal SVC. The line is ready to use. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS INDICATION: ___ year old man with aspiration, dysphagia // TWO SERIES DOBHOFF PLACEMENT TECHNIQUE: Single frontal view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Interval placement of Dobhoff tube with tip coiled in the stomach. Left PICC tip terminates in the cavoatrial junction. Well-circumscribed opacity in the right lower lobe adjacent to the right heart border viewed in conjunction with recent CT is concerning for a possible mass and should be followed with subsequent radiographs. Interval decrease in moderate right pleural effusion. Minimal left pleural effusion with retrocardiac atelectasis unchanged. There is no pneumothorax. Moderate cardiomegaly unchanged. IMPRESSION: Dobhoff tube is coiled in the stomach. Interval decrease in moderate right pleural effusion. Right lung lesion is concerning for possible lung mass and should be followed closely with subsequent radiographs. NOTIFICATION: The findings were discussed with Dr. ___ , M.D. by ___ ___, M.D. on the telephone on ___ at 8:16 AM, Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: Respiratory distress Diagnosed with Sepsis, unspecified organism, Severe sepsis with septic shock, Hypokalemia temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dr. ___- You were hospitalized for septic shock, and found to have a urinary tract infection. You also needed a breathing tube placed as you were having trouble breathing. You were given antibiotics which helped your infection, and you were able to be taken off the breathing tube. You had a feeding tube placed to help with your nutrition, and you should continue to get tube feeds while you are working on your swallowing.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: lisinopril / Cymbalta / hydrochlorothiazide / Prozac Attending: ___. Chief Complaint: Right knee pain Major Surgical or Invasive Procedure: ___: Right knee irrigation & debridement History of Present Illness: ___ hx DM2, dementia, HTN, HLD, who presented to the ED yesterday with complaint of right knee pain x 2 days. She reports that 2 days prior to presentation, she bent over while standing to pick up her cane and she felt a "pop" in the knee. Since this time, she's had increased difficulty bearing weight, and ranging that knee. She reports increased swelling and warmth in the knee, though denies any fevers, chills, sweats. Denies any other trauma to the knee. She does report mild pain in the left knee as well as in her right shoulder, though pain there is chronic. At baseline, she ambulates with a cane or walker. She lives with her daughter and does not leave the house without her daughter's assistance - either with a walker or wheelchair. Past Medical History: PAST MEDICAL HISTORY Hyperlipidemia Hypertension Osteoarthritis (R knee) Anxiety Back pain Cataract Colonic adenoma Constipation Dementia (cant remember daily activities) Depression Diabetes mellitus (insulin) Diverticulosis Glaucoma Fibroids PAST SURGICAL HISTORY Discectomy Hysterectomy d/t fibroids Shoulder surgery Social History: ___ Family History: Non-contributory Physical Exam: On admission: Vitals: AFVSS General: A&Ox3, NAD CAM/MINICOG: Negative Heart: Regular rate and rhythm peripherally Lungs: Breathing comfortably on room air. Right lower extremity: - Skin intact - Erythema, diffuse swelling, and warmth in the knee. No deformity, induration or ecchymosis - Diffuse TTP about the knee and joint line. Soft, non-tender thigh and lower leg - Unable to extend or flex knee from 45 degree position of flexion without exquisite pain. Full, painless active/passive ROM of hip and ankle - ___ fire - Sensation intact to light touch in SPN/DPN/Tibial/saphenous/Sural distributions - 1+ ___ pulses, foot warm and well perfused Pertinent Results: ___ 12:00PM BLOOD WBC-8.0 RBC-4.18 Hgb-12.7 Hct-38.8 MCV-93 MCH-30.4 MCHC-32.7 RDW-13.8 RDWSD-46.8* Plt ___ ___ 08:40AM BLOOD Neuts-60.8 ___ Monos-14.1* Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.47# AbsLymp-2.20 AbsMono-1.27* AbsEos-0.00* AbsBaso-0.03 ___ 08:40AM BLOOD Glucose-232* UreaN-7 Creat-0.8 Na-135 K-3.5 Cl-103 HCO3-21* AnGap-15 ___ 11:35AM JOINT FLUID ___ Polys-89* ___ Monos-9 Eos-2* Macro-0 ___ 11:35AM JOINT FLUID Crystal-NONE ___ 11:35AM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND Medications on Admission: Active Medication list as of ___: Medications - Prescription ATORVASTATIN - atorvastatin 80 mg tablet. 1 (One) tablet(s) by mouth once a day - (Prescribed by Other Provider) BUSPIRONE HCL - BUSPIRONE HCL 5MG tablet. TAKE ONE TABLET BY MOUTH TWICE A DAY CITALOPRAM - citalopram 20 mg tablet. 1.5 (One and a half) tablet(s) by mouth once a day - (Prescribed by Other Provider) INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous solution. 14 units once a day - (Prescribed by Other Provider) LOSARTAN - losartan 25 mg tablet. 3 tablet(s) by mouth once a day - (Prescribed by Other Provider) METOPROLOL SUCCINATE - metoprolol succinate ER 200 mg tablet,extended release 24 hr. 1 Tablet(s) by mouth DAILY (Daily) - (Prescribed by Other Provider) NIFEDIPINE - nifedipine ER 90 mg tablet,extended release. 1 Tablet(s) by mouth DAILY (Daily) - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 Capsule(s) by mouth once a day - (Prescribed by Other Provider) VORTIOXETINE [BRINTELLIX] - Brintellix 10 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by mouth once a day - (Prescribed by Other Provider; ___) CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 1,000 unit tablet. 1 tablet(s) by mouth qday - (Prescribed by Other Provider) DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 Capsule(s) by mouth twice a day - (Prescribed by Other Provider) LIDOCAINE-MENTHOL [LIDOPATCH] - Dosage uncertain - (Prescribed by Other Provider) MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a day - (___) Discharge Medications: 1. Atorvastatin 80 mg PO QPM 2. CefePIME 2 g IV Q12H 3. Enoxaparin Sodium 40 mg SC QHS Duration: 30 Days Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous at bedtime Disp #*30 Syringe Refills:*0 4. Gabapentin 100 mg PO TID 5. Losartan Potassium 25 mg PO DAILY 6. Metoprolol Tartrate 12.5 mg PO TID 7. Omeprazole 20 mg PO DAILY 8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 9. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation/insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Septic right knee (native) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with pain s/p fall // fx? TECHNIQUE: AP, oblique, and lateral views of the right knee. COMPARISON: ___. FINDINGS: Tricompartmental degenerative changes are again noted with osteophyte formation and joint space narrowing. Chondrocalcinosis again seen at the femorotibial compartments. Moderate suprapatellar effusion is noted, increased from prior. Atherosclerotic calcifications are identified. IMPRESSION: Tricompartmental degenerative changes without acute fracture. Moderate suprapatellar effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with right septic arthritis // pre op Surg: ___ (I D R knee) COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, the lung volumes have slightly decreased and a platelike atelectasis is seen at the right lung bases. Otherwise no relevant changes. No pneumonia, no pleural effusions, no pulmonary edema. Radiology Report INDICATION: 40cm R basilic SL PICC - ___ ___ ___ year old woman with new R PICC // 40cm R basilic SL PICC - ___ ___ Contact name: ___: ___ EXAMINATION: CHEST PORT. LINE PLACEMENT TECHNIQUE: Portable Chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Right PICC terminates in upper to mid SVC. There is no consolidation, pleural effusion, or pneumothorax. Cardiomediastinal and hilar silhouettes are normal size. IMPRESSION: Right PICC terminates in mid to upper SVC. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: R Knee injury Diagnosed with PYOGEN ARTHRITIS-LOWER LEG temperature: 99.0 heartrate: 74.0 resprate: 16.0 o2sat: 100.0 sbp: 168.0 dbp: 65.0 level of pain: 10 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: - Weight bearing as tolerated on your right leg MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take 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 ___ 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. INFECTIOUS DISEASE INSTRUCTIONS: OPAT Antimicrobial Regimen and Projected Duration: Agent & Dose: CefePIME 2 g IV Q12H Start Date: ___ (date of knee washout) Projected End Date: ___ (6 weeks) LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn after discharge, a specific standing order for Outpatient Lab Work is required to be placed in the Discharge Worksheet - Post-Discharge Orders. Please place an order for Outpatient Labs based on the MEDICATION SPECIFIC GUIDELINE listed below: ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ ALL OTHER B-LACTAMS (Penicillins, Cephalosporins, Aztreonam): WEEKLY: CBC with differential, BUN, Cr, ESR/CRP. FOLLOW UP APPOINTMENTS: Pending All questions regarding outpatient parenteral antibiotics after discharge should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when the clinic is closed. PLEASE NOTIFY THE ID SERVICE OF ANY QUESTIONS REGARDING THESE RECOMMENDATIONS OR WITH ANY MEDICATION CHANGES THAT OCCUR AFTER THE DATE/TIME OF THIS OPAT INTAKE NOTE. Physical Therapy: Right lower extremity: Weight bearing as tolerated Range of motion as tolerated. Treatments Frequency: WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please change dressing every 2 days OR if the dressing is saturated. - No dressing is needed if wound continues to be non-draining.

Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ___ Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Unsteady Gait Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ old man with a history of idiopathic unilateral vocal cord paralysis, left paraclinoid aneurysm s/p clipping c/b visual loss, transient L ICA occlusion and asymptomatic parietooccipital stroke who presents with unsteady gait and worsening vision which started ten days ago and worsened eight days ago. He was last in his normal state of health ten days ago when he awoke. As he was driving to work, he noticed a sensation that things were "cloudy and in slow motion." When he got to work he felt that his walking was not quite right, and that there was a "skip in the step." There were ___ other associated symptoms and he brushed it off. His symptoms were similar the next day, but on ___ (eight days ago) he woke up with significantly worsened gait. He went to work, where he was "staggering around" so much that they drove him home. The main symptom seems to have been unsteadiness at this time. He does not recall feeling any sensation of vertigo. He denies diplopia, dysarthria, incoordination, weakness or numbness. He saw his PCP briefly on ___, who prescribed him meclizine and prednisone. He took these faithfully over the next week without improvement or clear worsening in his symptoms. He was in communication with his PCP throughout and when he did not improve with this treatment, his PCP recommended that he come to the ED for evaluation and MRI. Regarding his history of L ICA aneurysm, he initially presented to an OSH is ___ with transient symptoms of dizziness. He had an MRI brain which was concerning for aneurysm, and a CTA head confirmed this. As a result, he underwent open clipping with Dr. ___ in ___. The procedure was complicated by L ICA occlusion. During his hospitalization he had transient right pronator drift which resolved prior to discharge. One week after discharge he presented to OSH ED with a sensation of fullness after sneezing; at that point a CT head was done. Per my review this showed a new small left parietooccipital junction infarct (watershed vs distal MCA). He subsequently complained of persistent diplopia and blurry vision and was evaluated in ___ clinic. That examination was notable for "Left relative afferent pupillary defect was present. Confrontation fields were full in the right eye. In the left eye, he was able to count fingers in the upper quadrants, but could only see hand movements in the inferotemporal quadrant and could not see hand movements in the inferonasal quadrant." This was thought to be most likely due to a branch retinal artery occlusion, and ___ further intervention was performed. One year after the initial procedure he underwent removal of the microplate and screw which was protruding. Then, in ___ presented with month-long headache (he tells me it was midline and deep). MRI/MRA was performed at OSH and was concerning for recanalization of aneurysm. CTA head was repeated here and appeared consistent with recanalization. He reports that he spoke with neurosurgery and was told that this was likely an artifact. Several years ago he had the acute onset of right vocal cord paralysis which was worked up at ___ and ___ etiology was found. He underwent a surgical procedure to medialize the vocal cord and since that time has had persistent but stable hoarseness. On neuro ROS, the pt reports since the aneurysm clipping he has intermittent "thunderclap headache," which improves with ibuprofen and rest, chronically blurred vision in the left eye, diplopia initially which subsequently resolved. He denies dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. ___ bowel or bladder incontinence or retention. On general review of systems, he endorses fatigue; he has been napping during the day for the past week which is unusual for him. Otherwise, the pt denies recent fever or chills. ___ 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. ___ recent change in bowel or bladder habits. ___ dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: PMHx: L paraclinoid aneurysm (4 mm) superior branch retinal artery occlusion in the left eye R vocal cord paralysis (etiology could not be determined) hyperlipidemia PSHx: ___ L craniotomy for aneurysm clipping ___ Incision and removal of microplate. Medialization thyroplasty (vocal cord repositioning) hernia repair Social History: ___ Family History: Mother died of emphysema (non-smoker); father died of unknown causes at age ___. Siblings and children are healthy. ___ known history of aneurysm, stroke, seizure, MS. ___ known history of inflammatory disease or hypercoagulability. Physical Exam: Vitals: T: 97.7 HR: 68 BP: 134/75 RR: 16 SpO2: 100% RA General: Well-nourished, fit appearing man sitting up in bed in NAD. HEENT: NC/AT. ___ scleral icterus, mucus membranes are moist. Could not appreciate supraorbital pulses bilaterally. Neck: Supple, ___ carotid or vertebral bruits appreciated. ___ nuchal rigidity. Pulmonary: Normal work of breathing. Vesicular breath sounds bilaterally, ___ wheezes or crackles appreciated. Cardiac: S1/S2 appreciated, RRR, ___ M/R/G. Abdomen: Soft, nontender, nondistended Extremities: ___ lower extremity edema Skin: ___ rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent and intact to repetition, naming of high and low frequency objects, comprehension of cross body, grammatically complex, multi-step commands. Able to register ___ items and recall ___ at 5 minutes. Calculations intact to subtraction and multiplication. Attentive to examination. There was ___ evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: Pupils equal in light, R 4 to 2mm and brisk, L 4 to 3 mm and sluggish with L RAPD. Visual acuity to snellen chart is OD ___ and OS ___. VFF to confrontation on the R. On the L, there was intact vision in superonasal quadrant, decreased red saturation in superotemporal quadrant, absent vision in inferior quadrants. Macula was spared. Funduscopic exam on the left revealed a pale, round disk with ___ edema. ___ hemorrhages noted. On the right there was ___ papilledema noted. III, IV, VI: EOMI. There was left-beating nystagmus most prominent on leftward gaze but also noted on upward and downward gaze. There was ___ nystagmus in primary position or on rightward gaze. There was saccadic breakdown of smooth pursuit in all directions. On HIT, he had to catchup in both directions. V: Facial sensation intact to light touch and pinprick in all distributions, with the exception of a patch extending along the left lateral and inferior jaw which is reportedly post-surgical. VII: ___ 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 tone throughout. Decreased bulk in ___ bilaterally. L pronator drift, R subtle pronation without drift. ___ tremor or asterixis. Slight proximal ataxia with eyes closed. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 4 4 R ___ ___ ___ 5 5 5 4 4 -DTRs: Bi Tri ___ Pat Ach L 2+ 2 2+ 2+ 2+ R 2+ 2 2+ 2+ 2+ - Plantar response was extensor bilaterally, more prominent on the right. -Sensory: ___ deficits to light touch, pinprick throughout. Proprioception intact to large and small mvt in great toes bilaterally. ___ extinction to DSS. -Coordination: Increased rebound on LUE. Mild ataxia on L FNF, finger tapping is slowed but accurate on the L. Normal on R. ___ dysmetria HKS bilaterally, toe tapping is slower but accurate on left than right. There is mild truncal ataxia sitting with eyes closed. -Gait: Good initiation. Wide based, ataxic. Takes step to the left consistently. Able to walk on heels and toes but cannot walk in tandem. Sways with feet together, takes step with eyes closed. ###DISCHARGE EXAM### Patient with resolved nystagmus and dysmetria. Symmetric, slight rebound with arms extended. Wide-based gait but ambulating independently without falling to the L. Pertinent Results: ___ 08:09AM BLOOD cTropnT-<0.01 ___ 08:09AM BLOOD %HbA1c-5.2 eAG-103 ___ 08:09AM BLOOD Triglyc-218* HDL-43 CHOL/HD-4.5 LDLcalc-108 ___ 1. Dental streak artifact, left ophthalmic artery aneurysm clip, and left frontal craniotomy or hardware streak artifact limits examination. 2. A 5 mm aneurysm is identified at the left paraclinoid ICA slightly larger compared to ___, finding is suggestive of recanalization. 3. A 2 mm aneurysm at the superior wall of right MCA M1 segment is unchanged. 4. Likely sequela of old infarct in the left parieto-occipital regions appear similar to before. 5. Please note MRI of the brain is more sensitive for the detection of acute infarct. ___ Brain MRI 1. ___ acute intracranial hemorrhage or infarct. 2. Encephalomalacia of the left precentral gyrus, left parietal and left parietal occipital lobe likely represents sequela of interval infarcts since examination of ___. 3. A single FLAIR hyperintense focus of the left centrum semiovale likely also represent sequela prior infarct. This is not in a distribution commonly seen in setting of demyelinating process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Meclizine 25 mg PO TID 2. Omeprazole 40 mg PO DAILY 3. Ibuprofen 600 mg PO TID 4. PredniSONE 20 mg PO BID Discharge Medications: 1. Atorvastatin 20 mg PO QPM 2. Omeprazole 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Vestibular neuronitis 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: ___ male with history of left ophthalmic aneurysm clipping, now with gait instability and headache. Evaluate for aneurysm, or steno-occlusive disease. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 76.2 mGy (Head) DLP = 38.1 mGy-cm. 3) Spiral Acquisition 5.2 s, 40.9 cm; CTDIvol = 32.0 mGy (Head) DLP = 1,309.5 mGy-cm. Total DLP (Head) = 2,245 mGy-cm. COMPARISON: ___ head CTA FINDINGS: Dental streak artifact, left ophthalmic artery aneurysm clip, and left frontal craniotomy or hardware streak artifact limits examination. CT HEAD WITHOUT CONTRAST: The areas of hypodensity in the left parieto-occipital region are unchanged (03:16, 22). The hypodensity located more medially (03:20) appear more conspicuous than before. There is no evidence of no evidence of hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is left frontotemporal craniotomy. 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: A 5 mm aneurysm is identified at the left paraclinoid ICA (5:246), slightly larger compared to ___ (previously 4 mm) Finding is suggestive of recanalization. Left ophthalmic ICA aneurysm clip is in unchanged position. A 2 mm outpouching in the superior wall of the right MCA M1 segment (5:256, ___:1, 602b:32) appears unchanged. The vessels of the circle of ___ and their principal intracranial branches are patent. 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. Left internal jugular vein is obliterated from the C4-5 level and up to the jugular foramen. Left internal jugular vein below C4-5 level is small caliber and does not opacify with IV contrast. Right internal jugular vein is large, likely compensatory. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. Scattered subcentimeter nonspecific lymph nodes are noted throughout the neck bilaterally, with no lymphadenopathy by CT size criteria. Chronic right lamina papyracea fracture is noted (see 5:244). IMPRESSION: 1. Dental streak artifact, left ophthalmic artery aneurysm clip, and left frontal craniotomy or hardware streak artifact limits examination. 2. A 5 mm aneurysm is identified at the left paraclinoid ICA slightly larger compared to ___, finding is suggestive of recanalization. 3. A 2 mm aneurysm at the superior wall of right MCA M1 segment is unchanged. 4. Likely sequela of old infarct in the left parieto-occipital regions appear similar to before. 5. Please note MRI of the brain is more sensitive for the detection of acute infarct. NOTIFICATION: The findings regarding slightly increased size of left ICA aneurysm were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 5:31 ___, 3 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with history of idiopathic vocal cord paralysis, L ICA aneurysm s/p clipping, who presents with eight days of gait instability. No clear vessel cutoff. // please evaluate for stroke or demyelinating disease TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CTA head and neck from ___. FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Encephalomalacia of the left pre central gyrus (series 10, image 23 and left parietal lobe (series 10, image 18 through 20) and of the left occipital parietal lobe (series 10, image 13) are new from examination of ___, suggesting sequela of interval embolic infarcts. Additional new rounded focus of FLAIR signal in the left centrum semiovale (Series 10, image 20) may also represent an additional region of infarct. There is no evidence of acute infarct or intracranial hemorrhage. The orbits are unremarkable. There is mild mucosal thickening in bilateral ethmoid air cells. The remaining visualized paranasal sinuses and mastoid air cells are clear. Intracranial flow voids are maintained. IMPRESSION: 1. No acute intracranial hemorrhage or infarct. 2. Encephalomalacia of the left precentral gyrus, left parietal and left parietal occipital lobe likely represents sequela of interval infarcts since examination of ___. 3. A single FLAIR hyperintense focus of the left centrum semiovale likely also represent sequela prior infarct. This is not in a distribution commonly seen in setting of demyelinating process. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ataxia and old strokes, no new stroke on MRI // infection? nodes? infection? nodes? IMPRESSION: Compared to chest radiograph ___. Aside from the new linear atelectasis or scarring in the left midlung, lungs are clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dizziness Diagnosed with Dizziness and giddiness temperature: 97.7 heartrate: 68.0 resprate: 16.0 o2sat: 100.0 sbp: 134.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the neurology service given concern for possible stroke. Your MRI did not reveal a stroke, and your symptoms of falling to the L rapidly improved during admission. It is most likely that you had an inflammation of the balance system in your inner ear after a viral illness that is self-resolving. You should follow-up with neurology and neurosurgery regarding your aneurysm.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Small bowel obstruction Major Surgical or Invasive Procedure: Closed loop small bowel obstruction with periaortic mass causing the closed loop bowel obstruction. -Open exploratory laparotomy, small bowel resection History of Present Illness: ___ with history of sigmoid colectomy for colon cancer in ___, now with 1-day history of nausea and abdominal pain. She was in her usual state of health until yesterday, when she developed epigastric abdominal pain and nausea. She had 2 episodes of non-bloody, non-bilious emesis. She last passed gas and had a bowel movement yesterday. She has no history of bowel obstruction. Had a normal colonoscopy earlier this month. Past Medical History: Sigmoid adenocarcinoma s/p resection ___ c/b pulmonary metastases Hyperlipidemia Hypertension GERD HBV Social History: ___ Family History: non-contributory Physical Exam: Temp: 97.3; P: 75; BP: 142/83; RR: 16: O2: 97%RA General: alert, oriented X3; in no acute distress HEENT: atraumatic, normocephalic, oral mucosa moist Resp: clear breath sounds bilaterally CV: RRR, no murmurs, rubs, or gallops ABD: midline incision C,D,I; abdomen soft, non-distended; appropriate ___ tenderness Extr: atraumatic, skin intact Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 09:10 7.0 4.72 9.7* 31.8* 67* 20.6* 30.5* 15.4 36.6 327 ___ 04:41 8.4 4.48 9.3* 30.6* 68* 20.8* 30.4* 15.3 37.1 299 ___ 10:04 8.7 4.01 8.4* 27.8* 69* 20.9* 30.2* 15.9* 39.6 223 ___ 05:29 9.9 4.66 9.7* 31.6* 68* 20.8* 30.7* 15.6* 37.2 248 ___ 14:45 5.5 5.88* 12.2 39.6 67* 20.7* 30.8* 16.5* 36.7 326 ___ 23:25 8.2 6.40* 13.4 43.8 68* 20.9* 30.6* 17.2* 36.6 341 ___ CT ABD & PELVIS WITH CO IMPRESSION: Small bowel obstruction with two transitions at the same location, 3 cm medial and superior to the sigmoidectomy anastamosis, concerning for closed loop obstruction from a single adhesion/band. The intervening small bowel is thickened with mesenteric edema, concerning for early ischemia. No pneumatosis or free air. ___ PATHOLOGIC DIAGNOSIS: 1. Jejunum, resection: - Metastatic serosal deposit of adenocarcinoma at site of iatrogenic enterotomy; see note. 2) "Mass at base of mesentery": - Serosal deposit of metastatic adenocarcinoma; see note. 3) Omentum: - Unremarkable omental tissue; no malignancy identified. Note: The carcinoma is histologically similar to the patient's previous colon carcinoma (___). Medications on Admission: viread 300', vitamin D2, gabapentin 300 ohs, ibuprofen, losartan 100', omeprazole 20", ranitidine 300', simvastatin 40' Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. Gabapentin 300 mg PO QHS 3. Omeprazole 20 mg PO BID 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*25 Capsule Refills:*0 5. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp #*30 Capsule Refills:*0 6. Simvastatin 40 mg PO QPM 7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Evaluate for pneumothorax or pneumoperitoneum, in a patient with abdominal pain. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs from ___. FINDINGS: Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal silhouette and fairly well-aerated lungs without focal consolidation, pleural effusion, or pneumothorax. Surgical changes in the let lung are noted, with mild atelectasis in the left mid lung. The visualized upper abdomen is unremarkable. Gaseous distension of the colon is noted, similar in appearance to multiple exams from ___. IMPRESSION: No acute cardiopulmonary process or evidence of pneumoperitoneum. Radiology Report INDICATION: Evaluate for acute abdominal pathology in a patient with abdominal pain and a history of colon cancer. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 8.2 mGy (Body) DLP = 453.0 mGy-cm. Total DLP (Body) = 461 mGy-cm. COMPARISON: CT abdomen/ pelvis from ___. FINDINGS: LOWER CHEST: Other than mild dependent atelectasis, the visualized lung bases are clear without pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver is homogeneous in attenuation. A simple hepatic cyst in segment 5 is unchanged. Other hepatic hypodensities are too small to characterize but again likely represent simple hepatic cysts or biliary hamartomas. No concerning focal lesion is identified. 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: The kidneys are symmetric and normal in size, demonstrating normal nephrograms and excreting contrast promptly. A large simple cyst arising from the interpolar region of the left kidney is unchanged, measuring 5.0 x 4.9 cm (series 2, image 40). Other smaller hypodensities are too small to characterize but again likely represent simple renal cysts. There is no concerning focal lesion or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. There are dilated small bowel loops, with a sharp transition point and distal decompression in the mid abdomen (02:56), approximately 3 cm superior and medial to the sigmoidectomy anastomosis. There is moderate fecalization at this level (series 2, image 57). Just proximal to this is a 10-15 cm of small bowel bowel demonstrating wall thickening and mesenteric edema (series 602b, image 40, 37, series 601b, image 21). Immediately proximal is a second focus of small bowel narrowing, at the same location as the distal transition point (series 602b, image 43, series 601b, image 26). The upstream small bowel is dilated with smooth tapering more proximally. There is no pneumatosis or free air. The patient is status post partial sigmoid colectomy, with the expected postsurgical changes and a patent anastomosis. A normal air-filled appendix is visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is a small amount of free fluid within the pelvis. REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no evidence of adnexal abnormality bilaterally. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: Small bowel obstruction with two transitions at the same location, 3 cm medial and superior to the sigmoidectomy anastamosis, concerning for closed loop obstruction from a single adhesion/band. The intervening small bowel is thickened with mesenteric edema, concerning for early ischemia. No pneumatosis or free air. NOTIFICATION: The findings were discussed in person and over the phone by Dr. ___ with Dr. ___, 5 minutes after discovery, approximately ___:40 on ___. Gender: F Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Abd pain, Vomiting Diagnosed with Epigastric pain temperature: 98.4 heartrate: 88.0 resprate: 16.0 o2sat: 97.0 sbp: 142.0 dbp: 89.0 level of pain: 5 level of acuity: 3.0

Ms. ___ you had undergone an open small bowel resection for a small bowel obstruction. 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: SURGERY Allergies: Vicodin / MS ___ / Gabapentin / Bactrim Attending: ___. Chief Complaint: Right second digit infection Major Surgical or Invasive Procedure: Right second digit amputation ___ History of Present Illness: ___ with diabetic neuropathy s/p right first toe amputation ___ returns with a 12 day history of right second toe pain, erythema and serosanginous discharge after stubbing his toe. He has noticed progressive redness, swelling, erythema and drainage from the nail bed extending only to the base of the toe. There has been no cellulitis extending up the foot. He has not experienced any fever, chills, shortness of breath, chest pain, nausea, vomiting or diarrhea. ROS otherwise negative. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Type 2 Diabetes w/neuropathy, nephropathy, retinopathy chronic - Diastolic CHF (___ Class III) - CKD (baseline 2.4-2.8) - OSA (Mask Choice: Swift II NV, BiPAP ___ EERS 100, 4L O2) - Chronic restrictive ventilatory disease secondary to a bile duct leak with pulmonary fibrosis requiring decortication - PVD w/lower extremity claudication - Anemia of chronic disease - Spinal stenosis - Severe degenerative arthritis - BPH - Glaucoma; on carbonic anhydrase inhibitor - Cataracts, bilateraly, s/p surgical removal - Depression - Erectile dysfunction s/p penile implant ___ Past Surgical History: - ___ Roux-en-y reconstruction after laparoscopic cholecystectomy c/b damage to CBD - ___ Decortication for fibrothorax complicated by respiratory failure requiring tracheostomy - Appendectomy - Left knee/hip replacement - L shoulder AC recection - R total hip arthroplasty ___ Social History: ___ Family History: ___, h/o several strokes. Mother died in her ___ from breast cancer. Father died at ___ from complications of emphysema, CHF. All children in good health. Physical Exam: PHYSICAL EXAM Vital Signs: Temp: 97.8 RR: 18 Pulse: 65 BP: 121/37 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, Guarding or rebound, No hepatosplenomegally, No hernia, No AAA. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. Brachial: P. LUE Radial: P. Ulnar: P. Brachial: P. RLE Femoral: P. Popiteal: P. DP: P. ___: D. LLE Femoral: P. Popiteal: P. DP: D. ___: D. Pertinent Results: ADMISSION LABS ___ 07:34PM LACTATE-1.2 ___ 07:22PM GLUCOSE-146* UREA N-47* CREAT-2.4* SODIUM-147* POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-36* ANION GAP-14 ___ 07:22PM CRP-3.5 ___ 07:22PM WBC-6.8 RBC-3.77* HGB-12.2* HCT-36.7* MCV-97 MCH-32.3* MCHC-33.2 RDW-14.1 ___ 07:22PM NEUTS-77.6* LYMPHS-13.9* MONOS-5.2 EOS-2.3 BASOS-0.9 ___ 07:22PM PLT COUNT-187 ___ 07:22PM ___ PTT-30.9 ___ ___ 07:22PM SED RATE-15 DISCHARGE LABS ___ 07:25AM BLOOD WBC-6.8 RBC-3.74* Hgb-12.3* Hct-36.0* MCV-96 MCH-32.9* MCHC-34.2 RDW-14.1 Plt ___ ___ 07:25AM BLOOD Glucose-149* UreaN-57* Creat-2.4* Na-141 K-4.3 Cl-97 HCO3-32 AnGap-16 ___ 07:25AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.1 ___ 01:16AM BLOOD Vanco-16 IMAGING Pre-op CXR ___: FINDINGS: Again seen is mild cardiomegaly. The mediastinal and hilar contours are unchanged compared to prior. There continues to be an area of volume loss on the left base and left lateral pleural thickening/effusion. Again seen is a patchy area of infrahilar opacity similar to prior that may represent atelectasis or scarring. IMPRESSION: No new infiltrate. EKG ___ Sinus rhythm. Diffuse low voltage complexes. Cannot exclude old inferoposterior myocardial infarction. No significant change compared to previous tracing of ___. Foot x-rays ___: IMPRESSION: Subcutaneous foci of air at the second distal phalanx. Correlate for any signs of infection, recent debridement or ulceration. Findings paged to the nurse covering for Dr. ___ on ___, who was in the ___. Non-invasive arterial studies ___: INDICATION: ___ male with diabetic neuropathy, status post toe amputation, now with toe infection. COMPARISON: ___. TECHNIQUE: Bilateral lower extremity blood pressure measurements, pulse volume recordings, Doppler tracings. FINDINGS: The apparent right ABI is 1.1. The left ABI cannot be determined as the vessels are not compressible, likely from calcification. Nonetheless, there are triphasic Doppler tracings noted in bilateral femoral arteries, popliteal arteries, posterior tibial arteries, and dorsalis pedis arteries. The pulse volume recordings are essentially normal. CONCLUSION: No evidence of large vessel arterial disease in the legs. Some difficulty in obtaining ABI as above secondary to noncompressible arteries. MICRO Blood cultures (___): pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Aspirin 325 mg PO DAILY 3. Calcitriol 0.5 mcg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY Please hold for SBP < 100 or HR < 60 7. Omeprazole 20 mg PO BID 8. Tamsulosin 0.8 mg PO DAILY 9. traZODONE 50 mg PO HS 10. Simvastatin 10 mg PO DAILY 11. Torsemide 50 mg PO DAILY 12. Diazepam 2 mg PO HS 13. Allopurinol ___ mg PO DAILY 14. Docusate Sodium 100 mg PO BID 15. pramipexole *NF* 0.125 mg Oral hs 16. LaMOTrigine 225 mg PO DAILY 17. Colchicine 0.6 mg PO DAILY 18. HYDROmorphone (Dilaudid) 2 mg PO BID Please hold for RR < 12 19. Losartan Potassium 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Allopurinol ___ mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Calcitriol 0.5 mcg PO DAILY 5. Diazepam 2 mg PO HS 6. Finasteride 5 mg PO DAILY 7. LaMOTrigine 225 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY Please hold for SBP < 100 or HR < 60 9. Omeprazole 20 mg PO BID 10. Simvastatin 10 mg PO DAILY 11. Tamsulosin 0.8 mg PO DAILY 12. Colchicine 0.6 mg PO DAILY 13. 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 14. Ferrous Sulfate 325 mg PO DAILY 15. HYDROmorphone (Dilaudid) 2 mg PO BID Please hold for RR < 12 16. pramipexole *NF* 0.125 mg Oral hs 17. Torsemide 50 mg PO DAILY 18. traZODONE 50 mg PO HS 19. Losartan Potassium 50 mg PO DAILY 20. Glargine 19 Units Bedtime Insulin SC Sliding Scale using REG Insulin 21. Oxycodone SR (OxyconTIN) 10 mg PO Q12H 22. Senna 1 TAB PO BID 23. Metolazone 2.5 mg PO DAILY 24. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth Q ___ HOURS Disp #*30 Tablet Refills:*0 25. Minocycline 100 mg PO BID RX *minocycline [Dynacin] 100 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right second digit osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Right toe redness. TECHNIQUE: Right foot, 2 views. COMPARISON: ___. FINDINGS: The patient is status post amputation of the great toe at the level of the mid proximal phalanx. No cortical destruction is identified to suggest osteomyelitis. Extensive degenerative changes are seen involving the ___ MTP joint with joint space narrowing, subchondral cysts, and osteophyte formation. Degenerative changes are also seen diffusely involving the PIP and DIP joints, as well as involving the midfoot. There are extensive vascular calcifications. No fracture or dislocation is noted. Moderate size dorsal calcaneal spur is visualized. Soft tissue swelling is most marked about the second toe. No definite subcutaneous gas is present, and there are no radiopaque foreign bodies. IMPRESSION: No radiographic evidence for osteomyelitis. No acute fracture or dislocation is identified, but please note that evaluation is slightly limited as an oblique view of the right foot was not obtained. Radiology Report INDICATION: ___ male with diabetic neuropathy, status post toe amputation, now with toe infection. COMPARISON: ___. TECHNIQUE: Bilateral lower extremity blood pressure measurements, pulse volume recordings, Doppler tracings. FINDINGS: The apparent right ABI is 1.1. The left ABI cannot be determined as the vessels are not compressible, likely from calcification. Nonetheless, there are triphasic Doppler tracings noted in bilateral femoral arteries, popliteal arteries, posterior tibial arteries, and dorsalis pedis arteries. The pulse volume recordings are essentially normal. CONCLUSION: No evidence of large vessel arterial disease in the legs. Some difficulty in obtaining ABI as above secondary to noncompressible arteries. Radiology Report INDICATION: Diabetic neuropathy with question second toe infection. COMPARISON: ___. FINDINGS: There is soft tissue swelling and a few foci of subcutaneous air at the level of the tuft of the second digit. No definite cortical destruction or periosteal reaction. Status post partial amputation of first proximal phalanx with severe degenerative changes of the first metatarsophalangeal joint. There are heavy vascular calcifications. There are severe degenerative changes of the tibiotalar joint. IMPRESSION: Subcutaneous foci of air at the second distal phalanx. Correlate for any signs of infection, recent debridement or ulceration. Findings paged to the nurse covering for Dr. ___ on ___, who was in the OR. Radiology Report CHEST ON ___ HISTORY: Infected right toe going to the OR, question effusion or atelectasis. REFERENCE EXAM: ___. FINDINGS: Again seen is mild cardiomegaly. The mediastinal and hilar contours are unchanged compared to prior. There continues to be an area of volume loss on the left base and left lateral pleural thickening/effusion. Again seen is a patchy area of infrahilar opacity similar to prior that may represent atelectasis or scarring. IMPRESSION: No new infiltrate. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: RIGHT TOE INFECTION Diagnosed with ULCER OF OTHER PART OF FOOT, CELLULITIS, TOE NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN temperature: 97.6 heartrate: 75.0 resprate: 18.0 o2sat: 97.0 sbp: 131.0 dbp: 62.0 level of pain: 4 level of acuity: 3.0

You were admitted to ___ for an infection of your right second toe. We gave you antibiotics through an IV to help control the infection. Please keep the surgical site clean and dry. You may shower 48 hours after your surgery. No tub baths. Please do not rub the area.

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: PO intolerance, nausea, vomiting Major Surgical or Invasive Procedure: ___: EGD . ___: Exchange of a gastrostomy for an 18 ___ MIC gastrojejunostomy tube. History of Present Illness: We had the pleasure of seeing Mr. ___ in the ___ Pancreas and Liver Institute today. As you know, he is a ___ year old man with a history of longstanding iron deficiency anemia and B12 deficiency with a 2.5cm mass in D2 with poorly differentiated adenocarcinoma. He underwent a pylorus sparing radical pancreaticoduodenectomy with en bloc resection of the transverse mesocolon and placement of fiducials on ___ and presents today for follow up. He had a protracted ___ operative course secondary to oral intolerance and delayed gastric emptying that required a PEG tube placement for nausea control purposes. He was also discharged home on total parenteral nutrition (discharged on ___. He had an upper GI study completed yesterday which reveals very slow and minimal passage of contrast through the pylorus with no dilation of the stomach. They have been venting his g-tube each night since he was discharged from the hospital and each night it puts out anywhere between 400-600cc of green appearing fluid. He keeps his G tube clamped during the day but still has episodes of emesis. In terms of his nutrition he was not able to get TPN on ___ or ___ night due to ___ issues. He was able to get TPN on ___. Then on ___ his PICC line was not functioning. He feels dehydrated and reports worsening nausea and dry heaving afer the study was completed. He denies fevers, chills, or shortness of breath. He denies leg swelling. Past Medical History: HTN/HLD, paroxysmal atrial fibrillation on Coumadin, pre-diabetes, BPH, GERD, lower back pain with R-sided sciatica, colonic adenomas, s/p appendectomy (___) and removal of testis ___, he says this was in ___ for a testicle that got out of position and may have not been necessary) Social History: ___ Family History: Mother had CLL which transformed, she died in her ___. Father, 4 brothers, 1 sister, and 3 children all without any history of cancer. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: 98.2, 78, 110/67, 18, 95% RA GEN: Pleasant with NAD HEENT: NC/AT, PERRL, EOMI, no scleral icterus CV: Irregular rhythm with normal rate. PULM: CTAB ABD: Subcostal incision healed well. Midline G/J-tube capped, site with drain sponge and c/d/I. EXTR: Warm, no c/c/e Pertinent Results: RECCENT LABS: ___ 09:45AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.1* Hct-26.6* MCV-88 MCH-26.7 MCHC-30.5* RDW-16.1* RDWSD-50.7* Plt ___ ___ 09:45AM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-138 K-5.3 Cl-101 HCO3-26 AnGap-11 ___ 05:07AM BLOOD ALT-30 AST-25 AlkPhos-193* TotBili-0.2 ___ 09:45AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.2 MICRO: ___ 10:59 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. 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--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ (___), ___ @ 13:33. RADIOLOGY: ___ CT ABD: IMPRESSION: 1. Small low-density lesion in the hepatic dome seem slightly larger measures 0.7 cm, previously 0.5 cm. This is incompletely characterized on this exam. 2. Interval improvement of subsegmental left lower lobe atelectasis with few areas focal hypoenhancing which could be due to retained secretions or small areas of infection. 3. Interval resolution of small right pleural effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 650 mg PO TID 4. Enoxaparin Sodium 60 mg SC Q12H 5. Lidocaine 5% Patch 1 PTCH TD QPM back pain 6. Metoclopramide 5 mg PO QID 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Pantoprazole 40 mg PO Q12H 11. Blood Glucose Monitoring (blood-glucose meter) 1 kit miscellaneous Q6H 12. GenStrip Test Strip (blood sugar diagnostic) 1 strip miscellaneous Q6H 13. lancets 28 gauge miscellaneous Q6H 14. Montelukast 10 mg PO DAILY 15. Rosuvastatin Calcium 5 mg PO QPM 16. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin Discharge Medications: 1. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit oral TID W/MEALS 2. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit oral TID W/MEALS RX *lipase-protease-amylase [Creon] 24,000 unit-76,000 unit-120,000 unit 3 capsule(s) by mouth TID W/MEALS Disp #*300 Capsule Refills:*3 3. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 6. Pantoprazole 40 mg PO Q24H 7. Enoxaparin Sodium 60 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL 60 mg SC every twelve (12) hours Disp #*60 Syringe Refills:*1 8. Finasteride 5 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Montelukast 10 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Rosuvastatin Calcium 5 mg PO QPM 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Adenocarcinoma, intestinal type 2. Delayed gastric emptying 3. Bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with malfunctioning PICC line, weakness// Please evaluate for pneumonia or effusion, please evaluate PICC line placement TECHNIQUE: AP and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Right PICC is seen with tip in the right atrium. If withdrawn by 2.5 cm it would be closer to the superior cavoatrial junction. Opacity over the posterior costophrenic angle on the lateral localizes to the left based on the frontal view, improved since prior. The right lung is clear. Cardiomediastinal silhouette is within normal limits. Peg tube projects over the upper abdomen. No acute osseous abnormalities. IMPRESSION: Right PICC tip over the right atrium. Improving left basilar opacity. Radiology Report INDICATION: ___ with pancreatic adenoCA now s/p Whipple and cholecystectomy c/b delayed gastric emptying// GJ exchange using existing PEG tube tract COMPARISON: No relevant comparisons available. TECHNIQUE: OPERATORS: Dr. ___ the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 50 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: 30 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 36.4 min, 210 mGy PROCEDURE: 1. Exchange of a gastrostomy for an 18 ___ MIC gastrojejunostomy 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. The existing tube was injected with contrast and showed opacification of the gastric rugae. The stay sutures were cut. A ___ wire was advanced through the tube into the stomach. The existing tube was then removed using gentle traction. Using a Kumpe catheter and glidewire, access was obtained into the jejunum. A 18 ___ gastrojejunostomy tube was advanced over the wire into the distal duodenum and the balloon was inflated using contrast diluted in sterile water. Contrast injection confirmed appropriate position. 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. 18 ___ MIC gastrojejunostomy tube in the jejunum. IMPRESSION: Successful exchange of a gastrostomy tube for a new 18 ___ MIC gastrojejunostomy tube. The tube is ready to use. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ 1 mo s/p whipple, new GJ replacement, rising WBC, eval placement of GJ and r/o abscess. PO and IV contrast please (OK to give PO contrast via g-tube)// evaluate GJ placement, abscess. PO and IV contrast (ok to give PO contrast via G tube) TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 541 mGy-cm. COMPARISON: Multiple prior CTA abdomen and pelvis examinations most recent dated ___ FINDINGS: LOWER CHEST: Small right pleural effusion has resolved. Moderate size left pleural effusion has improved with a small left pleural effusion remaining. There is interval improvement of subsegmental left lower lobe atelectasis with few areas focal hypoenhancing noted. 4 mm right middle lobe pulmonary nodule (series 2, image 3), unchanged. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 1.5 cm right hepatic lobe cyst is unchanged. There is a 0.7 cm low-density lesion in the hepatic dome (series 2, image 7) has increased in size from prior exam which measured 0.5 cm. There is no new evidence of focal lesions. Patient is status post hepaticojejunostomy. Postoperative fluid collections in hepatic hilum have improved with no ring-enhancing collection is seen to suggest abscess. There is no evidence of intrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: Patient is status post Whipple procedure. There is atrophy of the remaining body and tail of pancreas similar to prior exam. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. A Fiducial marker is seen anterior to the IVC. SPLEEN: The spleen shows normal size, without evidence of focal lesions. ADRENALS: The right adrenal gland is normal in size and shape. There is nodular thickening of left adrenal gland, unchanged. URINARY: The kidney is unremarkable except for multiple bilateral simple cysts.. GASTROINTESTINAL: Patient is status post pylorus sparing Whipple Procedure. There is a gastrojejunostomy tube in place. The remaining bowel is normal in appearance with no evidence obstruction PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Small low-density lesion in the hepatic dome seem slightly larger measures 0.7 cm, previously 0.5 cm. This is incompletely characterized on this exam. 2. Interval improvement of subsegmental left lower lobe atelectasis with few areas focal hypoenhancing which could be due to retained secretions or small areas of infection. 3. Interval resolution of small right pleural effusion. RECOMMENDATION(S): Recommend further evaluation with liver MR after improvement in ___ condition, preferably in no more than 1 month. Radiology Report EXAMINATION: G/GJ/GI TUBE CHECK INDICATION: ___ male please check J-tube position. Please bring gastrografin to the bed side. Thank you TECHNIQUE: Multiple supine abdominal radiographs were performed on the floor prior to and status post injection of a gastrojejunostomy tube COMPARISON: CT abdomen pelvis dated ___ and percutaneous GJ tube check performed ___. FINDINGS: 3 supine radiographic images of the abdomen are provided. The initial scout image demonstrates contrast filling nondilated loops of colon, likely from patient's recent CT abdomen pelvis from ___. Multiple surgical clips are seen in the right upper quadrant. A gastrojejunostomy tube is visualized overlying the left hemiabdomen, with the tip seen in the mid lower abdomen. Evaluation of free intraperitoneal air is limited on this supine only projection. No concerning osseous lesions are identified. The second portable abdominal radiographs performed after the jejunostomy port was injected at 08:55 on ___ demonstrates contrast in the left hemiabdomen opacifying gastric rugae, with no definite intraluminal contrast seen within small bowel loops. No evidence of extraluminal contrast. The third portable abdominal radiograph performed after the gastrostomy port was injected at 08:57 on ___ demonstrates contrast opacification in the left upper quadrant within the stomach. IMPRESSION: Multiple serial abdominal radiograph status post injection of a gastrojejunostomy tube demonstrate contrast only within the gastric lumen, consistent with proximal migration of the gastrojejunostomy tube. The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:32 am, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ with pancreatic adenoCA now s/p Whipple and cholecystectomy c/b persistent nausea, emesis, malnutrition with GJ placed by ___ on ___ now with tube study suggesting that the J is in the stomach.// Could we reposition? Thanks! (overnight tube feeds were found coming out of the G tube which was to gravity) COMPARISON: Previous G-J exchange TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 25 mins 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: CONTRAST: 20 ml of OPTIRAY contrast FLUOROSCOPY TIME AND DOSE: 10 min, 105 mGy PROCEDURE: - MIC gastrojejunostomy attempted placement - MIC ___ G-tube placed PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. The existing tube was injected with contrast and showed opacification of the gastric rugae. The jejunal component was flipped into the stomach. The existing feeding tube was then removed. A sheath was placed. A C2 glidecatheter was then introduced over the wire. A glidewire combination was utilized to navigate to the jejunum. A wire was placed distal into the jejunum and a ___ MIC G-J tube advanced into place. However, upon removal of the wire and fluoroscopy check, the tube had already flipped into the stomach. Further attempts were not made given the overwhelming likelihood of repeat migration. A ___ g-tube was then placed into the stomach. The catheters balloon was inflated with 7 ml of contrast contrast diluted in sterile water and locked in the stomach after confirming the position of the catheter with a contrast injection. The catheter was then flushed, capped. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Continual migration of G-J tube into the stomach, therefore G-tube left IMPRESSION: Continual migration of G-J tube back into the stomach. Unable to maintain G-J access with the current track access into the stomach. Therefore, G tube left in stomach currently. If a GJ tube is needed, recommend a new enteric access for better angulation and positioning. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Back pain, Vomiting, Weakness Diagnosed with Dehydration, Weakness temperature: 98.3 heartrate: 111.0 resprate: 18.0 o2sat: 99.0 sbp: 106.0 dbp: 61.0 level of pain: 5 level of acuity: 2.0

Mr. ___, you were readmitted from clinic with symptoms of dehydration and with non working PICC line. In ED your PICC was accessed and you were started on IV hydration. Gastroenterology team was consulted for EGD, and ___ team was consulted for PEG tube exchange to G/J-tube. You were continued on TPN during admission. On ___ you underwent EGD and PEG tube exchange to gastrojejunostomy tube. ___ procedure you were started on tube feeding. When you tolerate TF at goal, TPN was discontinued and PICC was removed. Unfortunately your J-tube migrated to your stomach, which required holding tube feeding. Your diet was advanced to regular and you were able to tolerate small meals. TF was restarted via J-tube and was well tolerated. During admission you was found to have blood infection and was treated with antibiotics. You are now safe to be discharged home with following instruction. . G/J Tube care: Please keep G-tube capped. J-tube with tube feeding overnight. Flush J-tube with 30 cc of tap water Q6H. Change dressing daily and prn. Keep tube securely attached to prevent dislocation. Monitor for signs and symptoms of infection.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Codeine / Lisinopril Attending: ___ Chief Complaint: severe progressive headache Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The pt is a ___ M with history of Pancreatitis, Diabetes, HTN, Depression, Anxiety, Chronic left hip and back pain, Migraines, who presents with 6 days of severe headache, initially intermittent and now constant. Patient reports that headache started last ___. Initially pain was on left side of head and was burning and then excrutiating, radiating to ___, lasting about 1.5 hours at a time, and would come and go. On ___ around 3am he woke up from sleep from the pain, now on the right side of his head. Felt like skewer from back of head out his right eye and then from temple to temple. Headache persisted and became more and more intense and now constant. Patient tried Excedrin and Oxycodone at home without relief. Of note, he did run out of home meds recently so has not had BP meds or Gabapentin. No recent illness that he recalls. Now pain is constant, ___, stabbing and painful and hollow, and feels like it has a grip on him and won't let go. Patient also with severe photophobia, unable to open eyes secondary to pain. Denies diplopia or blurred vision. Describes burning on right side of face but no numbness or tingling elsewhere. No weakness. No positional component to headache. No gait instability. No speech changes. Of note, in ___, patient was admitted with similar headache and required Demerol and Vistaril for control with headache subsiding over a couple of days. On neuro ROS, the pt reporst headache, burning, photophobia as above. No loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: PMH: - chronic pancreatitis - T2DM - Hypertension - Left hip pain d/t ___ problem treated conservatively - Possible schizoaffective disorder - Peripheral neuropathy - Migraines - Depression - Anxiety - Schizophrenia - Chronic low back pain; degenerative disc disease - Hypertriglyceridemia - History of alcohol abuse - Gout - Recurrent left lower quadrant pain with diverticulitis - History of unexplained chronic pancreatitis w/ acute exacerbations - Occasionally has flares which on CT scan appear to show inflammation of his terminal ileum and cecum which is located in the left lower quadrant because of congenital malrotation of his gut - Sleep disorder - states he has sleep apnea but doesn't like mask - History of chronic renal failure (in ___, when first diagnosed w DM) - Neck abscess drainage in ___ - neck abscess d/t seatbelt injury. Social History: ___ Family History: No FH migraines or neurological problems. Physical Exam: Admission Physical Exam: Vitals: T: 98.4 P: 86 BP: 170/96 RR: 18 SaO2: 100% RA General: In distress with ice pack over right eye HEENT: NC/AT, eyes closed, MMM, clear oropharynx Neck: Supple, no nuchal rigidity. No carotid bruits Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions Neurologic: -Mental Status: Alert, oriented x 3. Attentive, able to name ___ backward without difficulty. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Unable to test VF given intense photophobia. III, IV, VI: EOMF without nystagmus. V: Facial sensation decreased to LT, PP, temp over V1/V2/V3, splits midline 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 and has symmetric strengh. -Motor: Normal bulk, tone throughout. No pronator drift. No adventitious movements. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation throughout. Decreased vibratory sense and proprioception at toes bilaterally. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No dysmetria on FNF. -Gait: Not assessed. Pertinent Results: ___ 01:30PM GLUCOSE-114* UREA N-15 CREAT-0.9 SODIUM-142 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-16 ___ 01:30PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-60 TOT BILI-0.3 ___ 01:30PM CALCIUM-8.8 PHOSPHATE-4.6* MAGNESIUM-1.6 ___ 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:30PM WBC-5.7 RBC-3.60* HGB-10.8* HCT-33.4* MCV-93 MCH-30.0 MCHC-32.3 RDW-13.6 ___ 01:30PM NEUTS-83* BANDS-0 LYMPHS-17* MONOS-0 EOS-0 BASOS-0 ___ MYELOS-0 ___ 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL ___ 01:30PM ___ PTT-33.6 ___ ___ 01:30PM SED RATE-8 ___ 11:16PM GLUCOSE-86 UREA N-9 CREAT-0.8 SODIUM-140 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19 ___ 11:16PM estGFR-Using this ___ 11:16PM WBC-4.0 RBC-4.04* HGB-12.4* HCT-37.1* MCV-92 MCH-30.8 MCHC-33.5 RDW-13.8 ___ 11:16PM NEUTS-27* BANDS-0 LYMPHS-61* MONOS-2 EOS-2 BASOS-2 ATYPS-6* ___ MYELOS-0 ___ 11:16PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL PENCIL-OCCASIONAL TEARDROP-OCCASIONAL ___ 11:16PM PLT SMR-NORMAL PLT COUNT-152 CT head w/o contrast (___): 1. No acute intracranial abnormality. 2. Opacification of the right mastoid air cells may represent mastoiditis or eustachian tube dysfunction. There is no evidence of bony remodeling. MRI brain (___): 1. There is a vein crossing the trigeminal nerve root entry zones on each side. Similar findings may be associated with trigeminal neuralgia, but may also be seen in asymptomatic patients, and clinical correlation is needed. 2. Chronic opacification of right mastoid air cells with apparent viscous material, without evidence for osseous destruction on the preceding CT scan, and without middle ear cavity involvement. Please correlate clinically with any signs of chronic infection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. Mirtazapine 45 mg PO HS 3. Aspirin 325 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. Perphenazine 4 mg PO 1 (ONE) TABLET(S) BY MOUTH QAM, 2 PO QHS 6. GlipiZIDE 2.5 mg PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 8. Allopurinol ___ mg PO DAILY 9. Gemfibrozil 600 mg PO BID 10. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Atenolol 100 mg PO DAILY RX *atenolol 50 mg 2 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Gabapentin 800 mg PO TID RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #*90 Capsule Refills:*0 5. Gemfibrozil 600 mg PO BID 6. GlipiZIDE 2.5 mg PO DAILY 7. Mirtazapine 45 mg PO HS 8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 9. Omeprazole 20 mg PO DAILY 10. Perphenazine 4 mg PO 1 (ONE) TABLET(S) BY MOUTH QAM, 2 PO QHS 11. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID: prn Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary headache Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report INDICATION: ___ man with severe headaches, evaluate for intracranial hemorrhage. COMPARISON: ___. TECHNIQUE: Non-contrast axial MDCT images through the head with coronal and sagittal reformations. DLP: 891 mGy-cm. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. Ventricles and sulci are normal in size and configuration. Basilar cisterns are patent. Gray-white matter differentiation is preserved. No fracture is identified. Partially imaged paranasal sinuses demonstrate mild mucosal thickening within the ethmoid air cells. The right mastoid air cells are partially opacified. The left mastoid air cells and middle ear cavities are clear. Orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Opacification of the right mastoid air cells may represent mastoiditis or eustachian tube dysfunction. There is no evidence of bony remodeling. NOTE ADDED IN ATTENDING REVIEW: The fluid-opacification of many of the right mastoid air cells is not significantly changed from the non-enhanced MR study of ___, when there was no definite corresponding slow diffusion. This is unlikely to reflect eustachian tube dysfunction, as the ipsilateral middle ear cavity is completely clear. Correlate with clinical signs of mastoiditis. Radiology Report MRI BRAIN WITH AND WITHOUT CONTRAST, ___ INDICATION: ___ man with severe headache, question of trigeminal neuralgia. Evaluate for compression of trigeminal nerves. COMPARISON: Non-contrast head CT performed earlier on the same day, and ___ brain MRI. TECHNIQUE: Sagittal T1-weighted, and axial diffusion-weighted and FLAIR images of the brain were obtained. High-resolution axial T2-weighted gradient echo three-dimensional images through the cranial nerves were obtained with coronal reformations. Following intravenous gadolinium administration, axial MP-RAGE images of the brain with multiplanar reformations, axial T1-weighted images of the brain, and coronal high-resolution T1-weighted images through the cranial nerves, were obtained. FINDINGS: Artifacts at the vertex are noted on the current MRI as well as on the ___ MRI. These are likely related to the patient's dreadlocks, which are seen on the CT scan earlier today, and which were also noted in the MR technologist notes in ___. There is no evidence for a mass or abnormal contrast enhancement along the trigeminal nerves. Trigeminal nerves appear symmetric in size and signal intensity. There is a vein crossing the trigeminal nerve root entry zone on each side. There is no evidence of signal abnormalities in the brainstem or elsewhere in the brain parenchyma on diffusion-weighted, FLAIR, or post-contrast images. Ventricles, sulci, and basal cisterns are normal in size for age. There is mild mucosal thickening in bilateral ethmoidal air cells. There is opacification of right mastoid air cells with a T1 and T2 hyperintense material, indicating viscous material rather than simple fluid. The preceding CT demonstrates no evidence for osseous erosion. Bilateral middle ear cavities and left mastoid air cells are clear. IMPRESSION: 1. There is a vein crossing the trigeminal nerve root entry zones on each side. Similar findings may be associated with trigeminal neuralgia, but may also be seen in asymptomatic patients, and clinical correlation is needed. 2. Chronic opacification of right mastoid air cells with apparent viscous material, without evidence for osseous destruction on the preceding CT scan, and without middle ear cavity involvement. Please correlate clinically with any signs of chronic infection. Gender: M Race: BLACK/AFRICAN Arrive by WALK IN Chief complaint: Headache Diagnosed with HEADACHE temperature: 98.4 heartrate: 86.0 resprate: 18.0 o2sat: 100.0 sbp: nan dbp: nan level of pain: 10 level of acuity: 3.0

Dear Mr. ___, You were admitted for severe worsening headache. You underwent a Head CT which was normal as well as an MRI of your brain which was also normal. We trialed different medications for your headache including Depakote and Steroids which did not improve your headache. You were restarted on your home Gabapentin and on three days of Indomethacin as well as continued on home Oxycodone for pain. You were also started on Flexeril for muscle spasms. Given persistent headache, we increased your oxycodone after discussion with the Pain team here and your Primary Care Provider, Dr. ___. You also underwent occipital nerve blocks twice during your hospitalization and preaurical nerve block once with some relief of symptoms. You also received Toradol and Magnesium to aid in headache relief. Your headache improved during your hospital stay. Please keep your Neurology clinic, Pain center, and Primary Care provider appointments as listed below. Please also follow-up with your Psychiatrist following discharge. If you develop worsening of headache and would like for Dr. ___ to perform another nerve block, please call his office ___ to schedule. It was a pleasure taking care of you.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: C5 fracture, admission for syncope work up Major Surgical or Invasive Procedure: None History of Present Illness: Reliability: Patient with underlying dementia, AAOx1. Collateral information obtained from HCP. ___ dementia, CLL, atrial fibillation that was transferred from ___ for spine fracture evaluation. He apparently experienced an unwitnessed fall, but may have had a syncopal episode. When he was found on the floor, he was conscious and mentating well. The story is not clear given underlying dementia. CT Neck revealed a cervical spine fracture. He was hospitalized in ___ for urinary retention with a urinary tract infection with indwelling foley catheter since that time. Patient lives in assisted-living, has help with ADLs/AIDLs. He does not use any assistive devices except glasses. Patient has fallen once in the past in setting of illness about ___ years ago. He states that he remembered the whole episode this morning. He denies any associated chest pain/discomfort, shortness of breath, "black outs," warmness, seizure activity. He states that he was looking for something and "went to the ground." He denies loss of consciousness and remembers the entire event. He states that someone found him on the floor. His main concern is right posterior shoulder pain. In the ED, initial VS: 16:17 T 97.8 HR 80 BP 143/74 RR 18 pOx 98% Exam was significant for non-focal neurological exam, normal rectal tone, and t-spine tenderness. Imaging showing CT chest and CT abdomen showed no definite acute findings. There was trace right pleural effusion with widespread osseous changes with expansion of medullary spaces and cystic and sclerotic change consistent with fibrous dysplasia. Several vertebral bodies that demonstrate these changes, have wedge compression deformities which are age indeterminate. There are however no retropulsion of fragments or hematoma identified. ___ hospital imaging reports were not available for review in the chart sent to the floor. Labs were performed showing WBC 59.6 (unknown baseline, ? from CLL), Hgb 10 (unknown baseline) Plt 176 Diff N13,L80,Atyps4. Chem was within normal limits except glucose 164. LFTs were within normal limits including lipase. TropnT < 0.01. UA was significant for SpG > 1.050, nit neg, Leuks moderate, RBC 20, WBC 99 with no bacteria, epi 1, hyaline cast 4 The neurosurgery service was consulted for the C5 lamina fracture and bilateral pedicle fracture of C5. Impression was perfect anatomical alignment, non-displaced. They advised a medium aspen hard collar at all times for 6 weeks, pain control, and muscle relaxant prn. He was given 1 L NS and morphine 4 mg IV x 1. Given the uncertain nature of the story, he was admitted for a syncope work-up. VS on transfer: 98.0, 96, 133/72, 18, 97% RA Currently, he confirms the above story and concerns. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - atrial fibrillation - ? prior MI based on ECG or ECHO - benign prostatic hypertrophy with urinary retention - CLL Followed at ___ (Dr. ___. Uncertain treatment history Social History: ___ Family History: Unable to relate. Physical Exam: Admission: VS - T 96.8 PO, BP 148/77, HR 94, pOx 94 RA GENERAL - NAD, non-toxic, in pain HEENT - NC/AT, PERRLA, EOMI, mucous membranes were very dry with tongue stuck to mouth NECK - ___ J collar in place limiting exam. There is tenderness to palpitation on C-spine. LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. Unable to assess posterior lung fields due to patient cooperation. HEART - Distant heart sounds, regular rate and rhythm ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding Some tenderness in the right lower quandrant EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox1 (to person, ___, "Room 17"), CNs III-XII grossly intact. Patient unable to cooperate fully with strength testing. On right and left UE, at least ___, testing on right limited secondary to should pain. MSK: Right shoulder with posterior pain on scapula LABS: See below. Discharge: VS - 96.4-97.8, 92-140/61-81, 58-150, 95-96%RA ___ GENERAL - NAD, non-toxic. HEENT - NC/AT, PERRLA, EOMI, mucous membranes still dry, but improving NECK - ___ J collar in place limiting exam. There is tenderness to palpitation on C-spine and with movement. LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. Unable to assess posterior lung fields due to not wanting to disrupt patient and put her in pain. HEART - Distant heart sounds, regular rate and rhythm ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding Some tenderness in the right lower quandrant EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs III-XII grossly intact. Patient unable to cooperate fully with strength testing. On right and left UE, at least ___, testing on right limited secondary to should pain. MSK: Right shoulder with posterior pain on scapula Pertinent Results: ___ 05:05PM BLOOD WBC-59.6* RBC-3.63* Hgb-10.0* Hct-29.9* MCV-82 MCH-27.5 MCHC-33.4 RDW-15.9* Plt ___ ___ 06:50AM BLOOD WBC-54.2* RBC-3.57* Hgb-9.8* Hct-30.1* MCV-84 MCH-27.4 MCHC-32.5 RDW-16.6* Plt ___ ___ 06:26AM BLOOD WBC-38.7* RBC-3.22* Hgb-8.8* Hct-27.3* MCV-85 MCH-27.2 MCHC-32.2 RDW-15.9* Plt Ct-84* ___ 06:30AM BLOOD WBC-37.3* RBC-2.71* Hgb-7.6* Hct-23.2* MCV-85 MCH-28.1 MCHC-32.9 RDW-16.3* Plt Ct-79* ___ 05:05PM BLOOD Neuts-13* Bands-0 Lymphs-80* Monos-3 Eos-0 Baso-0 Atyps-4* ___ Myelos-0 ___ 06:50AM BLOOD Neuts-23* Bands-0 Lymphs-69* Monos-8 Eos-0 Baso-0 ___ Myelos-0 ___ 02:18AM BLOOD ___ PTT-31.0 ___ ___ 06:59PM BLOOD Ret Aut-1.5 ___ 05:05PM BLOOD Glucose-164* UreaN-22* Creat-1.0 Na-140 K-3.7 Cl-100 HCO3-26 AnGap-18 ___ 06:50AM BLOOD Glucose-117* UreaN-17 Creat-1.0 Na-141 K-4.1 Cl-105 HCO3-25 AnGap-15 ___ 06:26AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-139 K-3.9 Cl-106 HCO3-26 AnGap-11 ___ 05:05PM BLOOD ALT-26 AST-26 AlkPhos-69 TotBili-0.5 ___ 06:59PM BLOOD LD(LDH)-117 TotBili-0.6 DirBili-0.2 IndBili-0.4 ___ 05:05PM BLOOD Lipase-22 ___ 05:05PM BLOOD cTropnT-<0.01 ___ 06:50AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 ___ 05:50AM BLOOD Calcium-8.0* Phos-1.5*# Mg-1.9 ___ 06:26AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.0 ___ 06:59PM BLOOD Hapto-239* ___ 05:05PM BLOOD Digoxin-0.3* ___ 02:13PM URINE Color-Straw Appear-Hazy Sp ___ ___ 02:13PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 02:13PM URINE RBC-41* WBC->182* Bacteri-FEW Yeast-NONE Epi-3 TransE-<1 ___ 09:00PM URINE CastGr-3* ___ 09:10PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:10PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD ___ 09:10PM URINE RBC-20* WBC-99* Bacteri-NONE Yeast-NONE Epi-1 ___ 9:00 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Blood cultures pending x2 EKG ___ The rhythm is probably sinus rhythm. Marked baseline artifact. Left anterior fascicular block. No previous tracing available for comparison CT abdomen/ pelvis ___ INDICATION: Fall. Known C5 fracture. Dementia. TECHNIQUE: Multidetector helical CT scan of the chest, abdomen, and pelvis was obtained after the administration of 130 cc IV Omnipaque contrast. Coronal and sagittal reformations were prepared. COMPARISON: None available. FINDINGS: CHEST: There is a small right pleural effusion which appears simple. Additionally, there is mild bibasilar atelectasis. No evidence of pulmonary contusion is seen. No pneumothorax is present. The heart is mildly enlarged without evidence of pericardial effusion. There are coronary artery and aortic calcifications. The aorta is tortuous, however, not aneurysmally dilated. No evidence of endobronchial lesion is seen. No lymphadenopathy is identified. Note is made of fluid within the esophagus. ABDOMEN: The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys appear grossly unremarkable. Loops of small and large bowel are normal in size and caliber with note made of fecal loading within the large bowel. No abdominal free air, free fluid, or lymphadenopathy is seen. PELVIS: Distal loops of large bowel and rectum are normal in size and caliber with note made of extensive fecal loading. There is diverticulosis without evidence of diverticulitis. The bladder is collapsed around a Foley catheter. There is, however, the appearance of circumferential wall thickening of the bladder. An oblong calcification measuring 9 x 3 mm near the left inferior margin of the bladder (2:103) could represent a bladder stone. The distal ureters are not dilated. The prostate gland is enlarged measuring up to 5.2 cm in diameter. The aorta is tortuous with ectasia of the infrarenal portion; however, no aneurysmal dilation. Calcifications are seen throughout the abdominal aorta extending into the iliac arteries. There is a fat-containing left inguinal hernia. No pelvic free air, free fluid, or lymphadenopathy is identified. At the inferior margin of the imaging volume, note is made of fluid-filled tubular structures along the perineum and extending into the base of the pemis, of unclear etiology (2:18). Bone windows demonstrate Pagetoid changes with thickened expanded cortex, thickened disordered trabeculation of multiple bones including the scapulae, T8, T10, T11, L1, and L4 vertebral bodies. Similar findings are seen in the sacrum, the pelvis, and multiple bilateral ribs. Note is made of compression deformities in the involved vertebral bodies, greatest at the T11 level where the is acute kyphosis. No acute fracture is identified. No retropulsion of fragments is seen. There are multiple remote bilateral rib fractures. IMPRESSION: 1. No definite acute traumatic findings. 2. Pagetoid disease of bone as detailed without acute fracture. Compression deformities in the spine appear chronic. 3. Trace right pleural effusion. Mild cardiomegaly. 4. Partially imaged fluid-filled distended corpora cavernosa of unclear etiology or significance. Clinical correlation and, if indicated, correlation with ultrasound recommended. 5. Fluid within the esophagus, which could predispose to aspiration. ___ 11:27 AM RIGHT SHOULDER STUDY No prior shoulder radiographs for comparison. Comparison is made to the imaged portion of the right shoulder from a prior CT torso of ___. FINDINGS: The patient was unable to cooperate with standard radiographic positioning due to pain and difficulty understanding instructions from the technologist. With this limitation in mind, no definite acute fracture or dislocation is identified. Degenerative changes are present at the acromioclavicular joint. Note is also made of findings suggestive of Paget's disease including bony expansion and coarsened trabeculation involving portions of the right scapula with a relatively similar appearance demonstrated on recent CT torso of 1 day earlier. This is most marked in the region of the acromion and coracoid processes as well as the glenoid. IMPRESSION: 1. Limited radiograph demonstrating no gross evidence of fracture or dislocation. If symptoms persist, repeat radiographs with standard positioning would be recommended when the patient's condition permits. 2. Findings suggestive of Paget's disease. EKG ___ Atrial fibrillation with rapid ventricular response. Since the previous tracing atrial fibrillation is now again seen with more marked ST-T wave abnormalities related to sinus rhythm. Otherwise, findings are unchanged. Medications on Admission: - digoxin 0.25 mg PO ___ - proscar 5 mg PO qD - folic acid 5 mg PO qD - flomax 0.4 mg PO qHS - KCl 10 mg PO qD - Multivitamin PO qD - Caltrate 600 D BID - alendronate 70 mg PO q ___ - simvastatin 80 mg PO qHS - buthethamide 1 mg PO qD - tylenol prn pain Discharge Medications: 1. digoxin 250 mcg Tablet Sig: One (1) Tablet PO ___, ___ (). 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 6. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: On ___. 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day as needed for pain: As needed for pain 12 hours on, 12 hours off. 9. acetaminophen 500 mg Tablet Sig: ___ Tablets PO once a day as needed for fever or pain. 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: hold for sedation, RR<10. 11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: C5 cervical fracture, paget's disease of the bone, atrial fibrillation, advanced dementia Secondary: Hypertension, hyperlipidemia, benign prostatic hypertrophy, chronic lymphocytic leukemia 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: Fall. Known C5 fracture. Dementia. TECHNIQUE: Multidetector helical CT scan of the chest, abdomen, and pelvis was obtained after the administration of 130 cc IV Omnipaque contrast. Coronal and sagittal reformations were prepared. COMPARISON: None available. FINDINGS: CHEST: There is a small right pleural effusion which appears simple. Additionally, there is mild bibasilar atelectasis. No evidence of pulmonary contusion is seen. No pneumothorax is present. The heart is mildly enlarged without evidence of pericardial effusion. There are coronary artery and aortic calcifications. The aorta is tortuous, however, not aneurysmally dilated. No evidence of endobronchial lesion is seen. No lymphadenopathy is identified. Note is made of fluid within the esophagus. ABDOMEN: The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys appear grossly unremarkable. Loops of small and large bowel are normal in size and caliber with note made of fecal loading within the large bowel. No abdominal free air, free fluid, or lymphadenopathy is seen. PELVIS: Distal loops of large bowel and rectum are normal in size and caliber with note made of extensive fecal loading. There is diverticulosis without evidence of diverticulitis. The bladder is collapsed around a Foley catheter. There is, however, the appearance of circumferential wall thickening of the bladder. An oblong calcification measuring 9 x 3 mm near the left inferior margin of the bladder (2:103) could represent a bladder stone. The distal ureters are not dilated. The prostate gland is enlarged measuring up to 5.2 cm in diameter. The aorta is tortuous with ectasia of the infrarenal portion; however, no aneurysmal dilation. Calcifications are seen throughout the abdominal aorta extending into the iliac arteries. There is a fat-containing left inguinal hernia. No pelvic free air, free fluid, or lymphadenopathy is identified. At the inferior margin of the imaging volume, note is made of fluid-filled tubular structures along the perineum and extending into the base of the pemis, of unclear etiology (2:18). Bone windows demonstrate Pagetoid changes with thickened expanded cortex, thickened disordered trabeculation of multiple bones including the scapulae, T8, T10, T11, L1, and L4 vertebral bodies. Similar findings are seen in the sacrum, the pelvis, and multiple bilateral ribs. Note is made of compression deformities in the involved vertebral bodies, greatest at the T11 level where the is acute kyphosis. No acute fracture is identified. No retropulsion of fragments is seen. There are multiple remote bilateral rib fractures. IMPRESSION: 1. No definite acute traumatic findings. 2. Pagetoid disease of bone as detailed without acute fracture. Compression deformities in the spine appear chronic. 3. Trace right pleural effusion. Mild cardiomegaly. 4. Partially imaged fluid-filled distended corpora cavernosa of unclear etiology or significance. Clinical correlation and, if indicated, correlation with ultrasound recommended. 5. Fluid within the esophagus, which could predispose to aspiration. Radiology Report RIGHT SHOULDER STUDY No prior shoulder radiographs for comparison. Comparison is made to the imaged portion of the right shoulder from a prior CT torso of ___. FINDINGS: The patient was unable to cooperate with standard radiographic positioning due to pain and difficulty understanding instructions from the technologist. With this limitation in mind, no definite acute fracture or dislocation is identified. Degenerative changes are present at the acromioclavicular joint. Note is also made of findings suggestive of Paget's disease including bony expansion and coarsened trabeculation involving portions of the right scapula with a relatively similar appearance demonstrated on recent CT torso of 1 day earlier. This is most marked in the region of the acromion and coracoid processes as well as the glenoid. IMPRESSION: 1. Limited radiograph demonstrating no gross evidence of fracture or dislocation. If symptoms persist, repeat radiographs with standard positioning would be recommended when the patient's condition permits. 2. Findings suggestive of Paget's disease. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: TRANSFER C5 FX Diagnosed with FX C5 VERTEBRA-CLOSED, UNSPECIFIED FALL, DEHYDRATION, URIN TRACT INFECTION NOS temperature: 97.8 heartrate: 80.0 resprate: 18.0 o2sat: 98.0 sbp: 143.0 dbp: 74.0 level of pain: unable level of acuity: 2.0

Dear Mr. ___, It was our pleasure to care for you at ___. You were admitted from an outside hospital for a fall and new fracture in your C5 vertebrea. We found that you had fallen as a result of not drinking enough fluid to keep your blood pressure high enough to bring blood to your brain (orthostasis). We trated you with IV fluids and holding some medications which will make your blood pressure lower. We also found that you have atrial fibrillation with rapid ventricular response. We controlled this with a new medication, metoprolol. You should talk with your doctor about starting anticoagulation. We made the following changes to your medications: Please STOP flomax Please STOP KCL Please STOP bumetanide Please DECREASE simvastatin to 40mg daily Please START metoprolol succinate 25mg daily Please START tylenol Please START a lidocaine patch Please START tramadol as needed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bone marrow biopsy History of Present Illness: Ms. ___ is a ___ woman with history of smoking, COPD, atrial fibrillation not on anticoagulation, DMII, HTN, HLD, gastric bypass who presented from rehab to ___ with shortness of breath, found to be hypoxic and to have multiple hematologic abnormalities, transferred to ___ for further management. Per notes from ___, patient has had increase in lethargy since yesterday, stated feeling fine but more tired. Today, lethargy increased, resident was more difficult to rouse than usual. Speech decreased from baseline (not as talkative). Vitals remained stable until 1600 when resident O2 sat was found to be 84% on room air. Up to 93% on 2L via NC. At the ___, the patient has had fluctuating platelet count between 88-150 throughout the month of ___ of unknown etiology; normalized by ___. The physician in the facility trialed her off PPI as this was thought to be a possible culprit. At baseline, she is reportedly AOx2. On interview, the patient tells me that she has lost about 100 pounds in the last ___ years since her gastric bypass procedure. She reports that she has had progressive shortness of breath that has gotten worse over the past few days to week. She also reports a diffuse anterior chest tightness. She is not able to identify exacerbating or alleviating factors to the pain or shortness of breath. She denies any fevers or chills. She reports that she feels tired. She also notes that she has had easy bruising, she is not sure for how long. She also notes that she has back pain, also unable to state how long. In the ED, initial vitals: 97.4 81 141/85 18 98% 4L NC Exam notable: Resp: Breathing comfortably on nasal cannula. No incr WOB, CTAB Labs notable for: WBC 4.6 Hb 10.7 plt 17, hapto 154, LDH 1630, fibrinogen 410, INR 1.0, D-dimer 1122, uric acid 10.5; HCV Ab pos Imaging notable for: CT A/P pelvis with contrast Patient given: ___ 05:08 IV Morphine Sulfate 2 mg ___ 05:57 IV CefTRIAXone 1 g ___ 09:14 PO/NG Metoprolol Tartrate 12.5 mg ___ 09:21 PO LevETIRAcetam 1000 mg ___ 09:50 IV Morphine Sulfate 2 mg ___ 14:16 IVF NS ___ Started 100 mL/hr ___ 15:07 IV Morphine Sulfate 2 mg ___ 16:26 IV Haloperidol 1 mg ___ 17:00 IV CefTRIAXone 1 gm ___ 18:53 PO/NG Allopurinol ___ mg ___ 18:53 PO/NG OxyCODONE (Immediate Release) 5 mg ___ 20:00 PO LevETIRAcetam 1000 mg ___ 20:00 PO/NG Azithromycin 500 mg In the ED, patient was reportedly agitated for which she received Haldol prior to coming to the floor. On arrival to the floor, the patient report ongoing back pain. She also reports mild shortness of breath. She otherwise has no complaints at this time. She is aware of her likely cancer diagnosis and we discussed next steps. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Afib COPD Diabetes Hyperlipidemia Hypertension Social History: ___ Family History: Non contributory Physical Exam: Admission exam VITALS: 97.4 142/88 73 18 92 2L NC GENERAL: Alert and in no apparent distress; cachectic appearing with temporal wasting 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. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Ecchymoses on bilateral forearms; no petechiae NEURO: Alert, oriented x2, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge exam: 24 HR Data (last updated ___ @ 1433) Temp: 97.8 (Tm 97.9), BP: 109/70, HR: 71, RR: 16 (___), O2 sat: 93%, O2 delivery: Ra GENERAL: Cachectic female. Lying in bed. In no acute distress. EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx with areas of petechiae, no exudate. No cervical or supraclavicular lymphadenopathy. CV: Heart regular rate and rhythm, no murmur. Radial and DP pulses 2+ bilaterally. 2+ lower extremity edema increased through mid-shins. RESP: Lungs clear to auscultation with decreased air entry in right base. Breathing is non-labored. RR 16 by my bedside evaluation GI: Abdomen is soft. Mildly protuberant. Moderate RUQ tenderness, unchanged. No rebound or guarding. No lower abdominal tenderness. Bowel sounds present. GU: No suprapubic tenderness MSK: Neck supple, moves all extremities. Clubbing of fingers. SKIN: No rashes or ulcerations noted. Diffuse scattered upper>lower extremity ecchymosis. NEURO: Alert and easily arousable. Continues to be confused today and tangential at times. Not agitated during my evaluations. Face symmetric, gaze conjugate with EOMI, speech fluent. PSYCH: Confused at times per report by nursing Pertinent Results: Admission labs ___ 02:20AM BLOOD WBC-4.6 RBC-3.53* Hgb-10.7* Hct-34.7 MCV-98 MCH-30.3 MCHC-30.8* RDW-13.5 RDWSD-47.8* Plt Ct-17* ___ 02:20AM BLOOD Neuts-66.7 ___ Monos-10.6 Eos-0.2* Baso-0.4 NRBC-1.1* Im ___ AbsNeut-3.08 AbsLymp-0.96* AbsMono-0.49 AbsEos-0.01* AbsBaso-0.02 ___ 03:07AM BLOOD ___ PTT-25.8 ___ ___ 01:03PM BLOOD ___ D-Dimer-1122* ___ 02:20AM BLOOD Ret Aut-2.3* Abs Ret-0.08 ___ 02:20AM BLOOD Glucose-75 UreaN-41* Creat-1.1 Na-138 K-4.7 Cl-104 HCO3-22 AnGap-12 ___ 02:20AM BLOOD ALT-25 AST-56* LD(LDH)-1630* AlkPhos-257* TotBili-0.5 ___ 02:20AM BLOOD Albumin-3.2* Calcium-9.4 Phos-5.7* Mg-1.9 UricAcd-10.5* Iron-60 ___ 02:20AM BLOOD calTIBC-273 VitB12-358 Folate->20 ___ Ferritn-242* TRF-210 ___ 01:03PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* IgM HBc-NEG ___ 02:20AM BLOOD HCV Ab-POS* Discharge labs: No labs in 24 hours prior to discharge (last labs included) ___ 03:15PM BLOOD WBC-4.8 RBC-2.26* Hgb-6.9* Hct-22.5* MCV-100* MCH-30.5 MCHC-30.7* RDW-15.3 RDWSD-54.8* Plt Ct-9* ___ 10:10PM BLOOD Plt Ct-20* ___ 03:40PM BLOOD ___ ___ 01:03PM BLOOD ___ D-Dimer-1122* ___ 03:00PM BLOOD Ret Aut-2.2* Abs Ret-0.07 ___ 03:15PM BLOOD Glucose-82 UreaN-30* Creat-0.7 Na-139 K-5.2 Cl-107 HCO3-21* AnGap-11 ___ 03:15PM BLOOD ALT-53* AST-234* LD(LDH)-2283* AlkPhos-326* TotBili-0.7 ___ 03:40PM BLOOD Lipase-85* ___ 03:15PM BLOOD Calcium-8.6 Phos-2.3* Mg-2.0 UricAcd-4.6 ___ 01:03PM BLOOD calTIBC-233* VitB12-330 Folate->20 ___ Ferritn-215* TRF-179* ___ 05:50AM BLOOD Ammonia-24 ___ 01:03PM BLOOD TSH-1.5 ___ 01:03PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* IgM HBc-NEG ___ 03:00PM BLOOD HIV Ab-NEG ___ 01:03PM BLOOD HCV Ab-POS* ___ 03:00PM BLOOD HCV VL-5.2* ___ 02:20AM BLOOD CHCV VL-5.5* ___ 02:34AM BLOOD Lactate-1.5 ___ 01:03PM BLOOD METHYLMALONIC ACID-Test ___ 03:15PM BLOOD WBC-4.8 RBC-2.26* Hgb-6.9* Hct-22.5* MCV-100* MCH-30.5 MCHC-30.7* RDW-15.3 RDWSD-54.8* Plt Ct-9* ___ 03:15PM BLOOD Glucose-82 UreaN-30* Creat-0.7 Na-139 K-5.2 Cl-107 HCO3-21* AnGap-11 ___ 03:15PM BLOOD ALT-53* AST-234* LD(LDH)-2283* AlkPhos-326* TotBili-0.7 ___ 03:15PM BLOOD Calcium-8.6 Phos-2.3* Mg-2.0 UricAcd-4.6 Imaging ============================== Liver/GB US ___ IMPRESSION: 1. Coarsened and nodular liver in keeping with cirrhosis. No focal liver lesions are identified. Main portal vein is patent. 2. Small amount of ascites. 3. Prominence of the pancreatic duct without focal lesions. In addition, prominent CHD on recent CT raises the possibility of ampullary sphincter dysfunction. CT abd/pelvis ___ IMPRESSION: 1. Study is limited by increased noise and lack of oral contrast limiting evaluation of small metastases 2. Left adrenal thickening, nonspecific. Otherwise no findings to suggest metastatic disease in the abdomen pelvis. 3. Cirrhotic liver with portal hypertension, characterized by splenomegaly, upper abdominal varices and trace volume of ascites. No suspicious liver lesion on this single phase CT. 4. Left kidney small nonobstructive calculus measures 3 mm. 5. Partially included known right lower quadrant mass. 6. New subsegmental of right basilar atelectasis. 7. Stable left lower lobe ground-glass opacities, likely infectious etiology ___ ___ IMPRESSION: No evidence of an acute intracranial abnormality. CT C spine ___ IMPRESSION: No radiopaque foreign bodies identified. Multilevel degenerative change. Micro ============================== BCx ___ 2:20 am BLOOD CULTURE Site: ARM **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. U legionella negative Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. DULoxetine 60 mg PO DAILY 2. DULoxetine 30 mg PO QHS 3. FoLIC Acid 1 mg PO DAILY 4. Gabapentin 300 mg PO QHS 5. LevETIRAcetam 500 mg PO DAILY 6. LevETIRAcetam 250 mg PO QHS 7. Metoprolol Tartrate 25 mg PO BID 8. Morphine SR (MS ___ 30 mg PO Q12H 9. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Moderate 10. Pantoprazole 20 mg PO Q24H 11. Alendronate Sodium 70 mg PO QTUES 12. Calcium Carbonate 500 mg PO BID 13. Mirtazapine 7.5 mg PO QHS 14. amLODIPine 10 mg PO DAILY 15. glimepiride 1 mg oral DAILY 16. Fluticasone Propionate NASAL 1 SPRY NU DAILY 17. Vitamin D 1000 UNIT PO DAILY 18. Docusate Sodium 100 mg PO BID 19. LORazepam 0.5 mg PO Q8H:PRN Anxiety 20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 21. Salonpas (methyl salicylate-menthol) ___ % topical DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Duration: 24 Hours 2. Benzonatate 200 mg PO TID:PRN Cough 3. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions 4. Haloperidol 0.5-2 mg PO Q4H:PRN delirium 5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN moderate-severe pain or respiratory distress RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth q1 Disp ___ Milliliter Refills:*0 6. QUEtiapine Fumarate 12.5 mg PO BID:PRN Restlessness and agitation 7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity 8. LORazepam 0.5-2 mg PO Q2H:PRN anxiety RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) tablet(s) by mouth 2 hours Disp #*20 Tablet Refills:*0 9. LevETIRAcetam 500 mg PO DAILY 10. LevETIRAcetam 250 mg PO QHS Discharge Disposition: Extended Care Discharge Diagnosis: Metastatic small cell carcinoma lung cancer Right lower lung mass Pancytopenia B12 deficiency Acute toxic-metabolic encephalopathy Acute on chronic intermittent agitation and confusion Cirrhosis Hepatitis C Severe protein-calorie malnutrition Chronic back and pelvic pain Depression/anxiety Hypertension: Paroxysmal Atrial fibrillation Diabetes mellitus type II Acute hypoxic respiratory failure Acute kidney injury Asymtomatic bacteriuria Seizure disorder/prior traumatic brain injury with seizure. GERD Osteoporosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with new lung mass and mediastinal lymphadenopathy, concern for malignancy// please eval for evidence of metastatic disease or lymphadenopathy in the abdomen TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen without and with IV contrast. Initially the abdomen was scanned without IV contrast. Subsequently a single bolus of IV contrast was injected and the abdomen and pelvis was scanned in the portal venous phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.5 s, 46.2 cm; CTDIvol = 6.1 mGy (Body) DLP = 283.3 mGy-cm. 2) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 5.7 mGy (Body) DLP = 159.8 mGy-cm. 3) Spiral Acquisition 0.8 s, 10.7 cm; CTDIvol = 5.8 mGy (Body) DLP = 61.9 mGy-cm. 4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 5) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.0 mGy (Body) DLP = 20.0 mGy-cm. Total DLP (Body) = 527 mGy-cm. COMPARISON: CT chest dated ___. CT pelvis dated ___. FINDINGS: LOWER CHEST: Partially included right lower lobe lung mass measures 4.6 x 4.7 cm. Compared to prior CT chest the day before, there is a new incompletely included subpleural opacity right lower lobe likely atelectasis. Additional area of atelectasis seen in right lower lobe. Faint ground-glass opacities in left lower lobe are unchanged and incompletely included on this exam. ABDOMEN: HEPATOBILIARY: The liver is slightly nodular and demonstrating lobular contour with hypertrophy of the left hepatic lobe may represent underlying cirrhosis. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. Trace volume of perihepatic ascites is seen. 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 markedly enlarged measuring 15.3 cm, without evidence of focal lesions. ADRENALS: The right adrenal gland is normal in size and shape. URINARY: 3 mm nonobstructing calculus is seen in inter pole of the left kidney. Punctate low-density lesion in the left lower pole is too small to characterize. 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: Changes of post gastric bypass surgery are seen. The bowel is normal in caliber with no left obstruction. PELVIS: The urinary bladder and distal ureters are unremarkable. There is trace volume of free fluid in the pelvis. REPRODUCTIVE ORGANS: There is fibroid uterus LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Upper abdominal varices are seen including perisplenic and gastrohepatic ligament varices. The portal veins and hepatic veins are patent. There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Evidence of old healed pelvic fractures including superior and inferior pubic rami fractures are seen. Grade 1 anterolisthesis of L4 on 5 is unchanged. SOFT TISSUES: Diffuse infiltration of subcutaneous fat likely due to anasarca. Multiple foci of metallic density seen in the anterior abdominal and pelvic wall, indeterminate IMPRESSION: 1. Study is limited by increased noise and lack of oral contrast limiting evaluation of small metastases 2. Left adrenal thickening, nonspecific. Otherwise no findings to suggest metastatic disease in the abdomen pelvis. 3. Cirrhotic liver with portal hypertension, characterized by splenomegaly, upper abdominal varices and trace volume of ascites. No suspicious liver lesion on this single phase CT. 4. Left kidney small nonobstructive calculus measures 3 mm. 5. Partially included known right lower quadrant mass. 6. New subsegmental of right basilar atelectasis. 7. Stable left lower lobe ground-glass opacities, likely infectious etiology. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with unclear medical history, here with suspected malignancy and new diagnosis of cirrhosis// acute etiology of mental status, patient needs MRI but family cannot recall if patient has metal hardware given multiple falls TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.5 s, 21.6 cm; CTDIvol = 51.9 mGy (Head) DLP = 1,125.5 mGy-cm. Total DLP (Head) = 1,126 mGy-cm. COMPARISON: Outside hospital noncontrast head CTs including ___ and ___ FINDINGS: There is no evidence of large territorial infarction,hemorrhage,edema, or mass. Periventricular and subcortical white matter hypodensities are nonspecific but likely sequelae of chronic small vessel ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is evidence of prior left frontotemporal craniotomy including underlying dural thickening which is unchanged. There is no evidence of acute fracture. Small, partially imaged right maxillary sinus mucous retention cyst. Large left concha bullosa. The mastoid air cells and middle ear cavities appear clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No evidence of an acute intracranial abnormality. Radiology Report EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS INDICATION: ___ year old woman who presented with dyspnea/hypoxia and found to have pancytopenia, lung mass, and cirrhosis. Screening xray prior to MRI per radiology.// Pre-MRI screening. TECHNIQUE: Frontal and lateral views of the cervical spine COMPARISON: None FINDINGS: C1 through T1 are demonstrated on the lateral view. There is no prevertebral swelling. Cervical lordosis is preserved. The vertebral body heights are preserved. There is multilevel disc height loss, most pronounced at C5-C6, C6-C7 and C7-T1. additionally, there is multilevel uncovertebral and facet joint arthropathy as well as anterior posterior osteophytes. No fracture or spondylolisthesis is detected. No suspicious lytic or sclerotic lesion is identified. There are no radiopaque foreign bodies identified. IMPRESSION: No radiopaque foreign bodies identified. Multilevel degenerative change. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with new lung mass (? small cell cancer) cirrhosis (?new) with ongoing abdominal pain.// Assess ascites burden. Assess biliary tree in setting of increasing alkP. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis performed on ___ FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is nodular, consistent with cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is small amount of ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm, 10 mm on recent CT. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The head and body of the pancreas are within normal limits. The tail of the pancreas is not visualized due to the presence of gas. Prominence of the pancreatic duct measuring 4 mm is similar to recent CT. SPLEEN: Normal echogenicity. Spleen length: 12.5 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis.Simple cyst arises from the upper pole of the right kidney measures 6 x 7 x 11 mm. Right kidney: 9.3 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Coarsened and nodular liver in keeping with cirrhosis. No focal liver lesions are identified. Main portal vein is patent. 2. Small amount of ascites. 3. Prominence of the pancreatic duct without focal lesions. In addition, prominent CHD on recent CT raises the possibility of ampullary sphincter dysfunction. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Hypoxia, Transfer Diagnosed with Hypoxemia temperature: 97.4 heartrate: 81.0 resprate: 18.0 o2sat: 98.0 sbp: 141.0 dbp: 85.0 level of pain: 0 level of acuity: 2.0

Continue to follow with hospice for further guidance and medication adjustment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: S/P Fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of DM2, HTN, HLD, recurrent UTIs (on fosfomycin), recent RLE DVT (on apixaban), and schizophrenia who presented to the ED after a fall. She describes tripping over her shower chair this morning with the lights out. She fell on her left side and hit her chest and abdomen. She denied having chest pain, palpitations, shortness of breath, feeling lightheaded or nauseous prior to falling down. She also says she didn't lose consciousness or hit her head. Prior to this episode, she was feeling well although she had been hospitalized two months ago for acute liver injury ___ polypharmacy. In the ED, Initial vital signs were notable for: T98.8, HR 76, BP 161/67, RR 16, O2 98%RA UA showed persistence of her chronic pyuria: >182WBC, few bacteria, large leuk, trace blood, nitrite positive, 30 protein, 1 epithelial cell Pan CT (Head, Chest, A/P, C-spine) - all largely unremarkable, no signs of acute fracture or underlying acute pathologic process. Patient reportedly had episodic lightheadedness while in the ED and was found to be in a-fib with RVR with heart rates up to 150s. BP initially slightly elevated 160s/70s, but declined to ___ in the setting of her tachyarrhythmia. Limited objective records of this episode are available for review now that she has left the ED (just one unconfirmed EKG, which appears to start in sinus before going into probable a-fib). She was given 500 cc NS, a dose of IV metoprolol, and was admitted to medicine. Upon arrival to the floor, she is having pain on her left chest and upper abdomen. It's worse when she takes a deep breath but she appears in no distress. She is adamant that she hadn't had palpitations up until the ED. She denied recent illness or poor PO intake. She denied fevers/chills, lightheadedness, dizziness, chest pain, shortness of breath, nausea/vomiting, dysuria. Past Medical History: RLE DVT DM HTN HLD osteoarthritis schizeophrenia lichen sclerosis possible bladder cyst recurrent urinary tract infections - currently on fosfomycin suppression detrusor overactivity recurrent colitis anorexia, abnormal weight loss anemia bilateral ocular pseudophakia dry eye syndrome Social History: ___ Family History: Mother with HTN Physical Exam: ADMISSION EXAM ========= VITALS: T 98.0, BP 192/83, HR 90, RR 17, O2 sat99 Ra GEN: In NAD. HEENT: No scalp lacerations noted. PERRL, moist mucous membranes, oropharynx clear without exudates. NECK: No JVD, no cervical lymphadenopathy. CV: RRR, no murmurs/gallops/rubs. Tenderness to palpation over left lateral chest. PULM: CTAB, no wheezing/crackles/rhonchi. BACK: Kyphotic with no midline tenderness C-L spine. ABD: Soft, tender to palpation in LUQ radiating to left flank, no rebound or guarding, non distended. EXTREM: Trace ___ edema bilaterally. Pulses +2 ___P, ___ bilaterally. SKIN: No rashes. NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact. DISCHARGE EXAM ========= VITALS: Reviewed in OMR GENERAL: Alert and oriented, no acute distress ENT: NT/AC, MMM, EOMI CV: RRR, Grade II/VI SEM most prominent at the ___. RESP: CTAB, normal work of breathing GI: NT/ND, BS+ EXT: Warm and well perfused, non-edematous NEURO: CNII-XII grossly intact, no focal neurologic deficits Pertinent Results: ADMISSION LABS ========= ___ 09:39AM WBC-8.5 RBC-3.21* HGB-8.2* HCT-27.0* MCV-84 MCH-25.5* MCHC-30.4* RDW-17.2* RDWSD-53.0* ___ 09:39AM NEUTS-67.9 LYMPHS-17.2* MONOS-11.6 EOS-2.1 BASOS-0.7 IM ___ AbsNeut-5.78 AbsLymp-1.46 AbsMono-0.99* AbsEos-0.18 AbsBaso-0.06 ___ 09:39AM ___ PTT-30.1 ___ ___ 09:39AM GLUCOSE-95 UREA N-14 CREAT-0.7 SODIUM-136 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-14 DISCHARGE LABS ========= ___ 08:15AM BLOOD WBC-7.3 RBC-3.30* Hgb-8.3* Hct-27.6* MCV-84 MCH-25.2* MCHC-30.1* RDW-18.2* RDWSD-55.3* Plt ___ ___ 08:15AM BLOOD Glucose-113* UreaN-13 Creat-0.8 Na-139 K-4.3 Cl-103 HCO3-26 AnGap-10 IMAGING ======= ___ CXR: Top normal heart size, mild lower lung atelectasis, chronic compression deformity at the thoracolumbar junction. Otherwise unremarkable. ___ Chest/Abdomen/Pelvis: 1. No evidence of acute traumatic injury in the chest abdomen or pelvis. 2. Chronic appearing deformities of the anterolateral left sixth through ninth ribs are more conspicuous from prior, clinical correlation for site of pain is recommended. 3. Subtle ground-glass opacities at the lung bases may reflect aspiration. Mild to moderate hiatal hernia. 4. Pulmonary nodule in the left lower lobe are stable from prior. 5. 3 mm right thyroid nodules. No follow-up is recommended per ACR criteria. ___ Head CT: No acute intracranial process. Age-related involutional change. ___. No acute fractures identified. 2. No prior imaging available for comparison, however there is no definite evidence of traumatic malalignment. There is widening of the right facet joint at C4-C5, likely degenerative. 3. Multilevel degenerative change including uncovertebral hypertrophy and facet arthropathy as described above. 4. 3 mm nodule in the right thyroid lobe for which no follow-up is recommended per ACR criteria. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. OLANZapine 20 mg PO QHS 3. Metoprolol Tartrate 50 mg PO BID 4. Apixaban 5 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Aspirin 81 mg PO DAILY 8. GlipiZIDE XL 2.5 mg PO DAILY 9. Fosfomycin Tromethamine 3 g PO PRN UTI 10. Atorvastatin 80 mg PO QPM 11. Gabapentin 100 mg PO QHS 12. ascorbic acid (vitamin C) 1,000 mg oral BID Discharge Medications: 1. Apixaban 5 mg PO BID 2. ascorbic acid (vitamin C) 1,000 mg oral BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Fosfomycin Tromethamine 3 g PO PRN UTI 6. Gabapentin 100 mg PO QHS 7. GlipiZIDE XL 2.5 mg PO DAILY 8. Lisinopril 20 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. OLANZapine 20 mg PO QHS 11. Omeprazole 20 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary ======= Mechanical Fall Secondary ========= Hypertension Hyperlipidemia Recurrent Urinary Tract Infections History of Deep Vein Thrombosis with Inferior Vena Cava Filter Placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with L rib pain s/p fall// eval for fx/injury COMPARISON: ___ FINDINGS: AP upright and lateral views of the chest provided. Heart is top-normal in size. There is subtle lower lung atelectasis. No convincing evidence for pneumonia or edema. No large effusion or pneumothorax. Mediastinal contour stable. Imaged bony structures are intact. No displaced rib fracture is seen. A compression deformity in the thoracolumbar junction is unchanged from ___. Partially visualized in the upper abdomen is an IVC filter. IMPRESSION: Top normal heart size, mild lower lung atelectasis, chronic compression deformity at the thoracolumbar junction. Otherwise unremarkable. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ s/p fall// ? injury TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head ___ FINDINGS: There is no evidence of acute large territorial infarction,hemorrhage,edema,or discrete mass. Mild periventricular subcortical white matter hypodensities are nonspecific but likely reflect the sequelae of chronic small vessel ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the paranasal sinuses and middle ear cavities are clear. There is mild opacification of the right mastoid air cells posteriorly, similar to prior. The patient is status post bilateral lens replacements. IMPRESSION: No acute intracranial process. Age-related involutional change. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ s/p fall// ? injury TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Total DLP (Body) = 519 mGy-cm. COMPARISON: None. FINDINGS: 2 mm grade 1 anterolisthesis of C3 on C4, C4 on C5 and C7 on T1 is favored to be degenerative, although no prior exams are available for comparison. There is 2 mm grade 1 retrolisthesis of C5 on C6. There is no prevertebral soft tissue swelling to suggest traumatic malalignment. There is widening of the right facet joint at C4-C5, likely degenerative. No acute fractures are identified. Calcification of the posterior longitudinal ligament leads to very mild canal narrowing at C5-C6. Multilevel facet arthropathy and uncovertebral hypertrophy contribute to level moderate neural foraminal narrowing. There is a 3 mm hypodensity in the right thyroid lobe. The visualized lung apices are clear. IMPRESSION: 1. No acute fractures identified. 2. No prior imaging available for comparison, however there is no definite evidence of traumatic malalignment. There is widening of the right facet joint at C4-C5, likely degenerative. 3. Multilevel degenerative change including uncovertebral hypertrophy and facet arthropathy as described above. 4. 3 mm nodule in the right thyroid lobe for which no follow-up is recommended per ACR criteria. 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 torso. INDICATION: ___ s/p fall// ? injury TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 889 mGy-cm. COMPARISON: CT abdomen pelvis ___. FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. Heart size is top-normal. The pericardium, and great vessels are within normal limits. No pericardial effusion is seen. Note is made of mitral annular and aortic valve calcifications. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There are subtle bibasilar ground-glass opacities which likely reflect atelectasis, aspiration not excluded. In addition, there is bibasilar atelectasis. There is a 8 mm pulmonary nodule noted in the left lower lobe (2:69). More anteriorly, loss of in the left lower lobe there is a second 6 mm nodule, stable from prior (02:75). The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Sub 3 mm hypodensities are noted in the right thyroid lobe. Partially visualized portions of the neck are otherwise unremarkable. ABDOMEN: HEPATOBILIARY: There are numerous sub-centimeter hypodensities within the hepatic parenchyma, too small to characterize. The liver otherwise demonstrates homogenous attenuation throughout. There is no evidence of suspicious focal lesion or laceration. There is no evidence of intrahepatic biliary dilatation. Prominence of the common hepatic duct likely reflects cholecystectomy status. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesion or laceration. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is stable simple cysts bilaterally. Additional subcentimeter hypodensities are too small to characterize but are favored to represent simple cysts. There is no evidence of suspicious focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is small to moderate hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no evidence of mesenteric injury. There is no free fluid or free air in the abdomen. PELVIS: Very mild hyperemia of the anterior bladder wall with associated subtle fat stranding is improved in comparison to ___. Urinary bladder and distal ureters are otherwise unremarkable. There is no free fluid in the pelvis REPRODUCTIVE ORGANS: The uterus is unremarkable. Multiple surgical clips are noted in the pelvis. Adnexa are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Extensive atherosclerotic disease is noted. An IVC filter is again noted. BONES: There are multilevel moderate to severe degenerative changes about the thoracolumbar spine. There is an unchanged anterior compression deformity at L1. There is an unchanged fracture deformity of the inferior right pubic ramus. Chronic appearing deformities of the anterolateral left sixth through ninth ribs are more conspicuous from prior. SOFT TISSUES: There is a small fat containing ventral hernia. Calcification overlying the left gluteal muscles likely reflects injection granuloma. Visualized soft tissues are otherwise unremarkable. IMPRESSION: 1. No evidence of acute traumatic injury in the chest abdomen or pelvis. 2. Chronic appearing deformities of the anterolateral left sixth through ninth ribs are more conspicuous from prior, clinical correlation for site of pain is recommended. 3. Subtle ground-glass opacities at the lung bases may reflect aspiration. Mild to moderate hiatal hernia. 4. Pulmonary nodule in the left lower lobe are stable from prior. 5. 3 mm right thyroid nodules. No follow-up is recommended per ACR criteria. 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. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Rib pain, s/p Fall Diagnosed with Weakness temperature: 98.8 heartrate: 76.0 resprate: 16.0 o2sat: 98.0 sbp: 161.0 dbp: 67.0 level of pain: 10 level of acuity: 2.0

====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You had a fall and there was concern that you had an abnormal heart rhythm. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had a CAT scan of your head, neck, and chest/abdomen which showed no fractures or injuries. - You had EKGs which showed that while your heart rate was slow while you were here. This was thought to be due to the metoprolol that you were taking, so we discontinued it. You should continue to follow up with your PCP about this. - You urine showed signs of infection, you should continue to take your home antibiotics for this as discussed with your infectious disease doctor. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dehydration/ failure to thrive Major Surgical or Invasive Procedure: ___ EGD with post pyloric feeding tube placement History of Present Illness: Mr. ___ is a ___ y/o male who was recently admitted to transplant surgery for concerns of gallbladder malignancy and is s/p subcostal incision and intraoperative cholangiogram who was recently admitted to transplant surgery for concerns about gallbladder malignancy and underwent subcostal incision revealing perforated gallbladder with normal filling of biliary ducts via intraoperative cholangiogram (___). Patient was placed on Cipro X 1 week (GNR, no speciation). His post-operative course was c/b ileus requiring NPO/NGT decompression. Patient was discharged on ___. He had urinary retention prior to his operation and had a legbag and f/u with an urologist. Additionally his anti-HTN medications were reduced as he was stable on low doses of metoprolol. He was seen by the urologist and failed his voiding trial. He was also seen by his PCP for dizziness and hypotension. There do not seem to be any changes to his anti-HTN meds and his hypotension was treated with IVF hydration. He was seen in clinic on ___ and was complaining of nausea and poor appetite. He presented with hypotension, and his SBP was in the ___ during this encounter. He was admitted directly from clinic to the floor for further evaluation and management. Past Medical History: CAD: -___: CABG (LIMA-LAD, SVG-OM1 and OM2, SVG-rPDA) -___: IMI, BMS to SVG-OM c/b ISR s/p 3 DES to SVG-OM -___: MI s/p thrombectomy and BMS to SVG-OM PAD s/p right SFA PTA/stent ___ Hypertension Hyperlipidemia CKD BPH Hx ventral hernia Hx ampullary adenoma s/p endoscopic resection in ___ S/p partial colectomy in ___ (performed prophylactically due to attenuated FAP) Social History: ___ Family History: - Multiple family members with ___ cancer - Father ___ Disease - Maternal Aunt ___ Cancer - Mother ___ Cancer; ___ Cancer; Coronary Artery Disease; Gynecologic Cancer - Sister ___ Cancer(2) Physical Exam: Vitals: Temp 98.3 HR 68 BP 134/58 RR 18 SpO2 100% RA GEN: A&O, NAD, interactive and cooperative HEENT: No scleral icterus CV: RRR, normal S1 and S2, no murmurs/rubs/gallops PULM: Clear to auscultation bilaterally ABD: Soft, nondistended, nontender, no palpable masses, well-healed surgical scars, dressing on R abdomen clean/dry/intact Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 07:05AM BLOOD WBC-6.5 RBC-3.80* Hgb-11.4* Hct-35.7* MCV-94 MCH-30.0 MCHC-31.9 RDW-13.8 Plt ___ ___ 11:30AM BLOOD WBC-8.5 RBC-4.42*# Hgb-13.1*# Hct-41.8# MCV-95 MCH-29.6 MCHC-31.2 RDW-14.0 Plt ___ ___ 11:30AM BLOOD Neuts-58.4 ___ Monos-7.4 Eos-2.2 Baso-0.6 ___ 07:05AM BLOOD Plt ___ ___ 11:30AM BLOOD Plt ___ ___ 07:05AM BLOOD Glucose-105* UreaN-5* Creat-0.6 Na-140 K-4.4 Cl-107 HCO3-27 AnGap-10 ___ 11:30AM BLOOD Glucose-110* UreaN-10 Creat-0.9 Na-136 K-4.9 Cl-100 HCO3-28 AnGap-13 ___ 07:20PM BLOOD ALT-21 AST-19 AlkPhos-79 TotBili-0.5 ___ 11:30AM BLOOD ALT-28 AST-28 AlkPhos-99 TotBili-0.7 ___ 07:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.7 ___ 11:30AM BLOOD Albumin-4.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Tamsulosin 0.4 mg PO HS 4. Atorvastatin 80 mg PO DAILY 5. Metoprolol Succinate XL 200 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO HS 7. Finasteride 5 mg PO DAILY 8. Lisinopril 5 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy 11. Nitroglycerin SL 0.3 mg SL PRN chest pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy 5. Acetaminophen 650 mg PO Q6H:PRN pain 6. Tube Feed Jevity 1.5 continuous at 60cc/hour via post pyloric feeding tube Supply: 1 month Refill: 3 7. Nystatin Oral Suspension 5 mL PO QID swish and swallow RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp ___ Milliliter Refills:*1 8. Nitroglycerin SL 0.3 mg SL PRN chest pain 9. Tamsulosin 0.4 mg PO HS 10. Atorvastatin 80 mg PO DAILY 11. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 12. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Dehydration Failure to thrive Esophagitis/gastritis Urinary retention Incision wound s/p ccy/esophagogastroduodenostomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with hypotension // eval for pneumonia COMPARISON: ___. FINDINGS: AP portable upright view of the chest. Overlying EKG leads are present. Midline sternotomy wires and mediastinal clips are noted. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. IMPRESSION: No acute intrathoracic process Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ man with hypotension and anorexia status post ex lap for perforated cholecystitis, evaluate for intraabdominal infection/ abscess. TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis after the administration of intravenous contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. Oral contrast was administered. DLP: 454 mGy-cm COMPARISON: CT abdomen and pelvis ___. FINDINGS: CHEST: The visualized lung bases are clear. The heart is normal in size and there is no evidence of pericardial effusion. Coronary artery calcifications and mitral annular calcification are noted. ABDOMEN: The liver enhances homogeneously and is without focal lesions. The portal venous system is patent. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. A 1.3 x 0.8 cm fluid collection in the surgical bed has decreased in size from ___ (02:22). Mild stranding in the postsurgical bed has also improved. No drainable fluid collection is identified. The spleen is unremarkable. The pancreas is atrophic. The adrenal glands are unremarkable. The kidneys display symmetric nephrograms and excretion of contrast. There are no focal renal lesions. There is no hydronephrosis. The ureters are normal in caliber and course to the bladder. The patient is status post colectomy. Oral contrast extends from the small bowel to the J pouch. The distal esophagus is normal without a hiatal hernia. The stomach is grossly unremarkable in appearance. Small bowel loops are air and fluid filled and have overall decreased in caliber from ___. There is no abdominal free air. There are dense calcification of the abdominal aorta without aneurysmal dilation. A short stent is seen in the right common iliac artery. There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. There is no free abdominal fluid or pneumoperitoneum. PELVIS: A Foley catheter is seen within the bladder. There is bladder wall thickening. Air within the bladder is likely from instrumentation. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is identified. OSSEOUS STRUCTURES: Mild, multifactorial degenerative changes are seen within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion concerning for malignancy. SOFT TISSUES: In the right upper quadrant, there are postsurgical changes including soft tissue stranding and fluid in the anterior abdominal musculature, which has overall improved from ___. There is no drainable fluid collection. Surgical staples have been removed, but skin defects persists (2:27,34,42). IMPRESSION: 1. Nondilated loops of air/fluid small bowel with oral contrast extending to the J-pouch, overall improved from ___. 2. Improved postsurgical changes including decreased fluid in the gallbladder fossa and mild decrease in heterogeneity/stranding in right upper anterior abdominal wall musculature. 3. No evidence of intra-abdominal abscess/drainable fluid collection. 4. Bladder wall thickening, recommend correlation with urinalysis. NOTIFICATION: Changes to WET READ impression #4 were discussed with Dr. ___ by Dr. ___ on the day of the exam. Radiology Report INDICATION: ___ year old man with recent 50 pound weight loss, recent washout/GB stump oversewing for perforated gallbladder c/b ileus, presenting now w hypotension, dehydration, FTT // Assess swallow TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. COMPARISON: None FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration or penetration. IMPRESSION: No evidence of aspiration or penetration. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report EXAMINATION: Esophagram INDICATION: ___ year old man s/p washout/GB stump oversewing for perforated gallbladder c/b ileus, now w hypotension, dehydration, FTT 50 pound weight loss rule out motility issues vs anatomic problem // Please perform Barium swallow following video swallow per GI recommendations TECHNIQUE: Barium esophagram. COMPARISON: None FINDINGS: The esophagus was not dilated. There was no stricture within the esophagus. There was no esophageal mass. The esophageal mucosa appears normal. The primary peristaltic wave was normal, with contrast passing readily into the stomach. The lower esophageal sphincter opened and closed normally. There was no gastroesophageal reflux. There was no hiatal hernia. IMPRESSION: Normal esophagram. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p EGD // Please assess position of post-pyloric feeding tube. Thanks Please assess position of post-pyloric feeding tube. Thanks IMPRESSION: The post pyloric feeding tube extends beyond the ligament of Treitz into the proximal jejunum. Otherwise little change from the study of ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: DEHYDRATION, Hypotension Diagnosed with ANOREXIA temperature: 98.0 heartrate: 68.0 resprate: 20.0 o2sat: 98.0 sbp: 80.0 dbp: 48.0 level of pain: 0 level of acuity: 1.0

AllCare ___ and Home Solutions have been arranged to provide tube feeding supplies and assist you with managing the feedings. Please call Dr. ___ ___ if you have any of the following: temperature of 101, shaking chills, nausea, vomiting, abdominal pain, diarrhea, clogging of feeding tube, continued weight loss Continue tube feeds as instructed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ F pharmacy student with recent diagnosis of sickle cell disease who presents with back pain since ___. The pain is in her mid-upper back and worse with flexion. It started out as mild pain, and she did not present for medical evaluation initially since it had coincided with the onset of menses, and she felt it could be menstrual pain. However, her pain worsened and persisted, which was inconsistent with her typical menstrual cramps, and she became concerned for a sickle cell crisis, so she came in to be evaluated. Of note, she has not had any fever, chills, dyspnea, chest pain, N/V/D, rash, bleeding (other than menses), vision changes, numbness, tingling, weakness. In the ED initial vitals were: 97.8 95 107/56 16 100% - Labs were significant for WBC 11, HCt 23.5, LDH 774 - Patient was given 3mg IV dilaudid, 30mg MS ___, 1 U pRBC Vitals prior to transfer were: 98 72 104/71 16 100% On the floor she reports feeling well, but thinks her pain is worsening since she received pain medications several hours ago. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: - Sickle cell disease: HbA 45%, HbS 55%, HbC 0% * ___: Index admission with diffuse arthralgias, low back pain, chest pain, fever. Found to have hemolysis and elecrophoresis confirmed HbS. * ___: Started on hydroxyurea * ___: Admitted with acute chest syndrome * ___: Arm pain - Overactive bladder - Sensorineural hearing loss Social History: ___ Family History: - Sister: ___. Healthy - Mother: Healthy - Father: ___ from father but reports he is healthy. Father has a daughter with a different mother who ___ has sickle cell disease. - No family history of heart disease, cancer, or hemoglobinopathy Physical Exam: ON ADMISSION: =============================== Vitals - T 99.5 BP 126/74 HR 88 RR 20 SpO2 98% on RA Weight (bed): 55.8 kg GENERAL: Well appearing young female in no apparent distress HEENT: EOMI, MMM CARDIAC: RRR, no m/r/g LUNG: CTAB BACK: No tenderness to palpation of spinous processes or paraspinal muscles. Minimal tenderness to percussion of lower thoracic spine. ABDOMEN: Soft, nontender. Unable to palpate spleen EXTREMITIES: WWP, nonedematous NEURO: A&OX3. Moving all four extremities. Follows commands SKIN: No rashes. ON DISCHARGE: ================================== Vitals: T99.5 BP126/74 P88 RR20 98% General: Alert, pleasant, no acute distress. HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear. Neck: Supple, no lymphadenopathy. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. Chest: Area under breasts nontender to palpation. Back: Spinous processes nontender to palpation, paraspinal muscles nontender to palpation. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: +BS, soft, nondistended, nontender to palpation. No hepatosplenomegaly. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes. Neuro: Grossly intact. Pertinent Results: ON ADMISSION: ========================================== ___ 05:45PM BLOOD WBC-11.2* RBC-2.29* Hgb-7.7* Hct-23.5* MCV-103* MCH-33.8* MCHC-32.9 RDW-20.5* Plt ___ ___ 05:45PM BLOOD Neuts-57 Bands-0 ___ Monos-6 Eos-3 Baso-0 Atyps-1* ___ Myelos-0 NRBC-4* ___ 05:45PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+ Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-2+ Target-2+ Sickle-3+ ___ 05:45PM BLOOD ___ PTT-28.3 ___ ___ 05:45PM BLOOD Ret Man-18.1* ___ 05:45PM BLOOD Glucose-83 UreaN-6 Creat-0.5 Na-137 K-5.1 Cl-102 HCO3-25 AnGap-15 ___ 05:45PM BLOOD LD(LDH)-774* ___ 05:45PM BLOOD Calcium-9.3 Phos-4.7* Mg-2.0 ___ 05:45PM BLOOD Hapto-<5* ON DISCHARGE: ========================================== ___ 06:10AM BLOOD WBC-10.2 RBC-2.53* Hgb-8.2* Hct-25.9* MCV-102* MCH-32.6* MCHC-31.8 RDW-19.8* Plt ___ ___ 06:10AM BLOOD Glucose-76 UreaN-6 Creat-0.4 Na-136 K-4.3 Cl-102 HCO3-25 AnGap-13 ___ 06:10AM BLOOD LD(LDH)-532* ___ 06:10AM BLOOD Calcium-8.2* Phos-4.8* Mg-1.9 ___ 06:10AM BLOOD Hapto-<5* STUDIES: ========================================== CXR (___) No acute findings in the chest. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Morphine SR (MS ___ 30 mg PO Q12H 2. Docusate Sodium 100 mg PO BID 3. FoLIC Acid 5 mg PO DAILY 4. Hydroxyurea 1000 mg PO DAILY 5. Senna 8.6 mg PO BID:PRN constipation 6. Cyanocobalamin ___ mcg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY 8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Discharge Medications: 1. Cyanocobalamin ___ mcg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. FoLIC Acid 5 mg PO DAILY 4. Hydroxyurea 1000 mg PO DAILY 5. Magnesium Oxide 400 mg PO DAILY 6. Morphine SR (MS ___ 30 mg PO Q12H 7. Senna 8.6 mg PO BID:PRN constipation 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Sickle cell disease, acute pain episode 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 ___ ___. CLINICAL HISTORY: Sickle cell disease with back pain, question pneumonia. FINDINGS: PA and lateral views of the chest provided demonstrate no focal consolidation, effusion or pneumothorax. Cardiomediastinal silhouette appears normal and stable. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: No acute findings in the chest. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: SICKLE CELL Diagnosed with HB-SS DISEASE W/CRISIS temperature: 97.8 heartrate: 95.0 resprate: 16.0 o2sat: 100.0 sbp: 107.0 dbp: 56.0 level of pain: 9 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. As you know, you came in with back pain. This is due to an acute pain episode from your sickle cell disease. We believe your peroid may have been the trigger of this episode. We treated you with IV fluids and IV pain medications. As you were feeling better, we will discharge you on a higher dose of oxycodone (short-acting pain medication) for a few days until your pain further improves. We encourage you to talk to your primary care physician and hematologist about starting birth control as a way to decrease your acute pain episodes. We glad you are feeling better and we wish you a happy birthday!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Cervical hardware failure s/p c3-t9 fusion with wound dehiscence. Major Surgical or Invasive Procedure: ___ - Wound revision History of Present Illness: ___ with hx of ankylosing spondylitis s/p C3-T9 fusion for C7-T5-T6 fracture after fall down stairs on ___. Postoperatively he remained in TLSO brace until ___. He was seen in follow-up on ___ at that time he had a small opening in his incision with no signs of infection. The patient at that visit was noted to be cachectic and instrumentation was palpable through the skin, but there was no breakdown. He was referred for x-ray which showed hardware failure. Patient is currently demonstrating improvement- PEG is still in place but began taking medication by mouth and slowly advancing diet. Patient currently walks ___ FT with a walker. Patient reports slight tingling to his hands and feet. Foley catheter still in place. Denies any pain. Past Medical History: HTN HLD Prior epidural hematoma and T9-S1 spinal fusion spinal fusion T9-S1, prostetic hip, hernia repair Social History: ___ Family History: Non-contributory Physical Exam: 9On Admission: ___ ============================ Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G R 4 5 4 5 5 4 4 4 5 3 5 L 4 5 4 5 5 4 4 4 5 5 5 Bilater finger intrinsics ___ Bilateral grip ___ No ___, no clonus ON DISCHARGE: ___ ========================= General: ___ ___ Temp: 97.8 PO BP: 105/67 R Lying HR: 90 RR: 30 O2 sat: 95% O2 delivery: 1.5L Bowel Regimen: [x]Yes [ ]No Last BM: ___ Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip Right54-4+4+4+ Left54+554+ IPQuadHamATEHLGast Right4+ 4 4+ 5 5 5 Left4+ 4+ 4+ 5 5 5 [no]Clonus ___ [x]Sensation intact to light touch Wound: - Palpable hardware in cervical spine, no pain to palpation, no skin tenting or breakdown. - Revised wound: [x]Clean, dry, intact, no active drainage noted. Small portion of superior aspect of incision with separation. [x]Sutures in place Pertinent Results: See OMR for pertinent results Medications on Admission: Atropine prn secretions Pantoprazole 40mg qday Levalbuterol TID Melaotonin 9mg qhs Mirtazapine 15mg Qday Sevelamer Carbonate 0.8g oral powder TID Tamsulosin 0.4mg qday trazodone 25mgqhs albuterol sulfate nebs Q4hr prn Zofran 4mg PRN Oxycodone 5mg PRN Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4G per day. 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/SOB 3. Atropine Sulfate 1% 1 DROP SL DAILY:PRN excessive secretions 4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 5. Docusate Sodium 100 mg PO BID 6. Heparin 5000 UNIT SC BID 7. Lidocaine 5% Patch 1 PTCH TD QPM 8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth Q6hrs Disp #*20 Tablet Refills:*0 9. Ramelteon 8 mg PO QPM:PRN insomnia 10. Senna 17.2 mg PO QHS 11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days Start date ___ end date ___ 12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 13. Mirtazapine 15 mg PO DAILY 14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity 15. sevelamer CARBONATE 800 mg PO TID W/MEALS 16. Tamsulosin 0.4 mg PO QHS 17. TraZODone 25 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: C3-t9 fusion with interval cervical spine hardware failure 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: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE. INDICATION: ___ year old man with ankylosing spondylitis, prior c3-T9 fusion presents from ___ with interval hardware failure// preoperative planning for ___ OR hardware revision. preoperative planning for ___ OR hardware revision. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. COMPARISON: CT whole spine ___. FINDINGS: CERVICAL: The moderate to severe C7 vertebral body compression fracture is unchanged. There is no retropulsion, however disc protrusion remains unchanged causing anterior thecal sac deformity, there is no evidence of lesion or abnormal signal within the spinal cord at this level. C2-C3: Posterior disc bulge and ligamentum flavum thickening causing mild spinal canal narrowing. No neural foraminal stenosis. C3-C4: Posterior disc bulge and ligamentum flavum thickening causing mild spinal canal narrowing. Mild right neural foraminal narrowing. C4-C5: Posterior disc bulge and ligamentum flavum thickening causing moderate spinal canal narrowing. Mild right neural foraminal narrowing. C5-6: Posterior disc bulge and ligamentum with thickening within mild spinal canal narrowing and moderate right neural foraminal narrowing. C6-C7: Posterior disc bulge not causing spinal canal or neural foraminal stenosis. C7-T1: Posterior disc bulge indenting the thecal sac, not causing significant spinal canal or neural foraminal narrowing. Alignment is normal. There is mild loss of intervertebral disc height at C5-C6. Vertebral body and intervertebral disc signal intensity otherwise appear normal.The spinal cord appears normal in caliber and configuration. There is a fluid collection posterior to the posterior elements of C4 and C5, in the left side of the neck, measuring 23 mm (SI) x 6.7 mm (AP) x 23 mm (TV). This may be postoperative in nature and may represent a seroma. Does the patient have any symptoms or signs of infection? THORACIC: Chronic T6 and T12 vertebral body fractures with retropulsion and associated retrolisthesis T5 on T6 and T11 on T12, appear unchanged. The spinal cord is deviated at the level of retropulsion at T6, but there is no spinal cord compression. No definite T2 hyperintensity is identified within the cord.Vertebral body and intervertebral disc signal intensity appear normal. There is no evidence of infection or neoplasm. Note is made of a loculated right pleural effusion, which is chronic. LUMBAR: Chronic L2, L3 and L4 vertebral fractures. Vertebroplasty at L3 and L4. Appearances are unchanged. The spinal cord appears normal in caliber and configuration, on terminates at L1-L2 level.There is no evidence of infection or neoplasm. L1-L2: Diffuse disc bulge causing mild spinal canal narrowing. No neural foraminal narrowing. L2-L3: Diffuse disc bulge causing mild spinal canal narrowing. No neural foraminal narrowing. L3-L4: Central disc/posterior osteophyte causing mild-to-moderate spinal canal narrowing. Bilateral facet joint arthropathy causing moderate bilateral neural foraminal narrowing. L4-L5: Posterior osteophyte and ligamentum flavum thickening causing moderate spinal canal narrowing. In association with bilateral facet joint arthropathy there is bilateral neural foraminal narrowing, moderate on the right and mild on the left. L5-S1: Diffuse disc bulge causing mild spinal canal narrowing. There is no significant neural foraminal narrowing. OTHER: There is a 1.8 cm right adrenal mass, which is not fully characterized on this MRI and may represent an adrenal adenoma. Note is made of bilateral simple renal cysts. IMPRESSION: 1. Chronic T6 vertebral body fracture with retropulsion associated retrolisthesis of T5 and T6, with deviation of the cord at this level but no frank evidence of cord compression, there is persistent CSF fluid surrounding the cord at the level of the retropulsion. 2. No change compared with previous, post spinal fusion. 3. Fluid collection noted in the left posterior neck posterior to C4 and C5. This may represent a postoperative seroma. Does the patient have any symptoms or signs of infection? Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old man with c3-t9 fusion, ankylosing spondylitis, HTN, HLD, now failure of cervical hardware.// Preop for cervical hardware removal, exploration of wound. Surg: ___ (cervical removal of hardware, wound exploration) IMPRESSION: In comparison with the study of ___, there is little overall change and no evidence of acute pneumonia. In extensive cervical, thoracic, and lumbar hardware remain in place. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with tachycardia and new cough// Rule out pneumonia TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: Low lung volumes are noted. There are small bilateral pleural effusions. No focal consolidation or pneumothorax is identified. The cardiomediastinal silhouette is stable in appearance. There is no pulmonary edema. Spinal hardware and osseous structures are unchanged in appearance. Radiology Report EXAMINATION: CTA CHEST ___ INDICATION: ___ year old man hx of prior C3-T9 fusion, T6 laminectomy presents with hardware failure. patient with persistent tachycardia, chest pain, and desaturation, concern for PE// Evaluate for PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.5 s, 33.2 cm; CTDIvol = 13.4 mGy (Body) DLP = 443.2 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 4) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 23.2 mGy (Body) DLP = 11.6 mGy-cm. Total DLP (Body) = 458 mGy-cm. COMPARISON: Chest CTA ___ FINDINGS: CHEST PERIMETER: No incidental thyroid findings. No supraclavicular or left axillary adenopathy. There may be a new 13 mm right subpectoral lymph node. 301:107. No other soft tissue abnormalities in the chest wall. This study is not appropriate for subdiaphragmatic diagnosis but shows no subphrenic collection or adrenal mass. CARDIO-MEDIASTINUM: Esophagus is unremarkable. Atherosclerotic calcification mild in head and neck vessels, is heavy in at least left anterior descending coronary artery. Minimally calcified ascending thoracic aorta normal caliber. Pericardium is physiologic. PULMONARY ARTERIES: Pulmonary arteries are enlarged, main 35 mm, right 29 mm, previously 34 mm and 31 mm. No pulmonary emboli to the segmental level. THORACIC LYMPH NODES: No lymph nodes in the chest are pathologically enlarged or growing. LUNGS, AIRWAYS, PLEURAE: Moderate, right and small left, generally dependent nonhemorrhagic pleural effusions, including the right fissural component are comparable in volume to that on ___. No pleural mass or hematoma. Moderate atelectasis, posterior segment right upper lobe and severe atelectasis right basal lower lobe segments unchanged. No bronchial obstruction. CHEST CAGE: No interval change except for slight progression of callus formation in multiple healing fractures of the chest cage. No new fractures or evidence of chest wall infection. No migration of stabilized thoracic spine trauma or hardware. IMPRESSION: No pulmonary embolism. Chronic pulmonary hypertension. Moderate right and small left pleural effusions stable or recurrent. Stable atelectasis, moderate, right upper and severe, right lower lobes. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Neck pain Diagnosed with Cervicalgia temperature: 97.4 heartrate: 90.0 resprate: 18.0 o2sat: 97.0 sbp: 100.0 dbp: 54.0 level of pain: 0 level of acuity: 3.0

Discharge Instructions Surgery · Your dressing came off on the second day after surgery. · Your incision is closed with sutures. You will need suture removal. Please keep your incision dry until suture removal. · Do not apply any lotions or creams to the site. · Please avoid swimming for two weeks after suture removal. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · No contact sports until cleared by your neurosurgeon. Medications · Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · *** You may take Ibuprofen/ Motrin for pain. · You may use Acetaminophen(Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. · It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · New weakness or changes in sensation in your arms or legs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fevers Major Surgical or Invasive Procedure: Central venous line placement (IJ) ___ Bone marrow biopsy ___ Skin biopsy over dorsum of right foot ___ History of Present Illness: Ms. ___ is a ___ with no PMH who was recently seen in ED ___ for c/o fever who was discharged with diagnosis of viral illness and monospot was negative. She returns to the ED today with reported fever of 103.1. Patient reports 2 weeks of fever, chills, arthralgias, night sweats and sore throat associated with general myalgia and mild abdominal pain. Patient has been taking Tylenol and Ibuprofen with temporary resolution of most of her symptoms. Patient was seen 4 times at ___ in addition to ED on ___. Also notes chest pain and SOB when having fever. Patient also notes chest pain during fever and night sweats as well as an itchy rash on her extremities that comes and goes. Patient also says she has some positional dizziness, conjunctivitis, joint pain in hands, and nonbloody diarrhea. Patient not certain if she has weight loss. Patient reports that vaccines are up to date, and is not sure she had TB testing. In the ED, her initial vitals were: 99.4 ___ 20 97%. Her initial labs were significant for a normal WBC, H/H 11.3/33.6, PLT 138, normal Chem7, transaminitis with ALT/AST 86/139 (nl AP, last TB 0.3 on ___, LDH 656, Ca 8.3, CRP 101.4. bHCG negative. Lactate 1.4. While in the ED, she had a negative monospot and a preliminary ID work-up with initiated. She was started on empiric doxycycline given the report that she was recently in ___ and that she was spending time at a farm. She denies any sick contacts, no hx of infectious mono. No new foods or medication. She reports having a diffuse maculopapular rash that appears when she has high fevers or a hot shower, itchy, self resolves in an hour. No other complaints reported. She was initially admitted to the Medicine floor for further workup of FUO, including CT of her neck, chest, abdomen, and pelvis. Her vitals on arrival to the floor were T: 101.5 BP: 113/77 HR: 98 RR: 26 02 sat: 100%RA. Shortly after admission, she became hypotensive with SBPs in the ___ and was transferred to the MICU for septic shock. She had received roughly 7L IVF upon arrival to the ICU. Of note, she was briefly treated with peripheral Neo and Levo during transport. Past Medical History: None Social History: ___ Family History: No family history of autoimmune illness, cancers, heart or respiratory conditions. Parents are alive and healthy in ___. ___ grandparents are alive and well; patient unsure what the ___ died from. Physical Exam: Admission physical exam Vitals: T 101.5 BP 113/77 HR 98 RR 26 02 sat 100%RA GENERAL: rigoring in bed, worse when blankets pulled back or with movement, better with relaxation, anxious affect though pleasant and cooperative, NAD HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva, MMM, clear OP without ulcers or lesions, good dentition NECK: markedly tender on palpation of her tonsils allowing only limited exam, remainder of neck with small tender adenopathy, no thyromegaly CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, slightly tachypneic, better with reassurance ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose, no stigmata of endocarditis PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, ___ strength ___ though this seems effort-dependent SKIN: warm and well perfused, no excoriations or lesions, no rashes at this time. DISCHARGE PHYSICAL EXAM: Vitals: 98.5F 98/50 60 18 100%RA General: well-appearing, NAD HEENT: PERRL, sclera clear Neck: no LAD Lungs: CTAB, no crackles or wheezes. no cough with deep insiration CV: RRR, nl S1,S2, no murmurs, rubs, or gallops Abdomen: soft, non-tender, non-distended, no rebound or guarding Neuro: CN II-XII intact, passive and active ROM of the wrists, MCP joints intact, strength ___ UE bilaterally Pertinent Results: On admission: ___ 07:01PM BLOOD WBC-11.8* RBC-3.64* Hgb-11.3* Hct-32.5* MCV-89 MCH-31.1 MCHC-34.8 RDW-12.6 Plt ___ ___ 11:59PM BLOOD Neuts-81* Bands-11* Lymphs-5* Monos-1* Eos-0 Baso-0 ___ Metas-2* Myelos-0 ___ 11:59PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL Tear Dr-OCCASIONAL ___ 11:59PM BLOOD ___ PTT-76.1* ___ ___ 07:09PM BLOOD Lactate-3.2* ___ 06:02AM BLOOD CRP-101.4* ___ 06:02AM BLOOD ___ * Titer-1:40 ___ ___ 08:00AM BLOOD ___ Echo: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Borderline pulmonary hypertension. ___. Prominent cervical lymph nodes bilaterally. These may be reactive in nature however exact etiology is difficult to determine. 2. The right sternocleidomastoid muscle is enlarged and there is some stranding posteriorly, likely due to central line placement ___ CT A/P 1. Prominent cervical lymph nodes bilaterally. These may be reactive in nature however exact etiology is difficult to determine. 2. The right sternocleidomastoid muscle is enlarged and there is some stranding posteriorly, likely due to central line placement ___ CT chest 1. Moderate nonhemorrhagic, bilateral pleural effusions with adjacent atelectasis. 2. Significant consolidations within the left and right lower lobes. Findings may represent lobar atelectasis, however, superimposed infection cannot be excluded. 3. Non-obstructing, right hilar lymphadenopathy. 4. Enlarged thymus, probably reactive. Significant Labs: ___ 01:41AM BLOOD IgG-746 IgA-164 IgM-59 ___ 08:00AM BLOOD RheuFac-12 ___ 06:02AM BLOOD ___ * Titer-1:40 ___ ___ 06:02AM BLOOD CRP-101.4* ___ 10:00AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE IgM HAV-NEGATIVE ___ 05:50AM BLOOD Cortsol-2.4 ___ 05:50AM BLOOD TSH-1.2 ___ 06:00AM BLOOD Ferritn-1506* Discharge labs: ___ 07:30AM BLOOD WBC-15.1* RBC-3.36* Hgb-10.2* Hct-30.6* MCV-91 MCH-30.4 MCHC-33.4 RDW-16.3* Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 06:00AM BLOOD ___ ___ 07:30AM BLOOD Glucose-96 UreaN-11 Creat-0.3* Na-138 K-4.1 Cl-101 HCO3-28 AnGap-13 ___ 06:00AM BLOOD ALT-134* AST-67* LD(LDH)-447* AlkPhos-104 TotBili-0.5 ___ 07:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, discomfort Discharge Medications: 1. anakinra 100 mg SC DAILY RX *anakinra [Kineret] 100 mg/0.67 mL 1 syringe daily Disp #*30 Syringe Refills:*2 2. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*2 3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Vitamin D 400 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, discomfort 6. Calcium Carbonate 500 mg PO DAILY RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. PredniSONE 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hemophagocytic Lymphohistiocytosis, Adult Onset Still's Disease Secondary Diagnosis: Shock, Acute Kidney Injury, Disseminated Intravascular Coagulation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ yo woman with persistent fevers of unclear etiology x 2 weeks. // pneumonia? TECHNIQUE: PA and lateral images of the chest. COMPARISON: None. FINDINGS: The lungs are well expanded and clear. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: Q22 INDICATION: ___ year old woman with FUO now having hypotensive episodes // ? Lemierre's or intra-abdominal or intra-thoracic infection or malignancy TECHNIQUE: MD CT axial imaging of the neck were obtained following the administration of intravenous contrast material. Coronal and sagittal reformats were completed. DOSE: DLP: 378.9mGy-cm; CTDI: 10.2 mGy COMPARISON: None. FINDINGS: There are prominent level 2B, 5A and 5B lymph nodes bilaterally. There is no abscess or drainable fluid collection within the neck. The neck vessels enhance normally and are patent. The parotid and submandibular glands are unremarkable. The visualized intracranial structures are unremarkable. The paranasal sinuses and mastoid air cells are clear. The right sternocleidomastoid muscle is enlarged and there is some stranding posteriorly, likely due to central line placement. Please see the dedicated chest CT report for further details regarding intrathoracic findings. IMPRESSION: 1. Prominent cervical lymph nodes bilaterally. These may be reactive in nature however exact etiology is difficult to determine. 2. The right sternocleidomastoid muscle is enlarged and there is some stranding posteriorly, likely due to central line placement. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with septic shock // Evaluate IJ CVL placement Contact name: ___: ___ COMPARISON: ___ IMPRESSION: As compared to the previous radiograph, the patient has received a right-sided internal jugular vein catheter. The course of the catheter is unremarkable, the tip of the catheter projects over the cavoatrial junction. The stomach is overinflated. Obviously reflecting the known septic shock, the patient shows bilateral parenchymal opacities, with perihilar and lower lung predominance. Given the simultaneous 0 current 's of a wide and right-sided mediastinum, the changes most likely reflect hydrostatic pulmonary edema. A coexisting right pneumonia or aspiration can not be excluded. Mild cardiomegaly. No larger pleural effusions. Radiology Report INDICATION: Fever of unknown origin now hypotensive. Evaluate for intra-abdominal infection, lymphadenopathy or malignancy. TECHNIQUE: MDCT axial images were acquired through the torso after the uneventful administration of 130 mL Omnipaque. Oral contrast was not administered. Coronal and sagittal reformations were provided and reviewed. Findings in the chest are reported separately from this study. DOSE: DLP: 830.91 mGy-cm COMPARISON: None. FINDINGS: The bilateral pleural effusions and intrathoracic findings are reported separately. The liver enhances homogeneously without focal lesions. There is substantial gallbladder wall edema without additional evidence for acute cholecystitis. The spleen, pancreas and adrenal glands are unremarkable. The kidneys enhance symmetrically and excrete contrast without hydronephrosis The stomach, small and large bowel. There is no bowel wall thickening or obstruction. The appendix is air-filled (601B: 27). There is a cluster of enlarged lymph nodes centered near the cecum, which measure up to 12 mm (2:87). There is minimal fat stranding in this area as well, with thickening of the lateral conal fascia. Retroperitoneal lymph nodes are not enlarged by CT criteria but are prominent and numerous (2:78). There is no free air. The aorta is normal caliber. The portal vein, splenic vein and superior mesenteric vein are patent. There is a small amount of free pelvic fluid. The rectum is unremarkable. Air and a Foley catheter noted within the bladder. Multiple follicular cysts are seen in the both ovaries and range in size up to 11 mm. The uterus is unremarkable. There is no inguinal or pelvic sidewall lymphadenopathy. There are no lytic or blastic osseous lesions within the abdomen or pelvis. IMPRESSION: 1. Nonspecific right lower quadrant lymphadenopathy and prominent retroperitoneal lymph nodes, not amenable to biopsy. The differential is broad and includes a reactive process, lymphoma or granulomatous disease. 2. Substantial gallbladder wall edema is presumably related to volume status and hepatic dysfunction. There are no findings to suggest acute cholecystitis. 3. Bilateral pleural effusions and intrathoracic findings are reported separately. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ telephone on ___ at 11:20 AM, 30 minutes after discovery of the findings. Radiology Report EXAMINATION: CT Chest INDICATION: Fever of unknown origin, hypotension. Evaluate for infectious etiology. TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper abdomen. IV Omnipaque contrast was administered. Axial images were interpreted in conjunction with sagittal and coronal reformats. COMPARISON: Comparison is made to chest radiographs dated ___. FINDINGS: The thyroid is normal. There is mild-moderate right hilar lymphadenopathy which is nonobstructing. Axillary, supraclavicular, and mediastinal lymph nodes are not pathologically enlarged. Increased soft tissue density seen within the anterior mediastinum, likely representing an enlarged thymus. The great vessels are normal caliber. The heart size is normal. No pericardial effusion. A right internal jugular venous catheter terminates at the cavoatrial junction. There are moderate-sized, bilateral, pleural effusions with adjacent atelectasis. Significant bilateral lower lobe consolidations are noted, left greater than right, and may represent lobar atelectasis although concurrent infection is not excluded. Septal thickening is most pronounced within the right upper lobe, likely secondary to interstitial edema. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. The examination is not tailored for evaluation of the subdiaphragmatic structures. For further details, please see the concomitant dedicated CT abdomen and pelvis. IMPRESSION: 1. Moderate nonhemorrhagic, bilateral pleural effusions with adjacent atelectasis. 2. Significant consolidations within the left and right lower lobes. Findings may represent lobar atelectasis, however, superimposed infection cannot be excluded. 3. Non-obstructing, right hilar lymphadenopathy. 4. Enlarged thymus, probably reactive. Gender: F Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED, NONSPECIF SKIN ERUPT NEC, JOINT PAIN-MULT JTS temperature: 99.4 heartrate: 112.0 resprate: 20.0 o2sat: 97.0 sbp: 98.0 dbp: 65.0 level of pain: 5 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at ___. You were admitted with fever, rash and joint pain and found to have a disease called Adult Onset Still's Disease and HLH. You were treated for this problem with steroids and anakinra. You will ___ with your doctors in ___ and ___ Care Associate's here at ___ for management of this problem going forward. Plaese continue your prednisone at 50mg a day until directed to decrease the dose by your Rheumatology doctor. Best wishes, Your ___ 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: Abdominal Pain Major Surgical or Invasive Procedure: ___: Small bowel resection and repair of incarcerated umbilical hernia. History of Present Illness: Patient is a ___ year old male with PMH significant for NICM with EF 15% now recovered to >55%,HTN, COPD, AICD, CKD, and a known umbilical hernia, who is presenting today to the ED with one day of pain and swelling at the hernia site. He states that he has vomited three times this morning last one of which have been bilious. The patient underwent a CT in the ED which showed incarcerated bowel, with SBO and TP in the hernia sac. His Cr is 2.3. lactate 1.9, bicarb 24. he denies SOB, CP, fever, chills, dysuria, frequency. Past Medical History: - non-ischemic/hypertrophic cardiomyopathy with EF of 15% ___ thought to be less likely amyloidosis - severe aortic regurgitation s/p bioprosthetic aortic valve replacement - ICD placement ___ for primary prevention of sudden cardiac death - HTN - CKD (baseline Cr 1.5-2) - sellar/parasellar meningioma s/p radiation therapy (done at Mass Eye and Ear per patient, unclear dates) Social History: ___ Family History: Mother and brother with heart disease. Physical Exam: Admission Physical Exam: Vitals: 97 55 ___ 99% RA 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, nontender, midline umbilical hernia noted, irreducible, firm and TTP, with overlying skin changes Ext: No ___ edema, ___ warm and well perfused Discharge Physical exam: VS: 97.4 PO ___ 16 99 1L GEN: awake, alert, interactive. HEENT: PERRL, EOMI. CV: RRR PULM: Rhonchorus and crackles in bases. ABD: Soft, non-tender, non-distended. Surgical incision CDI with staples. EXT: Warm and dry. no edema. NERUO: A&O. follows commands and moves all extremities equal and strong. Speech is delayed, but clear. Pertinent Results: ___ 04:54AM BLOOD WBC-4.2 RBC-3.45* Hgb-10.2* Hct-33.1* MCV-96 MCH-29.6 MCHC-30.8* RDW-14.4 RDWSD-50.4* Plt ___ ___ 04:21AM BLOOD WBC-6.3 RBC-3.34* Hgb-10.2* Hct-31.7* MCV-95 MCH-30.5 MCHC-32.2 RDW-14.6 RDWSD-51.0* Plt ___ ___ 04:44AM BLOOD WBC-8.0 RBC-3.44* Hgb-10.6* Hct-32.4* MCV-94 MCH-30.8 MCHC-32.7 RDW-14.6 RDWSD-49.9* Plt ___ ___ 06:09AM BLOOD WBC-8.7 RBC-4.12* Hgb-12.6* Hct-37.7* MCV-92 MCH-30.6 MCHC-33.4 RDW-14.4 RDWSD-48.0* Plt ___ ___ 04:51AM BLOOD WBC-13.4* RBC-4.45* Hgb-13.4* Hct-42.0 MCV-94 MCH-30.1 MCHC-31.9* RDW-14.4 RDWSD-49.7* Plt ___ ___ 12:57PM BLOOD WBC-5.7 RBC-4.72 Hgb-14.5 Hct-43.7 MCV-93 MCH-30.7 MCHC-33.2 RDW-14.2 RDWSD-47.9* Plt ___ ___ 06:09AM BLOOD ___ PTT-28.7 ___ ___ 04:54AM BLOOD Glucose-108* UreaN-74* Creat-2.1* Na-153* K-3.8 Cl-110* HCO3-30 AnGap-13 ___ 06:06PM BLOOD Glucose-147* UreaN-81* Creat-2.3* Na-150* K-3.7 Cl-110* HCO3-28 AnGap-12 ___ 04:21AM BLOOD Glucose-126* UreaN-87* Creat-2.6* Na-151* K-3.9 Cl-110* HCO3-28 AnGap-13 ___ 04:44AM BLOOD Glucose-82 UreaN-95* Creat-2.8* Na-148* K-4.3 Cl-108 HCO3-26 AnGap-14 ___ 06:09AM BLOOD Glucose-125* UreaN-74* Creat-3.1* Na-145 K-4.2 Cl-102 HCO3-25 AnGap-18 ___ 04:39AM BLOOD Glucose-121* UreaN-72* Creat-3.2* Na-148* K-4.5 Cl-100 HCO3-28 AnGap-20* ___ 04:51AM BLOOD Glucose-91 UreaN-32* Creat-2.3* Na-146 K-3.5 Cl-103 HCO3-28 AnGap-15 ___ 12:57PM BLOOD Glucose-103* UreaN-30* Creat-2.3* Na-142 K-4.1 Cl-100 HCO3-24 AnGap-18 ___ 12:57PM BLOOD ALT-18 AST-28 AlkPhos-58 TotBili-0.9 ___ 04:54AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.3 ___ 06:06PM BLOOD Calcium-8.2* Phos-2.9 Mg-2.4 ___ 04:21AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.8* ___ 04:44AM BLOOD Calcium-8.1* Phos-5.0* Mg-2.9* ___ 06:09AM BLOOD Calcium-8.6 Phos-6.4* Mg-2.8* ___ 04:39AM BLOOD Calcium-8.7 Phos-6.5* Mg-2.9* ___ 04:51AM BLOOD Calcium-8.5 Phos-5.7* Mg-1.4* ___ 01:03PM BLOOD Lactate-1.9 ___ 03:09AM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG* ___ 03:09AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 03:09AM URINE Hours-RANDOM Creat-122 Na-<20 Cl-<20 Calcium-<0.8 ___ R Heel Xray: Mild irregularity of a small plantar calcaneal enthesophyte may relate to prior trauma. If there is concern for acute on chronic injury MRI can be performed. ___ CXR: Comparison to ___. The extent and severity of the pre-existing multifocal parenchymal opacities is stable. Stable moderate cardiomegaly. No new opacities. No pleural effusions. The left pectoral pacemaker is in stable correct position ___ CXR: 1. Multifocal bilateral opacities, worse on the right lung, concerning for moderate pulmonary edema. Small right pleural effusion. 2. Moderate cardiomegaly and widened mediastinum the mediastinum, likely exaggerated in current study due to positioning. ___ Xray abd: The entire abdomen is not demonstrated on plain abdominal radiographs. Partially visualized large bowel measures up to 6.6 cm which may represent ileus. The small bowel is not well delineated suggesting fluid within the intraluminal cavity better characterized on CT abdomen and pelvis dated ___. ___ CT A/P: 1. Supraumbilical ventral hernia containing small bowel loops with associated small bowel obstruction. Small amount of fluid in the hernia sac. Please correlate for incarceration. 2. Severe cardiomegaly with mild interstitial pulmonary edema. ___ 04:49AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0 UricAcd-13.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Bumetanide 2 mg PO BID 3. CARVedilol 25 mg PO BID 4. Lisinopril 40 mg PO DAILY 5. Pantoprazole 40 mg PO Q12H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Polyethylene Glycol 17 g PO DAILY 3. Aspirin 81 mg PO DAILY 4. Bumetanide 2 mg PO BID 5. CARVedilol 25 mg PO BID 6. Pantoprazole 40 mg PO Q12H 7. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until follow up with PCP. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Incarcerated umbilical hernia, with bowel ischemia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ___ or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ year old man with umbilical hernia, CKD, and NICM presenting with abdominal pain// evaluate for bowel obstruction TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered.Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 628 mGy-cm. COMPARISON: CT ___ FINDINGS: LOWER CHEST: Mild pulmonary edema is noted in the lower lungs with septal thickening and engorged vasculature. There is severe cardiomegaly which appears worsened compared to the prior study. No pleural or pericardial effusion. A intraventricular pacing lead is partially visualized. ABDOMEN: HEPATOBILIARY: The unenhanced appearance of the liver is normal. The gallbladder is unremarkable. PANCREAS: The pancreas is grossly unremarkable. SPLEEN: The spleen is normal in size. ADRENALS: No adrenal lesions. URINARY: No kidney stone or hydronephrosis. No definite worrisome renal lesion on this unenhanced exam. GASTROINTESTINAL: There is a small hiatal hernia. Multiple small bowel loops are dilated and fluid-filled. The proximal small bowel is decompressed. There is progressive small bowel dilation which can be traced to a ventral supraumbilical hernia which contains a small bowel loop. Distal to this hernia, small bowel is decompressed. A small amount of fluid is also seen within the hernia sac. The hernia neck is small measuring 14 x 17 mm, correlate for incarceration. A small amount of free fluid within the right lower quadrant (series 2, image 49). The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is trace free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: A ventral abdominal wall defect measures 1.4 x 1.7 cm. The soft tissue adjacent to the hernia demonstrates moderate stranding. IMPRESSION: 1. Supraumbilical ventral hernia containing small bowel loops with associated small bowel obstruction. Small amount of fluid in the hernia sac. Please correlate for incarceration. 2. Severe cardiomegaly with mild interstitial pulmonary edema. Radiology Report INDICATION: ___ h.o NICM, AICD, CKD with incarcerated umbilical hernia s/p SBR and hernia repair // ? ileus or obstruction TECHNIQUE: Supine abdominal radiograph was obtained. COMPARISON: Abdominal x-ray dated ___. CT abdomen and pelvis dated ___ FINDINGS: The entire abdomen is not included on the plain abdominal radiographs. The demonstrated large bowel is mildly dilated up to 6.6 cm. The small bowel is not well delineated suggesting fluid within the intraluminal cavity. There is no free intraperitoneal air. Osseous structures are unchanged. There are staples overlying the left paraspinal region. An AICD lead and inferior-most sternotomy wire is demonstrated at the inferior chest. Chronic interstitial changes are demonstrated at the lower lung fields, most pronounced on the left. IMPRESSION: The entire abdomen is not demonstrated on plain abdominal radiographs. Partially visualized large bowel measures up to 6.6 cm which may represent ileus. The small bowel is not well delineated suggesting fluid within the intraluminal cavity better characterized on CT abdomen and pelvis dated ___. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with s/p SBR, hernia repair, now with decreased BS left ant chest, crackles bases// evaluate for consolidation/interval change TECHNIQUE: Portable AP COMPARISON: Chest radiograph ___ FINDINGS: Single lead pacemaker and defibrillator projects over the right ventricle, unchanged from prior. Median sternotomy wires and round hyperdensities projecting over the mediastinum are unchanged. Multifocal patchy airspace opacities, worse on the right. No pneumothorax. Persistent widening of the vascular mediastinum, likely worsened by position. The right hemidiaphragm interface is not well seen, could be secondary to small pleural effusion cardiac size is moderately enlarged. IMPRESSION: 1. Multifocal bilateral opacities, worse on the right lung, concerning for moderate pulmonary edema. Small right pleural effusion. 2. Moderate cardiomegaly and widened mediastinum the mediastinum, likely exaggerated in current study due to positioning. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ h.o NICM, AICD, CKD with incarcerated umbilical hernia s/p SBR and hernia repair// hypoxia, evaluate heart failure vs atelectasis hypoxia, evaluate heart failure vs atelectasis IMPRESSION: Comparison to ___. The extent and severity of the pre-existing multifocal parenchymal opacities is stable. Stable moderate cardiomegaly. No new opacities. No pleural effusions. The left pectoral pacemaker is in stable correct position. Radiology Report EXAMINATION: HEEL (AXIAL AND LATERAL) RIGHT INDICATION: ___ year old man with right heel pain worse with weight bearing.// ? fracture TECHNIQUE: Two views of the right calcaneus. COMPARISON: None. FINDINGS: There is mild irregularity of a small plantar calcaneal enthesophyte. Dorsal calcaneal enthesophyte appears intact.There are mild degenerative changes of the tibiotalar, subtalar and talonavicular joints.Bone mineralization is age appropriate. IMPRESSION: Mild irregularity of a small plantar calcaneal enthesophyte may relate to prior trauma. If there is concern for acute on chronic injury MRI can be performed. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with desat in POP// Interval change TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: Median sternotomy wires are noted. There is a left chest wall AICD with a single lead terminating in the regions of the right ventricle. There are multifocal parenchymal opacities, which are not significantly changed compared to prior study. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette stable in appearance. There are no acute osseous abnormalities. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain, Nausea Diagnosed with Periumbilical pain, Athscl heart disease of native coronary artery w/o ang pctrs temperature: 97.0 heartrate: 55.0 resprate: 17.0 o2sat: 99.0 sbp: 108.0 dbp: 77.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, You were admitted to the Acute Care Surgery Service on ___ with abdominal pain and found to have a hernia that was obstructing your intestines. You underwent surgery and had your hernia repaired. After surgery your diet was gradually advanced and you were monitored closely. You are now doing better, tolerating a regular diet, and ready to be discharged to rehab to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. 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. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: postoperative abdominal pain Major Surgical or Invasive Procedure: ___ ERCP with CBD stent placement History of Present Illness: This patient is a ___ year old female status post lap cholecystectomy, POD#6 who presents to the ED with abdominal pain. The patient states the pain has been present and has persisted since the operation. The pain is diffuse in her abdomen but predominantly localized to her left sided rib cage. It radiates to both of her shoulders. She describes the pain as stabbing in nature. It is triggered by being lying on her back or positional changes. It is not meal related. She denies fever, chills, nausea, emesis, choluria, acholia. She endorses dysuria. Denies hematuria. She says that she's been more irregular with bowel movements, yet, she is passing flatus and last bm was two days ago. Upon arrival to the ED. VS: 97.8, 107 132/81, 16, 100% RA. She is no acute distress. There is not jaundice on exam. Oral mucosa is dry. Abdomen is slight obese, soft, non-distended. I could not appreciate any tenderness in the abdomen or over the rib cages. She has + CVA tenderness to the right side. ROS: (+) per HPI (-) Denies pain, fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: Past Medical History: Acne, obesity with weight loss. Past Surgical History: Per HPI. Dental implants Social History: ___ Family History: Family history is negative for gallstones. Physical Exam: VS: 98.1 ___ GEN: A&Ox3, NAD, resting comfortably HEENT: NCAT, EOMI, sclera anicteric CV: RRR PULM: no respiratory distress ABD: soft, NT ND, no rebound or guarding EXT: warm, well-perfused, no edema PSYCH: normal insight, memory, and mood WOUND(S): Incision c/d/i Pertinent Results: ___ 07:20AM BLOOD WBC-6.5 RBC-3.21* Hgb-9.8* Hct-28.6* MCV-89 MCH-30.5 MCHC-34.3 RDW-11.5 RDWSD-36.9 Plt ___ ___ 04:00AM BLOOD WBC-9.3 RBC-3.51* Hgb-10.6* Hct-31.5* MCV-90 MCH-30.2 MCHC-33.7 RDW-11.8 RDWSD-38.2 Plt ___ ___ 10:30AM BLOOD WBC-9.8 RBC-3.49* Hgb-10.7* Hct-31.6* MCV-91 MCH-30.7 MCHC-33.9 RDW-11.9 RDWSD-38.6 Plt ___ ___ 10:30AM BLOOD Neuts-84.1* Lymphs-10.1* Monos-5.1 Eos-0.0* Baso-0.3 Im ___ AbsNeut-8.24* AbsLymp-0.99* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.03 ___ 04:00AM BLOOD ___ PTT-32.0 ___ ___ 07:20AM BLOOD Glucose-61* UreaN-5* Creat-0.4 Na-141 K-3.8 Cl-101 HCO3-25 AnGap-15 ___ 04:00AM BLOOD Glucose-93 UreaN-6 Creat-0.4 Na-141 K-4.2 Cl-102 HCO3-26 AnGap-13 ___ 07:20AM BLOOD ALT-33 AST-19 AlkPhos-122* TotBili-0.8 ___ 04:00AM BLOOD ALT-36 AST-15 AlkPhos-100 TotBili-0.8 ___ 10:30AM BLOOD ALT-47* AST-15 AlkPhos-102 TotBili-0.6 ___ 07:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7 ___ 04:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8 Medications on Admission: Medications - OTC IBUPROFEN - ibuprofen 200 mg tablet. 3 tablet(s) by mouth as needed for pain last dose ___ - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Biliary leak s/p lap chole 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: ___ with recent lap chole p/w epigastric pain and back pain// Please assess for evidence of cholangitis, retained stones TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Comparison is made to ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm. The distal common bile duct is not well visualized. No evidence of distal obstructing stones. GALLBLADDER: The patient is status post cholecystectomy. Small fluid collection visualized in the postop bed. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 15.1 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. Patient is status post cholecystectomy. Small fluid collection in the postop bed may represent a postoperative seroma or biloma however, superimposed infection cannot be excluded. The common bile duct measures 5 mm. The distal common bile duct is not well visualized, however there is no evidence of distal obstructing stones. 2. Mild splenomegaly measuring up to 15.1 cm, was not well demonstrated on prior exam however this is likely secondary to differences in technique. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with recent lap chole p/w abdominal pain and shoulder pain. Evaluate for subphrenic hematoma or other pathology to explain abdominal pain. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 2) Spiral Acquisition 7.0 s, 55.1 cm; CTDIvol = 20.2 mGy (Body) DLP = 1,112.2 mGy-cm. Total DLP (Body) = 1,119 mGy-cm. COMPARISON: Abdominal ultrasound from earlier on the same date. FINDINGS: LOWER CHEST: There is trace right pleural effusion with adjacent compressive atelectasis. Mild left basilar atelectasis. No pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is mild intrahepatic biliary dilatation in the setting of prior cholecystectomy. Notably, a smaller 6 mm rounded density adjacent to the surgical clips in the gallbladder fossa may represent the remnant cystic duct. There is moderate perihepatic and perisplenic fluid, of simple internal attenuation, tracking down the bilateral paracolic gutters, into the pelvis. 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: The urinary bladder and distal ureters are unremarkable. There is a small to moderate amount of free pelvic fluid. REPRODUCTIVE ORGANS: The uterus is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No significant atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Post cholecystectomy, with mild intrahepatic biliary dilatation and a moderate amount of gallbladder fossa, perihepatic, and perisplenic fluid tracking down the bilateral gutters and into the pelvis. In the setting of prior surgery, biliary leak is not excluded on the basis of this CT. 2. Trace right pleural effusion. NOTIFICATION: The above findings were communicated in person by Dr. ___ to Dr. ___ at 15:45 on ___, 2 minutes after discovery. Radiology Report EXAMINATION: MRCP INDICATION: ___ year old woman ___ s/p cholecystectomy, with abdominal pain and free fluid on CT, concern for biliary leak. Needs MRCP WITH EOVIST to further evaluate for bile leak.// ___ year old woman ___ s/p cholecystectomy, with abdominal pain and free fluid on CT, concern for biliary leak. Needs MRCP WITH EOVIST to further evaluate for bile leak. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 8 mL Eovist. Oral contrast: None was administered COMPARISON: ___ abdomen and pelvis CT FINDINGS: Redemonstrated is large volume ascites. The patient is post cholecystectomy. Mild prominence of the intra and extrahepatic bile duct is unchanged compared prior imaging. The common bile duct tapers normally to the ampulla without filling defect to suggest choledocholithiasis. There is a prominent fluid collection at the porta hepatis which extends to the region of the cystic duct stump, also seen on the prior CT. Post Eovist 20 minute delayed images demonstrate appropriate opacification of the intrahepatic bile ducts and left and right hepatic ducts to their confluence/very proximal portion of the common bile duct (series 20, image 30). The remainder of the common bile duct is not opacified. However, there is extraluminal pooling of excreted biliary contrast in the gallbladder fossa where a prominent fluid collection was present previously, consistent with biliary leakage (20:25). Although the exact site of biliary leakage is not identified, it is likely somewhere between confluence of the right and left hepatic ducts and the region of the cystic duct stump. There are no focal liver lesions. The spleen, pancreas, adrenal glands, bilateral kidneys are within normal limits. The stomach and visualized loops of bowel are unremarkable. There are vascular abnormalities. There is no lymphadenopathy. A small right pleural effusion is noted. IMPRESSION: 1. Biliary leakage status post cholecystectomy as evidenced by pooling of biliary excreted contrast within the gallbladder fossa. The exact site of leakage is not identified but likely lies between the confluence of the right and left hepatic ducts and the cystic duct insertion. 2. Large volume ascites in the setting of active biliary leakage, overall similar to most recent prior CT scan of the abdomen and pelvis. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:50 pm, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: US INTERVENTIONAL PROCEDURE INDICATION: ___ s/p laparoscopic cholecystectomy ___ with persistent abdominal pain, imaging showing bile leak with biloma: please drain biloma, send for fluid cultures and please leave drain// please drain biloma, send for fluid cultures and please leave drain TECHNIQUE: Limited gray scale ultrasound images were obtained of the liver. COMPARISON: Ultrasound dated ___ FINDINGS: Limited preprocedure evaluation of the gallbladder fossa demonstrated a small residual fluid pocket measuring 6 mm in short axis. This has significantly decreased in size compared to ultrasound from 1 day prior where it measured 2.5 cm in short axis. IMPRESSION: Decrease in size of the fluid collection in the gallbladder fossa. No drainable collection identified on today's examination. If clinically warranted, interval follow-up ultrasound or CT may be considered if clinically warranted to assess for fluid reaccumulation. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Back pain, Epigastric pain, Shoulder pain Diagnosed with Unspecified abdominal pain temperature: 97.8 heartrate: 107.0 resprate: 16.0 o2sat: 100.0 sbp: 132.0 dbp: 81.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at ___! You were here for abdominal pain, and MRI and CT scans show that you had bile leakage. You underwent a procedure called ERCP and you received a stent in your bile duct. You will need a Repeat ERCP in 4 weeks for stent pull and re-evaluation. 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: Bactrim / Vioxx / Penicillins / CellCept / Ceftriaxone / Ferrlecit / Sulfa (Sulfonamide Antibiotics) Attending: ___ ___ Complaint: HEMOPTYSIS Major Surgical or Invasive Procedure: LEFT BRONCHIAL ARTERY EMBOLIZATION UNDER FLUOROSCOPY RIGHT INTERNAL JUGULAR LINE PLACEMENT, REPOSITIONING, AND REMOVAL IVC FILTER PLACEMENT INTUBATION AND MECHANICAL VENTILATION History of Present Illness: ___ with history of lupus, lupus nephritis with ESRD on peritoneal dialysis on transplant list, hx of PE/Antiphopholipid antibody on coumadin, mitral regurg, presents with ___ month history of cough, worse in the morning, one week of trace blood, now producing bright red blood over last couple days. Patient states that the amount of blood she has been coughing has been increasing and is now almost hourly, aprroximately 1 teaspoon bright red blood. Patient states that the cough produced primarily yellow sputum until it turned to blood. Patient denies any other symptoms such as dizziness or lightheadedness. She denies any changes in her BMs, including consistency, frequency, and color. Patient visited PCP on ___, and a CXR was negative. Her was also noted to be subtherapeutic and she took an extra day of 10 mg warfarin as instructed. . Initial vitals in the ED were: 108 138/95 18 100% RA. Her HCT was 29.6, her baseline is unclear but appears to be low ___. INR was 4.4. A CTA was done for concern of PE which showed: 1. Left lower lobe consolidation with large amount of secretions/fluid within the left lower lobe segmental bronchi. 2. Centrilobular nodules and ground glass opacities throughout both lungs, compatible with chronic collagen vascular disease, progressed since ___. Ground glass opacities could also represent hemorrhage. 3. Chronic left lower segmental pulmonary arterial PE, unchanged since ___. No new acute PE detected to the subsegmental levels. She was initially admitted to medicine but then transferred to the ICU. . On arrival to the MICU initial vitals were: 110 163/96 20 95%RA. She is breathing comfortably but complains of pain in her chest. Her EKG was reviewed which did not show changes from her prior. She also complains of a HA that she says she occasionally recieves toradol. She has had emesis in the ED that looked dark/possibly coffee ground but currently denies nausea. Past Medical History: # Lupus rash # Herpes Simplex I - ___, white lesions on the tongue and buccal mucosa # Axillary Adenopathy - ___, biopsied -> reactive lymph node # Osteopenia - ___, L spine Tscore -2.40, Fem neck -1.91, Tot Hip -1.41 # Hypercholesterolemia - ___ # Lung abscess - ___ # Pulmonary emboli (PE) - ___ # Angioedema vs Anasarca - ___, associated with 2 grand mal seizures, required intubation for massive facial/laryngeal swelling # Pleural Effusions - s/p pleurodesis in ___ nephrotic syndrome # Lupus nephritis / Nephrotic syndrome - ___, renal bx showed focal proliferative class III # GERD / Gastric ulcer - ___, seen on barium swallow # Recurrent pneumonia - ___, possibly from aspirations, most recent ___ # Antiphospholipid antibody syndrome (APS) - ___, requiring anticoagulation to INR of 2 to 3 # Breast Masses - ___, bilateral, largest right upper outer quadrant ___ cm # Thrombotic thrombocytopenic purpura (TTP) - ___, s/p plasmapheresis # Inflammatory eye mass - ___, s/p excision of mass, ___ lupus # Gonorrhea - ___, disseminated gonococcus # Abnormal pap smear - ___, subsequent paps x 2 normal # Systemic lupus erythematosus (SLE) - ___, followed by Dr. ___ # Raynaud's syndrome # Stroke - hemiparalysis # Asthma - no problems for several years Social History: ___ Family History: Mother with MS ___ with sarcoid ___ discoid lupus Physical Exam: ADMISSION EXAM Vital signs: 110 163/96 20 95%RA. Gen: Uncomfortable appearing but no acute distress. HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP clear. Neck: Supple. Resp: Absent breath sounds entire L Lung fields, R lung firels CTA CV: Tachycardic, regular rhythym. Normal s1 and s2. ___ SM at apexNo M/G/R. Abd: +BS. Soft. NT/ND. No rebound or guarding. No hepatosplenomegaly. Ext: Warm and well-perfused. Radial and DP pulses 2+ bilaterally. Neuro: A+Ox3. PERRL. EOMI, with no nystagmus. Face symmetric. . DISCHARGE EXAM VS T 98.0 HR 128 (regular) BP 102/76 RR 22 O2 100/RA GEN thin young woman resting in bed, somnolence but easily roused, NAD NCAT MMM EOMI OP clear Lungs CTAB, prominent breath sounds, no wheeze no L dullness CV tachycardic at regular rate, nl S1 S2 no mumur Abd full but nondistended and nontender, soft Ext no edema, warm and dry Pertinent Results: ADMISSION LABS ___ 07:30AM WBC-7.9# RBC-3.19* HGB-9.2* HCT-29.6* MCV-93 MCH-28.8 MCHC-31.0 RDW-16.9* ___ 07:30AM NEUTS-64.1 ___ MONOS-4.4 EOS-6.4* BASOS-0.8 ___ 07:30AM PLT COUNT-376# ___ 07:30AM GLUCOSE-96 UREA N-58* CREAT-13.0*# SODIUM-142 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-24 ANION GAP-23* ___ 07:30AM ___ PTT-46.9* ___ . OTHER PERTINENT LABS ___ 05:04PM BLOOD ___ * Titer-1:160 dsDNA-POSITIVE * ___ 04:57AM BLOOD dsDNA-NEGATIVE ___ 11:44AM BLOOD SM ANTIBODY-3.6 POS (<1.0 NEG AI) ___ 05:04PM BLOOD ANCA-NEGATIVE B ___ 04:57AM BLOOD dsDNA-NEGATIVE ___ 07:00PM BLOOD Lupus ANTICOAGULANT-POS ___ 05:13AM ANTICARDIOLIPIN IgG-5.5(NEG) ANTICARDIOLIPIN IgM-5.6(NEG) ___ 05:04PM BLOOD ___ * Titer-1:160 dsDNA-POSITIVE (1:10) ___ 05:13AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-PND ___ 07:30AM BLOOD C3-109 C4-44* ___ 04:57AM BLOOD C3-87* C4-29 ___ 03:36AM BLOOD C3-104 C4-30 . DISCHARGE LABS ___ 03:12AM BLOOD WBC-14.2* RBC-3.89* Hgb-11.5* Hct-35.9* MCV-92 MCH-29.5 MCHC-31.9 RDW-15.9* Plt ___ ___ 03:12AM BLOOD ___ PTT-31.8 ___ ___ 03:12AM BLOOD Glucose-90 UreaN-77* Creat-12.1* Na-136 K-4.1 Cl-94* HCO3-25 AnGap-21* ___ 03:12AM BLOOD Calcium-10.1 Phos-6.4* Mg-2.4 . MICRO ___ BLOOD CULTURE -PENDING ___ BLOOD CULTURE -PENDING ___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL ___ URINE CULTURE-FINAL ___ BLOOD CULTURE -PENDING ___ BLOOD CULTURE -PENDING ___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL ___ DIALYSIS FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL ___ STOOL C. difficile DNA amplification assay-FINAL ___ BLOOD CULTURE -FINAL ___ BLOOD CULTURE -FINAL ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT ___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL . ___ CTA CHEST The lung apices are excluded from this examination, which was optimized for assessment of the pulmonary vasculature. Coarse calcifications within the breasts are new on the left (2:33), and slightly increased in size on the right (2:24), in comparison to the ___ examination. No distinct mass is seen, although the breast tissue is diffusely dense. There is no axillary or mediastinal lymphadenopathy. The heart size is top normal. There is no pericardial effusion. The aorta is normal in caliber and patent. There is no dissection. The main pulmonary arteries are normal in caliber. There is a chronic pulmonary embolus within the left lower segmental pulmonary artery (3:57), which is present since the ___ CT examination. No superimposed acute pulmonary embolus is detected to the subsegmental levels. Endobronchial secretions are seen within the left lower lobe segmental bronchus (3:54), extending into the left lower lobe, where there is a moderate-sized consolidation (3:86) filling a previously-seen large air collection from ___. There are neighboring areas of ___ and ground-glass opacities (3:72). Ground-glass and ___ opacities are also seen throughout both lungs, slightly worse at the lower zones (right lower lobe 3:104, right middle lobe 3:109, right upper lobe 3:49, lingula 3:95), distributed along a centrilobular pattern, with associated mild bronchiectasis, all progressed since ___. There is no pleural effusion. Mild pleural thickening along the left lower lobe (3:78) has slightly progressed since ___. Moderate intraabdominal ascites is present. OSSEOUS STRUCTURES: There is no bony lesion concerning for infection or neoplasm. IMPRESSION: 1. Left lower lobe consolidation with large amount of secretions/fluid within the left lower lobe segmental bronchi. A small air-filled space within the left lower lobe seen on the ___ CT examination is now filled with fluid and/or blood. Findings could represent hemorrhage secondary to collagen vascular disease. Infection and abscess also have the same appearance on CT. 2. Centrilobular nodules and ground glass opacities throughout both lungs, with a basilar predominance, with associated mild bronchiectasis, compatible with chronic collagen vascular disease, progressed since ___. There is no advanced fibrosis. Superimposed infection cannot be excluded by imaging alone. Ground glass opacities could also represent hemorrhage. 3. Chronic left lower segmental pulmonary arterial PE, unchanged since ___. No new acute PE detected to the subsegmental levels. . ___ CXR CHEST, SINGLE AP PORTABLE VIEW Suspect background hyperinflation. Superimposed on this, the heart is not enlarged. The left hemidiaphragm is elevated. There is patchy dense opacity at the left base, increased compared with ___. Blunting of the left costophrenic angle suggests a small effusion. Smudgy densities scattered in the right and ? left upper lung are compatible with ground glass oapcities seen on chest CTA obtained earlier the same day. There is minimal biapical pleural scarring. Note is made of calcification along the bronchial walls, an unusual finding in an individual of this age. A large (13 mm) coarse calcification overlying the right lung lies within the right breast. Minimal superior endplate scalloping is noted in several mid/upper thoracic vertebral bodies. IMPRESSION: Irregular dense opacity at left base, increased compared with ___, associated with an elevated left hemidiaphragm. Differential diagnosis includes alveolar processes such as infection and hemorrhage. . ___ CT ABD/PELVIS ABDOMEN: There is atelectasis at the left base with a small left pleural effusion. Centrilobular nodules and ground-glass opacities at the right base remain unchanged from CTA chest performed yesterday. Lack of intravenous contrast limits evaluation of the solid abdominal viscera. The liver, spleen, adrenal glands and pancreas demonstrate a grossly unremarkable unenhanced appearance. The kidneys are small in size. There is vicarious excretion of contrast within the gallbladder from contrast CT performed yesterday. Nonenlarged retroperitoneal lymph nodes are visualized. There is no adenopathy. The abdominal aorta is normal in caliber with atherosclerotic calcifications noted predominantly infrarenally. A peritoneal dialysis catheter is present, looped in the right mid abdomen entering from the left. There is a moderate amount of ascites, which measures higher than simple fluid in ___ units. There is no evidence of retroperitoneal hematoma. PELVIS: The bladder, uterus and rectum are within normal limits. Ascites is redemonstrated within the pelvis. There are no dilated or thick-walled loops of bowEl. There is no inguinal or pelvic adenopathy. OSSEOUS STRUCTURES: Mild degenerative changes are present in the right hip and sacroiliac joints. A sclerotic 9-mm lesion in the left iliac bone appears nonaggressive and is essentially unchanged from ___ suggesting a benign lesion. IMPRESSION: 1. Moderate ascites. Given the fluid withdrawn from the peritoneal dialysis catheter is nonhemorrhagic, and the patient underwent a contrast-enhanced CT yesterday, this is likely increased in density from the contrast administration. No evidence of retroperitoneal hematoma. 2. Vicarious excretion of contrast in the gallbladder consistent with stated history of chronic kidney disease. 3. Left basilar disease is poorly evaluated on this examination. Centrilobular nodules and ground-glass opacities are redemonstrated consistent with known chronic collagen vascular disease. Again, superimposed infection cannot be excluded by imaging. . ___ FLUOROSCOPIC-GUIDED EMBOLIZATION L BRONCHIAL ARTERY FINDINGS: 1. Existing right IJ temporary triple-lumen catheter was seen with the tip in the axillary vein. This was successfully repositioned/replaced with the new catheter tip positioned in the distal SVC. 2. Angiography demonstrated dilated tortuous left bronchial artery, supplying the left lung and specifically, the left lower lobe. Some filling of an adjacent pulmonary artery was seen at the end of the angiography suggesting microvascular shunting. 3. No contributor was identified from the left bronchial artery anywhere in its course to an anterior spinal artery. 4. During selective microcatheterization of the left bronchial artery, a small amount of contrast extravasation was noted in the mediastinum from the proximal portion of the artery. Subsequent aortic angiography demonstrated no contrast extravasation from the aorta or evidence of aortic dissection. 5. Following this, 5 ___ was again used to select the ostium of the left bronchial artery. From this location, particle embolization with 300-500 micron Embospheres was performed to good slowing of flow and angiographic result. IMPRESSION: 1. Successful particle embolization in the left bronchial artery, as described above. 2. Successful replacement and repositioning of non-tunneled right internal jugular vein triple lumen catheter, with the tip now in distal SVC. The line is ready to use. . ___ CT CHEST FINDINGS: AIRWAYS AND LUNGS: Since ___, high-density consolidation in the left lower lobe sparing only a portion of the superior segment has increased and new in posterior basal segment of the right lower lobe. Preexisting left lower lobe cavity is obscured by this large consolidation. In addition, diffuse ground-glass opacities without septal thickening in both lungs (left side more than right), are also new since ___. Keeping with clinical history, these are highly suggestive of multifocal pulmonary hemorrhage, most pronounced in the left lower lobe. Thin rim of hyperdensity along the posterior pleural space in the left lower lobe is probably due to the dissection of the blood from the consolidation. MEDIASTINUM: Thyroid gland is normal. Endotracheal tube tip lies 3 cm above the carina. There are no pathologically enlarged, mediastinal, supraclavicular or axillary lymph nodes. Heart is normal size, and thin rim of pericardial fluid is likely reactive. Coronary artery calcification is minimal. ABDOMEN: The study is not designed for assessment of subdiaphragmatic pathology; however, limited views were remarkable for moderate ascites with an attenuation value ranging between 19 to 35, suggesting complex fluid, unchanged since ___. BONES: There is no bone lesion concerning for malignancy or infection. IMPRESSION: 1. CT featuRes are concerning for progressive multifocal pulmonary hemorrhage, most pronounced in left lower lobe. 2. Left lower lobe bronchial tree occlusion is likely from aspirated blood. 3. Moderate ascites with attenuation ranging between 19 to 35 is probably complex fluid, unchanged since ___. . ___ CXR FINDINGS: As compared to the previous radiograph, there is substantial improvement with substantially improved ventilation of the left lung. Only at the left lung base, areas of atelectasis with subsequent elevation of the left hemidiaphragm persists. Two new tubular structures project over the left hemithorax. There is no evidence of pneumothorax. The monitoring and support devices are overall constant. Constant appearance of the right lung. . ___ LENIS FINDINGS: There is normal phasicity within the common femoral veins bilaterally. The visualized vessels are patent and compressible with normal waveforms and augmentation. No thrombus identified. IMPRESSION: No evidence of DVT within the lower extremities bilaterally. . ___ TTE Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are elongated. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Poor image quality (patient difficult to position and unable to cooperate). Preserved regional and global left ventricular systolic function. Based on limited views, right ventricular cavity size and function are probably normal. Pulmonary pressures were undetermined. Compared with the prior study dated ___ (images reviewed), left ventricular function is more vigorous. Other findings are probably similar although current suboptimal image quality precludes definite comparison. Medications on Admission: AMITRIPTYLINE - 25 mg Tablet QHS B COMPLEX-VITAMIN C-FOLIC ACID CALCITRIOL 0.25 mcg Capsule six times weekly CODEINE-GUAIFENESIN ___ tsp(s) prn cough DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - 60 mcg/0.3 mL Syringe -Q2weeks GENTAMICIN - 0.1 % Cream - apply to exit site as directed HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg Tablet - 1 Tablet(s) by mouth ONE BY MOUTH EVERY DAY, TWO BY MOUTH EVERY OTHER DAY LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day -recently stopped for concern of contributing to chroninc cough RANITIDINE HCL - 150 mg Tablet - BID SEVELAMER CARBONATE [RENVELA] 800 mg Tablet - 3 Tablet TID VALACYCLOVIR - 500 mg Tablet - one Tablet(s) by mouth x 1 dose as needed for cold sore outbreak as soon as ___ have symptoms WARFARIN - Alternating 7.5 mg and 10 mg Discharge Medications: 1. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 6x/week. 4. Aranesp (polysorbate) 60 mcg/0.3 mL Syringe Sig: One (1) injection Injection q2weeks. 5. gentamicin 0.1 % Cream Sig: One (1) Topical once a day: apply to exit site as directed. 6. hydroxychloroquine 200 mg Tablet Sig: AS DIRECTED Tablet PO once a day: 200 MG (1 TAB) AND 400 MG (2 TABS) ON ALTERNATING DAYS. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 8. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO x1: take 1 tablet immediately as needed for cold sore outbreak as soon as ___ have symptoms. 10. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q6H (every 6 hours) as needed for throat pain. Disp:*QS * Refills:*0* 11. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: take 4 tabs (40 mg) ___ morning, then 3 tabs (30 mg) every morning until further instructions from your rheumatologist. Disp:*50 Tablet(s)* Refills:*1* 12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety or nausea for 30 doses. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: LEFT BRONCHIAL ARTERY BLEED VENTILATOR-ASSOCIATED PNEUMONIA END-STAGE RENAL DISEASE, PERITONEAL DIALYSIS-DEPENDENT HISTORY OF PULMONARY EMBOLISM 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 history of PE, on Coumadin, history of lupus nephritis, with coughing and hemoptysis. COMPARISON: Chest CT available from ___ and chest radiographs from ___ through ___. TECHNIQUE: MDCT-acquired 3.5 mm axial images of the chest were obtained following the uneventful administration of 100 cc of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. Additional right and left oblique reconstructions were obtained for further evaluation of the pulmonary vasculature. CT OF THE CHEST WITH IV CONTRAST: The lung apices are excluded from this examination, which was optimized for assessment of the pulmonary vasculature. Coarse calcifications within the breasts are new on the left (2:33), and slightly increased in size on the right (2:24), in comparison to the ___ examination. No distinct mass is seen, although the breast tissue is diffusely dense. There is no axillary or mediastinal lymphadenopathy. The heart size is top normal. There is no pericardial effusion. The aorta is normal in caliber and patent. There is no dissection. The main pulmonary arteries are normal in caliber. There is a chronic pulmonary embolus within the left lower segmental pulmonary artery (3:57), which is present since the ___ CT examination. No superimposed acute pulmonary embolus is detected to the subsegmental levels. Endobronchial secretions are seen within the left lower lobe segmental bronchus (3:54), extending into the left lower lobe, where there is a moderate-sized consolidation (3:86) filling a previously-seen large air collection from ___. There are neighboring areas of ___ and ground-glass opacities (3:72). Ground-glass and ___ opacities are also seen throughout both lungs, slightly worse at the lower zones (right lower lobe 3:104, right middle lobe 3:109, right upper lobe 3:49, lingula 3:95), distributed along a centrilobular pattern, with associated mild bronchiectasis, all progressed since ___. There is no pleural effusion. Mild pleural thickening along the left lower lobe (3:78) has slightly progressed since ___. Moderate intraabdominal ascites is present. OSSEOUS STRUCTURES: There is no bony lesion concerning for infection or neoplasm. IMPRESSION: 1. Left lower lobe consolidation with large amount of secretions/fluid within the left lower lobe segmental bronchi. A small air-filled space within the left lower lobe seen on the ___ CT examination is now filled with fluid and/or blood. Findings could represent hemorrhage secondary to collagen vascular disease. Infection and abscess also have the same appearance on CT. 2. Centrilobular nodules and ground glass opacities throughout both lungs, with a basilar predominance, with associated mild bronchiectasis, compatible with chronic collagen vascular disease, progressed since ___. There is no advanced fibrosis. Superimposed infection cannot be excluded by imaging alone. Ground glass opacities could also represent hemorrhage. 3. Chronic left lower segmental pulmonary arterial PE, unchanged since ___. No new acute PE detected to the subsegmental levels. Radiology Report HISTORY: Hemoptysis, limited air movement. Question interval change. CHEST, SINGLE AP PORTABLE VIEW Suspect background hyperinflation. Superimposed on this, the heart is not enlarged. The left hemidiaphragm is elevated. There is patchy dense opacity at the left base, increased compared with ___. Blunting of the left costophrenic angle suggests a small effusion. Smudgy densities scattered in the right and ? left upper lung are compatible with ground glass oapcities seen on chest CTA obtained earlier the same day. There is minimal biapical pleural scarring. Note is made of calcification along the bronchial walls, an unusual finding in an individual of this age. A large (13 mm) coarse calcification overlying the right lung lies within the right breast. Minimal superior endplate scalloping is noted in several mid/upper thoracic vertebral bodies. IMPRESSION: I Irregular dense opacity at left base, increased compared with ___, associated with an elevated left hemidiaphragm. Differential diagnosis includes alveolar processes such as infection and hemorrhage. Radiology Report CHEST RADIOGRAPH INDICATION: Line placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, a right internal jugular vein catheter has been placed. The catheter is malpositioned in the right axillary vein. Repositioning is required. The observation was made at the time of dictation, 8:36 a.m. on ___, and Dr. ___ was contacted by telephone. Radiology Report CHEST RADIOGRAPH INDICATION: ___ woman with line placement, to look for the position. TECHNIQUE: Semi-erect portable chest view was read in comparison with multiple prior radiographs with the most recent from ___ acquired two to three hours apart. FINDINGS: Right-sided internal jugular line courses along lower neck till medial portion of the clavicle and then laterally upto the upper and lateral chest wall, suggesting persistant malpositioned line into the right subclavian vein. There is no pneumothorax. A dense opacity in the left lung disease and mild haziness in the left upper lung is unchanged since prior radiograph acquired three to four hours apart, but worsened since yesterday suggesting left lower lung collapse with effusion. Right cardiac margin is indistinct owing to left lower lung volume loss. Mild right lung base atelectasis and the presumed small effusion is unchanged since prior study. IMPRESSION: 1. Internal jugular line malpositioned with its tip positioned in the right internal jugular line, persisting since prior radiograph acquired ___ hours apart. 2. Lower lung collapse and mild-to-moderate left effusion is unchanged since ___ but worsened since yesterday. Minimal right lung base atelectasis and presumed small right effusion is similar. ___ discussed findings with Dr. ___ by phone on ___, ___ at 8.46AM Radiology Report CT ABDOMEN AND PELVIS WITHOUT CONTRAST COMPARISON: CTA chest ___, renal ultrasound ___, CT abdomen and pelvis ___. CLINICAL INDICATION: ___ woman with lupus and chronic kidney disease on peritoneal dialysis who presents with falling hematocrit, with concern for intraperitoneal and retroperitoneal bleed. TECHNIQUE: Unenhanced axial images of the abdomen and pelvis were obtained. Coronal and sagittal reformatted images were constructed. TOTAL EXAM DLP: 391.36 mGy-cm. FINDINGS: ABDOMEN: There is atelectasis at the left base with a small left pleural effusion. Centrilobular nodules and ground-glass opacities at the right base remain unchanged from CTA chest performed yesterday. Lack of intravenous contrast limits evaluation of the solid abdominal viscera. The liver, spleen, adrenal glands and pancreas demonstrate a grossly unremarkable unenhanced appearance. The kidneys are small in size. There is vicarious excretion of contrast within the gallbladder from contrast CT performed yesterday. Nonenlarged retroperitoneal lymph nodes are visualized. There is no adenopathy. The abdominal aorta is normal in caliber with atherosclerotic calcifications noted predominantly infrarenally. A peritoneal dialysis catheter is present, looped in the right mid abdomen entering from the left. There is a moderate amount of ascites, which measures higher than simple fluid in ___ units. There is no evidence of retroperitoneal hematoma. PELVIS: The bladder, uterus and rectum are within normal limits. Ascites is redemonstrated within the pelvis. There are no dilated or thick-walled loops of bowel. There is no inguinal or pelvic adenopathy. OSSEOUS STRUCTURES: Mild degenerative changes are present in the right hip and sacroiliac joints. A sclerotic 9-mm lesion in the left iliac bone appears nonaggressive and is essentially unchanged from ___ suggesting a benign lesion. IMPRESSION: 1. Moderate ascites. Given the fluid withdrawn from the peritoneal dialysis catheter is nonhemorrhagic, and the patient underwent a contrast-enhanced CT yesterday, this is likely increased in density from the contrast administration. No evidence of retroperitoneal hematoma. 2. Vicarious excretion of contrast in the gallbladder consistent with stated history of chronic kidney disease. 3. Left basilar disease is poorly evaluated on this examination. Centrilobular nodules and ground-glass opacities are redemonstrated consistent with known chronic collagen vascular disease. Again, superimposed infection cannot be excluded by imaging. Radiology Report INDICATION: ___ woman with history of lupus and end-stage renal disease with hemoptysis, and worsening opacities of the left suggestive of left bronchial artery source. Additionally, she had a temporary right IJ line placed which is malpositioned with tip in the axillary vein. PHYSICIAN: Dr. ___, the attending radiologist, was present and performed the procedure. Dr. ___, fellow. PROCEDURE: 1. Fluoroscopic guided repositioning/replacement of non-tunneled right IJ triple-lumen central venous catheter. 2. Fluoroscopic-guided right common femoral artery access. 3. Aortogram and selective left bronchial angiogram. 4. Embolization of left bronchial artery (300-500 micron Embospheres). 5. Post-embolization angiogram. MEDICATIONS: The procedure was performed with general anesthesia. 135 cc Optiray was used. PROCEDURE: Prior to initiation of procedure, written informed consent was obtained and a preprocedure timeout was performed. Patient was brought to the angiographic suite and placed supine on the angiographic table. Patient underwent endotracheal intubation. Following this, the right groin and right neck were prepped and draped in sterile manner. Initially, a fluoroscopic image demonstrated the tip of the central venous catheter was positioned in the axillary vein. A ___ wire was advanced through this catheter which was removed, and a new catheter was placed via the existing right internal jugular vein access such that the tip was in the distal SVC. All three ports were flushed and aspirated and the catheter was secured to the skin with suture and dressed in the requisite manner. Next, under fluoroscopic and manual palpation, right common femoral artery access was obtained using a micropuncture set, followed by placement of a 5 ___ sheath. ___ catheter was formed over ___ wire over the arch, this was used to look for the left brachial artery origin. This was identified in the upper aorta, and contrast injection was performed in multiple projections demonstrating this. Next, attempts to access this with a STC microcatheter and a Headliner and Double-Ended guidewire were made. During these attempts, the microcatheter was advanced over the wire and contrast injection demonstrated some contrast extravasation out of the proximal portion of the left bronchial artery, into the mediastinum. The microcatheter was removed and the ___ was changed for a 5 ___ pigtail catheter. An angiogram was performed in multiple projections, and demonstrating no aortic extravasation or dissection. Next, the ___ was replaced and used to re-select the left bronchial artery origin. Brisk forward flow was seen so particle embolization was performed with 300-500 micron Embospheres to slow flow. Post-embolization contrast injection demonstrated good angiographic result. The ___ catheter was removed over ___ wire, the 5 ___ sheath was removed and manual pressure was applied to hemostasis. The patient tolerated the procedure well, and was returned to the ICU. FINDINGS: 1. Existing right IJ temporary triple-lumen catheter was seen with the tip in the axillary vein. This was successfully repositioned/replaced with the new catheter tip positioned in the distal SVC. 2. Angiography demonstrated dilated tortuous left bronchial artery, supplying the left lung and specifically, the left lower lobe. Some filling of an adjacent pulmonary artery was seen at the end of the angiography suggesting microvascular shunting. 3. No contributor was identified from the left bronchial artery anywhere in its course to an anterior spinal artery. 4. During selective microcatheterization of the left bronchial artery, a small amount of contrast extravasation was noted in the mediastinum from the proximal portion of the artery. Subsequent aortic angiography demonstrated no contrast extravasation from the aorta or evidence of aortic dissection. 5. Following this, 5 ___ ___ was again used to select the ostium of the left bronchial artery. From this location, particle embolization with 300-500 micron Embospheres was performed to good slowing of flow and angiographic result. IMPRESSION: 1. Successful particle embolization in the left bronchial artery, as described above. 2. Successful replacement and repositioning of non-tunneled right internal jugular vein triple lumen catheter, with the tip now in distal SVC. The line is ready to use. Radiology Report CLINICAL HISTORY: ___ woman with hemoptysis. Change in clips and change in pulmonary hemorrhage. COMPARISON: ___. FINDINGS: Left lung has progressed to complete complete opacification consistent with collapse. Trachea is deviated to the left consistent with volume loss. The left bronchus also appears to have secretions within it, likely clot causing this atelectasis. ET tube is approximately 5 cm from the carina. Right IJ terminates likely in the low SVC. The right lung is essentially clear. IMPRESSION: Collpase of the left lung probably from bronchial plugging/clot. Size of the hemorrhage is difficult to evaluate. These findings were discussed with Dr ___ by Dr ___ telephone at 11 AM. Radiology Report HISTORY: For ET tube placement. FINDINGS: In comparison with study of ___, there is little change. Again there is a complete collapse of the left lung presumably from bronchial plugging with mucus impaction or clot. Shift of the mediastinum to the left as well as the trachea is consistent with the volume loss. The right lung is essentially clear. Radiology Report INDICATION: History of lupus anticoagulant, prior PEs, with current pulmonary hemorrhage, IVC filter placement was requested. OPERATORS: Dr. ___ (fellow), Dr. ___ (resident), and Dr. ___, (attending physician). Dr. ___ was present and supervised throughout the procedure. ANESTHESIA: Moderate sedation was provided via divided doses of fentanyl 75 mcg and Versed 1.5 mg administered throughout the total intraservice time of 40 minutes during which the patient's hemodynamic parameters were continuously monitored. PROCEDURE AND FINDINGS: After explaining the risks, benefits and alternatives to the patient's designated proxy (husband), informed consent was obtained. The patient was brought to the angiographic suite and placed supine on the table. The right groin was prepped and draped in the usual sterile fashion. A timeout and huddle were performed per ___ protocol. Under ultrasound guidance, the right femoral vein was accessed at the level of the mid femoral head with a 19-gauge micropuncture needle through which a ___ wire was advanced. The needle was removed and a ___ Omniflush catheter was placed and positioned to the contralateral common iliac vein. A venogram was performed from the left common iliac vein demonstrating no evidence of duplication, patent single IVC without evidence of thrombus and IVC diameter of 20 mm. The level of the renal veins was noted at approximately the L2 level, with left renal vein slightly inferior to the right. Based on these diagnostic findings, a retrievable Option IVC filter was placed via the right femoral vein just below the level of the inferior margin of the left renal vein via the 6.5 ___ provided sheath. The sheath was then removed and pressure applied for 5 minutes to achieve hemostasis. A sterile dressing was applied. There were no immediate complications. IMPRESSION: 1. Diagnostic venogram demonstrating single patent IVC. 2. Successful placement of infra-renal potentially retrievable Option IVC filter. Radiology Report CHEST RADIOGRAPH INDICATION: Woman with lupus, endotracheal tube placement. COMPARISON: ___, 2:05 a.m. FINDINGS: As compared to the previous radiograph, the tip of the endotracheal tube has been minimally advanced. The tip of the tube is within 5 cm of the carina. The left lung apex shows minimally ventilation. However, the entire left hemithorax is still subtotally opacified. The course of the right internal jugular vein catheter is unchanged. Unchanged appearance of the right lung without evidence of pneumonia or pulmonary edema. No right pleural effusion. Radiology Report INDICATION: ___ woman with lupus, history of PE on Coumadin and presents with hemoptysis, to look for blood collection. TECHNIQUE: Unenhanced multidetector CT of thorax was performed using a standard department protocol. Contiguous axial images at 5-mm and 1.25-mm slice thickness were reviewed concurrently with coronal and sagittal reformats. The study was reviewed in comparison with prior chest CTs through ___ with the most recent from ___. FINDINGS: AIRWAYS AND LUNGS: Since ___, high-density consolidation in the left lower lobe sparing only a portion of the superior segment has increased and new in posterior basal segment of the right lower lobe. Preexisting left lower lobe cavity is obscured by this large consolidation. In addition, diffuse ground-glass opacities without septal thickening in both lungs (left side more than right), are also new since ___. Keeping with clinical history, these are highly suggestive of multifocal pulmonary hemorrhage, most pronounced in the left lower lobe. Thin rim of hyperdensity along the posterior pleural space in the left lower lobe is probably due to the dissection of the blood from the consolidation. MEDIASTINUM: Thyroid gland is normal. Endotracheal tube tip lies 3 cm above the carina. There are no pathologically enlarged, mediastinal, supraclavicular or axillary lymph nodes. Heart is normal size, and thin rim of pericardial fluid is likely reactive. Coronary artery calcification is minimal. ABDOMEN: The study is not designed for assessment of subdiaphragmatic pathology; however, limited views were remarkable for moderate ascites with an attenuation value ranging between 19 to 35, suggesting complex fluid, unchanged since ___. BONES: There is no bone lesion concerning for malignancy or infection. IMPRESSION: 1. CT features are concerning for progressive multifocal pulmonary hemorrhage, most pronounced in left lower lobe. 2. Left lower lobe bronchial tree occlusion is likely from aspirated blood. 3. Moderate ascites with attenuation ranging between 19 to 35 is probably complex fluid, unchanged since ___. Radiology Report REASON FOR EXAMINATION: Lupus and recent hemoptysis. Portable AP radiograph of the chest was reviewed in comparison to ___. The ET tube tip is 4.7 cm above the carina. The right internal jugular line tip is at the level of low SVC. There is interval improvement of the left lung aeration with still substantial collapse and left mediastinal shift. Calcifications in the right lower lobe are redemonstrated. No appreciable pneumothorax is seen. Radiology Report INDICATION: ___ woman, intubated with new OG tube, assess OG tube placement. COMPARISON: Portable AP chest radiograph from ___. FINDINGS: There has been placement of an OG tube which is coiled within the stomach. ET tube is in appropriate positioning. Since the prior radiograph, there has been no significant change. Again seen is complete opacification of the left hemithorax with volume loss in the left upper and left lower lobes. There is leftward mediastinal shift, consistent with volume loss. There is no pneumothorax. Right IJ central line is in appropriate position within the right atrium. IMPRESSION: Appropriate placement of OG tube. No significant interval change. Radiology Report PORTABLE AP CHEST FILM, ___ AT 3:04 AM CLINICAL INDICATION: ___ with left lung bleed, intubated, assess for interval change. Comparison is made to the patient's previous study dated ___ at 13:08. A single portable supine chest film ___ at 3:04 a.m. is submitted. IMPRESSION: 1. There is persistent opacification of the left hemithorax with some residual aeration at the left lower lobe associated with volume loss and mediastinal and cardiac shift to the left. Overall, the appearance does not appear to be significantly changed. The endotracheal tube continues to have its tip 4 cm above the carina. A right internal jugular central line has its tip in the distal SVC. Nasogastric tube is seen coursing below the diaphragm with the tip within the stomach. A portion of an inferior vena caval filter is also visualized at the edge of the film within the abdomen. The right lung is well inflated without evidence of focal airspace consolidation, pulmonary edema, or pleural effusion. There is a stable calcified nodule measuring 1.3 cm in the seventh interspace. This most likely represents a calcified granuloma. No acute bony abnormality is appreciated. Radiology Report STUDY: AP chest ___. CLINICAL HISTORY: ___ woman with SLE, hemoptysis. She is ventilated and sedated. FINDINGS: Comparison is made to the prior study performed one and a half hours earlier. Endotracheal tube, feeding tube, right IJ central venous lines are unchanged in position. There remains extensive volume loss and increased density within the right and left lung, stable. The right lung field is clear. A calcified granuloma is seen adjacent to the sixth rib interspace, stable. Radiology Report CHEST RADIOGRAPH INDICATION: Lupus, hemoptysis, intubation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is no relevant change. Volume loss in the left lung with subsequent mediastinal and cardiac shift. Moderate atelectasis at the left lung base with evidence of a coexisting left pleural opacity. The size of the cardiac silhouette cannot be determined. The normal appearance of the right lung is unchanged. Unchanged monitoring and support devices. Radiology Report CHEST RADIOGRAPH INDICATION: Lupus, hemoptysis, current intubation, new fever, evaluation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is unchanged position of the monitoring and support devices. The appearance of the normal right lung is unchanged. Unchanged volume reduction of the left lung, with rather extensive both pleural and parenchymal opacities and signs of leftward mediastinal shift. No newly appeared opacities. The more central aspect of the ventilated left lung shows unchanged ___. Radiology Report CHEST RADIOGRAPH INDICATION: Lupus, bronchial artery bleed, evaluation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is substantial improvement with substantially improved ventilation of the left lung. Only at the left lung base, areas of atelectasis with subsequent elevation of the left hemidiaphragm persists. Two new tubular structures project over the left hemithorax. There is no evidence of pneumothorax. The monitoring and support devices are overall constant. Constant appearance of the right lung. Radiology Report INDICATION: ___ woman with hemoptysis, assess for interval change. COMPARISONS: Multiple prior radiographs, most recently AP radiograph from ___. FINDINGS: The left upper lobe is well aerated but left lower lobe atelectasis persists, with associated elevation of the left hemidiaphragm due to volume loss. The right lung is clear. A right IJ central line terminates in the lower SVC. There is no pneumothorax or pleural effusion. The cardiomediastinal silhouette is normal. IMPRESSION: Persistent left lower lobe atelectasis with associated elevation of the left hemidiaphragm. Radiology Report ULTRASOUND BILATERAL LOWER EXTREMITY DOPPLER DATED ___ INDICATION: ___ woman with lupus, persistent tachycardia, and dyspnea. Assess for DVT. COMPARISON: No relevant ultrasounds available for comparison. TECHNIQUE: Grayscale and color Doppler images performed of bilateral common femoral veins, superficial femoral veins, popliteal veins, posterior tibial veins, and peroneal veins. FINDINGS: There is normal phasicity within the common femoral veins bilaterally. The visualized vessels are patent and compressible with normal waveforms and augmentation. No thrombus identified. IMPRESSION: No evidence of DVT within the lower extremities bilaterally. Radiology Report STUDY: CHEST RADIOGRAPH. INDICATION: Hemoptysis, status post extubation. Assess for interval change. TECHNIQUE: Portable AP radiograph was obtained. COMPARISON: ___ REPORT: Right-sided central line appears at the lower SVC or the cavoatrial junction. This is unchanged. There is unchanged patchy opacification slightly elevated left hemidiaphragm reflects an atelectasis. Unchanged right-sided granuloma. Reasonably heavy tracheobronchial calcifications noted. Nonspecifically mildly increased lung markings are noted. There is no acute cardiopulmonary finding noted. A right caval temporary filter is noted. CONCLUSION: No Significant change from prior study. No acute findings. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: COUGHING BLOOD Diagnosed with HEMOPTYSIS, UNSPECIFIED, ABNORMAL COAGULATION PROFILE temperature: 98.2 heartrate: 108.0 resprate: 18.0 o2sat: 100.0 sbp: 138.0 dbp: 95.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ were admitted to the hospital with a life-threatening bleed into your left lung. Your INR was >4 so we stopped coumadin. ___ underwent a procedure to localize and cauterize the source of the bleed: a left bronchial artery. ___ required intubation to help ___ breathe as the blood in your left lung resolved. ___ had multiple bronchoscopies to remove blood clots and mucous plugs. ___ were followed closely by rheumatologists who recommended steroids to dampen any possible lupus vasculitis, which could have caused the bleed. ___ also developed ventilator-associated pneumonia and were treated with antibiotics. Your PCP ___ continue to manage your coumadin. For now, do not take coumadin. We will recommend restarting coumadin in approximately 1 week, after IVC filter removal, but the final decision will be made by Dr. ___ in cooperation with your hematologist and rheumatologist. Please see below for a list of ___ signs. Please pay special attention to any difficulty breathing, chest pain including discomfort with breathing, leg or calf pain or swelling. Also be aware of ___ signs for stroke including sudden weakness or numbness, difficulty speaking, and change in vision. We recommended ___ rehabilitation because ___ were very weak after 10 days in bed in the hospital. Physical therapy did not think ___ were safe to go home. However, ___ refused to go to rehab. We made the following changes to your medications: STOP COUMADIN STOP LISINOPRIL (RECENTLY DISCONTINUED BY YOUR PCP) STOP GUAIFENESIN STOP LOSARTAN, please discuss resuming this medication with your PCP and ___ START CHLOROSEPTIC SPRAY FOR THROAT DISCOMFORT, EVERY 6 HOURS AS-NEEDED START PREDNISONE TAPER, 40 MG ___ THEN 30 MG DAILY UNTIL ___ SEE YOUR RHEUMATOLOGIST, WHO WILL GIVE FURTHER TAPERING INSTRUCTIONS. START ATIVAN 0.5 mg UP TO EVERY 8 HOURS FOR ANXIETY OR NAUSEA FOR 10 DAYS. PLEASE DO NOT DRINK ___ WHILE TAKING THIS MEDICATION.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Nifedipine Attending: ___ Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS =============== ___ 12:14AM BLOOD WBC-18.1* RBC-5.59 Hgb-16.7 Hct-48.9 MCV-88 MCH-29.9 MCHC-34.2 RDW-13.1 RDWSD-41.8 Plt ___ ___ 12:14AM BLOOD Neuts-88.3* Lymphs-6.6* Monos-4.5* Eos-0.1* Baso-0.1 Im ___ AbsNeut-16.01* AbsLymp-1.20 AbsMono-0.81* AbsEos-0.02* AbsBaso-0.02 ___ 12:14AM BLOOD ___ PTT-31.1 ___ ___ 12:14AM BLOOD Glucose-165* UreaN-34* Creat-1.8* Na-138 K-4.1 Cl-80* HCO3-23 AnGap-35* ___ 12:14AM BLOOD Albumin-5.7* Calcium-10.9* Phos-5.2* Mg-2.4 ___ 12:14AM BLOOD ALT-16 AST-30 AlkPhos-163* TotBili-0.6 ___ 12:14AM BLOOD Lipase-20 ___ 12:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 12:20AM BLOOD Lactate-4.9* ___ 03:22AM BLOOD Lactate-1.9 ___ 05:52AM URINE Blood-TR* Nitrite-NEG Protein-70* Glucose-NEG Ketone->150* Bilirub-NEG Urobiln-NORMAL pH-6.5 Leuks-NEG ___ 05:52AM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-<1 ___ 05:52AM URINE CastHy-10* DISCHARGE LABS =============== ___ 07:22AM BLOOD WBC-11.5* RBC-4.51* Hgb-13.3* Hct-41.3 MCV-92 MCH-29.5 MCHC-32.2 RDW-13.1 RDWSD-44.3 Plt ___ ___ 07:22AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-143 K-3.8 Cl-96 HCO3-32 AnGap-15 ___ 07:22AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.3 STUDIES/IMAGING ================ ___ CXR No acute cardiopulmonary abnormality. ___ CT ABD/PELVIS W/ CONTRAST No acute intra-abdominal or intrapelvic pathology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lidocaine 5% Patch 1 PTCH TD QAM 2. Gabapentin 600 mg PO TID 3. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY 4. Morphine SR (MS ___ 45 mg PO Q12H 5. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 6. Senna 17.2 mg PO DAILY Discharge Medications: 1. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 2. Gabapentin 600 mg PO TID 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY 5. Morphine SR (MS ___ 45 mg PO Q12H 6. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 7. Senna 17.2 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======== Hematemesis SECONDARY ========== Hypertension Phantom limb pain 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 hematemesis // Evaluate for pneumomediastinum, widened mediastinum, pneumonia, or other acute abnormalities TECHNIQUE: Chest AP upright and lateral COMPARISON: Multiple prior chest radiographs dating back to ___, most recently ___. Chest CT dated ___. FINDINGS: Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes are normal. As before, there is a trace pleural thickening in the right lung base. Spinal fusion hardware is in unchanged position. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: +PO contrast; History: ___ with hematemesis+PO contrast // Evaluate for perforated ulcer, SBO, appendicitis or other acute abnormalities TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP = 13.2 mGy-cm. 2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 13.9 mGy (Body) DLP = 682.8 mGy-cm. Total DLP (Body) = 696 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Aside from 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. A 1.5 x 1.0 cm left hepatic hemangioma (2:18) is unchanged. Focal fat adjacent to the falciform ligament (2:15) is also stable. 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. There is an 8 mm splenule located posteriorly. 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. Subcentimeter hypodensities bilaterally are too small to characterize, but statistically likely represent simple cysts. There is no evidence of solid renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no free intraperitoneal air. Oral contrast is seen passing into the proximal large bowel. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Redemonstrated is a homogeneously hyperdense linear structure lying between the corpora cavernosa, which remains indeterminate (series 2, image 82). LYMPH NODES: Subcentimeter mesenteric lymph nodes are likely reactive. 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. A healed fracture in the posterior left ninth rib is again noted. There marked degenerative changes in the lower lumbar spine, most severe at L4-5 and L5-S1 as evidenced by loss of intervertebral disc space height, vacuum phenomena, endplate sclerosis, facet hypertrophy, subcortical cystic change and anterior posterior osteophyte formation. SOFT TISSUES: There is a small left fat containing inguinal hernia. IMPRESSION: No acute intra-abdominal or intrapelvic pathology. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Hematemesis, N/V Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 98.2 heartrate: 164.0 resprate: 22.0 o2sat: 99.0 sbp: 151.0 dbp: 115.0 level of pain: 10 level of acuity: 1.0

Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had many episodes of bloody vomiting WHAT HAPPENED IN THE HOSPITAL? ============================== - We gave you fluid through your IV to replenish the fluid you lost from vomiting and bleeding. This made you feel much better. - We monitored your lab values to check for ongoing bleed. Your labs were stable, so we felt your bleed had improved and was minimal at discharge. - We recommended performing a study called an EGD, where a scope is used to look at your stomach. You did not want an EGD while inpatient. We explained the benefits of this procedure, including: - Identifying a source of bleeding - Identifying ongoing bleed which would require more IV fluids, possible blood transfusions, and/or ablation with the scope to stop the bleeding WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications as listed below - Please schedule follow up with your primary care doctor and with the gastroenterologists to have your bloody vomiting evaluated. This is important to make sure you don't have any more episodes of bleeding. - If you have any difficulty breathing, lightheadedness, continued vomiting of blood, please go to the emergency room urgently. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / atenolol / naproxen / aspirin Attending: ___. Chief Complaint: Seizure, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history of polysubstance use disorder, alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal seizures who presented with altered mental status and hypoxia s/p a presumed seizure. According to EMS, this morning around 10am, Mr. ___ had a presumed seizure. He called his ___, who then alerted EMS. On arrival, EMS found him awake and alert. However, in transit to the hospital, Mr. ___ acutely worsened, becoming progressively somnolent and hypoxic. In the ED, he endorsed R sided chest wall pain s/p reported rib fractures ___ a seizure and fall. He reports taking Keppra 1500mg daily, differing from his 1000 BID Rx. He denies taking Zonisamide, one of his other Rx, and he endorses having a drink today. It was difficult to obtain a clear history given his current mental status, though it continues to improve. In the ED: - Initial vital signs were notable for: T 97.6, HR 81, BP 107/78, RR 14, 88% RA - Exam notable for: General: Somnolent but arousable HEENT: Normal oropharynx, no exudates/erythema, atraumatic head, EOMI, PERRL MSK: No deformities or signs of trauma, no focal deficits noted Neuro: Alert and oriented x1, slurred speech, right leg weakness which is pain limited. The rest of his exam is non-focal. - Labs were notable for: BLOOD WBC: 3.5* RBC: 3.83* Hgb: 11.4* Hct: 35.7* Plt Ct: 51* Monos: 14.0* AbsNeut: 1.56* ___: 15.0* ___: 1.4* Glucose: 115* Cl: 110* HCO3: 21* ALT: 30 AST: 91* AlkPhos: 220* TotBili: 1.5 Ethanol: ___ Lactate: 1.3 URINE cocaine: POS* - Studies performed include: CT Head 1. No acute intracranial abnormality. 2. Sinus disease. CXR Mild-to-moderate pulmonary edema. - Patient was given: IV LevETIRAcetam (1000 mg ordered) PO/NG Thiamine 500 mg PO Multivitamins 1 TAB - Consults: Neuro Vitals on transfer: Temp: 97.4 PO BP: 113/78 HR: 77 RR: 18 O2 sat: 95% O2 delivery: 4L Upon arrival to the floor, the patient confirmed much of the previous history. He explained that his seizures began roughly six months ago, when he was struck in the back of the head with a lead pipe. Since that accident, he has experienced seizures roughly every other day. He reports that they are triggered by stress and that he experiences a metallic taste in his mouth before the onset of each seizure. He attempts to lower himself to the floor before the onset to prevent a fall, but he is not always aware of the onset and able to do so in time. He reports rib fractures due to a seizure roughly one week ago during which he fell off of his bed onto his nightstand. He is followed by a neurologist at ___. He reports being more stressed over the last year due to the passing of both his parents and his sibling in quick succession. When asked about his alcohol consumption, Mr. ___ reports drinking ___ beers about 4 times per week. He reports having his last drink at 10am today. He denied additional substance use, noting that someone had slipped cocaine into his beverage to trigger the positive cocaine screen. He endorsed fevers, chills, and feeling incredibly cold. Past Medical History: PAST MEDICAL HISTORY: R 8 and 9 Rib Fractures HCV Alcoholic Cirrhosis Portal Vein Thromboses Esophageal Varices s/p Banding OA pseudoseizures vs. seizures COPD panctyopenia Social History: ___ Family History: N/a Physical Exam: GENERAL: AOx3, engaging in conversation appropriately EYES: NCAT. EOMI. Dilated pupils b/l, reactive to light. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. Unable to appreciate JVD given body position. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Poor air movement. Diffusely ronchorus with expiratory wheeze. ABDOMEN: Hypoactive bowels sounds, mildly distended, TTP along the R. EXTREM: Clubbing of the fingers. Pulses Radial 2+ bilaterally, ___ 2. +1 pitting edema. Extremities warm and well-perfused NEUROLOGIC: AOx3. Dilated pupils. Otherwise, CN2-7 evaluated and intact. Moving extremities appropriately. Normal sensation. Mild tremor PSYCH: appropriate Pertinent Results: ___ 01:00PM URINE HOURS-RANDOM ___ 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 01:00PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG ___ 01:00PM URINE RBC-1 WBC-2 BACTERIA-FEW* YEAST-NONE EPI-<1 ___ 01:00PM URINE MUCOUS-RARE* ___ 12:50PM GLUCOSE-115* UREA N-6 CREAT-0.5 SODIUM-146 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15 ___ 12:50PM estGFR-Using this ___ 12:50PM ALT(SGPT)-30 AST(SGOT)-91* ALK PHOS-220* TOT BILI-1.5 ___ 12:50PM LIPASE-57 ___ 12:50PM LIPASE-57 ___ 12:50PM ALBUMIN-3.5 ___ 12:50PM ASA-NEG ___ ACETMNPHN-NEG tricyclic-NEG ___ 12:50PM LACTATE-1.3 ___ 12:50PM WBC-3.5* RBC-3.83* HGB-11.4* HCT-35.7* MCV-93 MCH-29.8 MCHC-31.9* RDW-16.3* RDWSD-55.2* ___ 12:50PM NEUTS-44.7 ___ MONOS-14.0* EOS-4.0 BASOS-0.3 IM ___ AbsNeut-1.56* AbsLymp-1.28 AbsMono-0.49 AbsEos-0.14 AbsBaso-0.01 ___ 12:50PM PLT SMR-VERY LOW* PLT COUNT-51* ___ 12:50PM ___ PTT-35.7 ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Tiotropium Bromide 1 CAP IH DAILY 2. LevETIRAcetam 1000 mg PO BID 3. Ciprofloxacin HCl 500 mg PO Q24H 4. Ferrous Sulfate 325 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. FoLIC Acid 0.8 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. Lactulose 15 mL PO BID 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/wheeze 10. Magnesium Oxide 400 mg PO BID 11. Melatin (melatonin) 5 mg oral QHS:PRN sleep aid 12. Multivitamins 1 TAB PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Spironolactone 100 mg PO DAILY 15. tadalafil 40 mg oral DAILY 16. Thiamine 100 mg PO DAILY 17. rifAXIMin 550 mg PO BID 18. ergocalciferol (vitamin D2) 50,000 unit oral 1X/WEEK 19. Prazosin 1 mg PO DAILY 20. QUEtiapine Fumarate 100 mg PO QHS 21. Venlafaxine XR 75 mg PO TID Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/wheeze 3. Ciprofloxacin HCl 500 mg PO DAILY 4. ergocalciferol (vitamin D2) 50,000 unit oral 1X/WEEK 5. Ferrous Sulfate 325 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Furosemide 40 mg PO DAILY 8. Lactulose 15 mL PO BID 9. LevETIRAcetam 1000 mg PO BID 10. Magnesium Oxide 400 mg PO BID 11. Melatin (melatonin) 5 mg oral QHS:PRN sleep aid 12. Multivitamins 1 TAB PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Prazosin 1 mg PO DAILY 15. QUEtiapine Fumarate 100 mg PO QHS 16. rifAXIMin 550 mg PO BID 17. Spironolactone 100 mg PO DAILY 18. tadalafil 40 mg oral DAILY 19. Thiamine 100 mg PO DAILY 20. Tiotropium Bromide 1 CAP IH DAILY 21. Venlafaxine XR 75 mg PO TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Final diagnoses: - Acute Toxic/Metabolic/Postictal/Hepatic encephalopathy - Seizure - Acute pulmonary edema c/b acute hypoxic respiratory failure - Polysubstance use disorder - ETOH intoxication/use disorder/withdrawal - ETOH cirrhosis c/b portal hypertension and coagulopathy - Pancytopenia d/t ETOH and splenomegaly - PTSD/Depression/Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ with altered mental status and hypoxia // Hypoxia COMPARISON: None FINDINGS: AP portable upright view of the chest. Overlying EKG leads are present. There is ground-glass opacity concerning for edema which is mild to moderate in extent. No large effusion is seen though the right CP angle is excluded. No pneumothorax. No gross signs for pneumonia. Cardiomediastinal silhouette appears normal. Bony structures are intact IMPRESSION: Mild-to-moderate pulmonary edema. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with AMS, seizure, // eval for bleed DOSE: Total DLP (Head) = 1,204 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of fracture, acute major infarction,hemorrhage,edema,or definite mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is near complete opacification of the right maxillary sinus and adjacent ethmoid air cells. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal. IMPRESSION: 1. No acute intracranial abnormality. 2. Sinus disease. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: Mr. ___ is a ___ with a history of EtOH use disorder,alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal seizures. // ___ screen TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. Evaluation for focal liver masses is limited. The main portal vein is patent with hepatofugal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 8 mm GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 20.3 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 13.4 cm Left kidney: 13.9 cm RETROPERITONEUM: Although not well visualized, the visualized portions of aorta and IVC are within normal limits. OTHER: Incidental note is made of midline varicosity. IMPRESSION: Cirrhotic liver morphology with sequelae of portal hypertension including hepatofugal portal flow, midline varices, and splenomegaly. Evaluation for focal liver lesions is limited on this study given heterogeneity of the liver. Liver MRI or multiphasic liver CT is recommended for further screening. RECOMMENDATION(S): Liver MRI or multiphasic liver CT is recommended for further screening. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hypoxia, Seizure Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus temperature: 97.6 heartrate: 81.0 resprate: 14.0 o2sat: 88.0 sbp: 107.0 dbp: 78.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted because you had a seizure at home, and you were found to be confused and requiring oxygen to maintain normal oxygen levels. WHAT WAS DONE WHILE I WAS HERE? - You were seen by our neurology team, who recommended that you stay on Keppra 1000 mg twice a day. - Your labs were monitored closely. - You had some confusion, which we thought was due to your liver disease. This improved with you taking lactulose. - You required some supplemental oxygen briefly, but you no longer required oxygen on day of discharge. WHAT DO I NEED TO DO ONCE I LEAVE? - Please take your medications and keep your appointments. - It is very important for you to take your lactulose and rifaximin, as this will prevent you from becoming confused due to your liver disease. - We would strongly recommend that you stop drinking. - If you develop fevers (T > 100.4 F), confusion, belly swelling, or shortness of breath, please call your doctor or go to the nearest Emergency Room. Be well, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old male with a history of asthma presenting with SOB at rest and with exertion. For the past few weeks, he has had some rhinitis, congestion with a productive cough and a mild sore throat. He notes that for the past week he has developed increasing SOB with exertion, and more recently at rest as well. He has also had associated nasal congestion and cough. He denies fevers, chills, nausea, vomiting, abd pain, dysuria, diarrhea. He reports that he has had asthma exacerbations in the past, but has never been hospitalized before. Typically his asthma exacerbations are managed as an outpatient occasionally requiring PO steroids. He also takes Flovent, but only when he has an exacerbation. His only routine asthma medication is albuterol rescue inhaler. He says that when he is feeling at his baseline he usually uses his rescue inhaler ___ per day. He does not have night time awakenings with shortness of breath or cough. He also has seasonal allergies and will take fluticasone nasal spray when needed. In the ED, the patient was noted to be tachycardic with a HR of 113, but was satting 96% on room air. He was noted to be diffusely wheezing in all lung fields, and was given albuterol and ipratropium nebs, as well as IV solumedrol 125mg, and IV magnesium sulfate 2g. The patient was then placed on BiPAP. Labs were drawn which were only notable to a lactate of 3.1. The patient was satting well on room air following multiple nebs and IV steroids and was normotensive, however a repeat lactate was 6.0, and the patient was admitted to the ICU. Past Medical History: Asthma Social History: ___ Family History: Notable for DM, HTN in multiple family members Physical ___ Physical Exam VITALS: Tm 98.6, HR 110s, BP 120s-140s/60s-80s, RR 19, > 95%RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. Peak flow 220 CV: Tachycardic, regular rhythm, no murmurs, rubs or gallops ABD: NABS, soft, NT, ND, no rebound or guarding EXT: Warm, well perfused, no edema NEURO: CN II-XII grossly intact, moving all 4 extremities spontaneously and purposefully, gait normal, speech fluent Discharge Physical Exam VITALS: reviewed in Metavision GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. Peak flow 220 CV: Tachycardic, regular rhythm, no murmurs, rubs or gallops ABD: NABS, soft, NT, ND, no rebound or guarding EXT: Warm, well perfused, no edema NEURO: CN II-XII grossly intact, moving all 4 extremities spontaneously and purposefully, gait normal, speech fluent Pertinent Results: Admission Labs ___ 07:03PM LACTATE-6.0* ___ 05:03PM ___ PO2-28* PCO2-45 PH-7.36 TOTAL CO2-26 BASE XS--1 ___ 01:44PM ___ PO2-43* PCO2-46* PH-7.37 TOTAL CO2-28 BASE XS-0 ___ 01:44PM O2 SAT-76 ___ 01:17PM LACTATE-3.1* ___ 01:00PM GLUCOSE-118* UREA N-11 CREAT-0.8 SODIUM-143 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18 ___ 01:00PM WBC-7.2 RBC-5.93 HGB-14.2 HCT-44.8 MCV-76* MCH-23.9* MCHC-31.7* RDW-16.4* RDWSD-42.1 ___ 01:00PM NEUTS-67.3 ___ MONOS-7.8 EOS-2.4 BASOS-0.6 IM ___ AbsNeut-4.84 AbsLymp-1.55 AbsMono-0.56 AbsEos-0.17 AbsBaso-0.04 ___ 01:00PM PLT COUNT-222 ___ 01:00PM ___ PTT-30.1 ___ DISCHARGE LABS ___ 02:03AM BLOOD WBC-9.1 RBC-5.43 Hgb-12.9* Hct-40.7 MCV-75* MCH-23.8* MCHC-31.7* RDW-15.4 RDWSD-41.1 Plt ___ ___ 02:03AM BLOOD Glucose-211* UreaN-12 Creat-0.9 Na-138 K-4.7 Cl-102 HCO3-24 AnGap-12 ___ 02:03AM BLOOD Calcium-8.9 Phos-1.2* Mg-2.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Cialis (tadalafil) 10 mg oral PRN 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing Discharge Medications: 1. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth DAILY Disp #*6 Tablet Refills:*0 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing 3. Cialis (tadalafil) 10 mg oral PRN 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation 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 asthma exacerbation// PNA? TECHNIQUE: Portable frontal views of the chest. COMPARISON: None. FINDINGS: Heart size is normal. Cardiomediastinal silhouette and hilar contours are preserved. Lungs are clear. Pleural surfaces are clear without effusion or pneumothorax. There is no acute osseous abnormality. IMPRESSION: No acute cardiopulmonary abnormality. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Cough, Dyspnea Diagnosed with Unspecified asthma with (acute) exacerbation temperature: 98.1 heartrate: 113.0 resprate: 18.0 o2sat: 96.0 sbp: 143.0 dbp: 45.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital with an asthma exacerbation. You were given steroids and nebulizers and your symptoms improved. Your exacerbation was most likely triggered by a viral upper respiratory infection. You will continue to take oral steroids for 3 more days after you are discharged in order to treat your asthma exacerbation. You should continue to take your albuterol inhaler as needed. Please attend your follow up appointment as listed below. Thank you for choosing ___. It was a pleasure caring for you! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abnormal imaging Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of recurrent GI bleeds, CVAs, UTIs, Grave's disease, DMII, atrial fibrillation on apixaban, and asthma who presents with dyspnea and a CT scan from an outside facility suggestive of right lower lobe pneumonitis. Since earlier this week, her family has noticed she has had a productive cough with yellow phlegm and vomited ___. She also had a fever to ___ on ___ and ___. Her family was giving her cool towels and treating her at home and overall felt she was feeling better with that treatment. She had a CT scan on ___ which was ordered for evaluation of a lung nodule at ___ that revealed evidence of RLL pneumonitis. She was unable to provide a history in the ED and history was obtained from her niece. There is possible chest pain associated with her cough. No history of significant shortness of breath. Denied sick contacts at home. At baseline, she is wheelchair bound after multiple cardioembolic strokes with fluctuating alertness. Last had a stroke ___ months ago and was admitted with a stroke. Since then, she has been wheelchair bound and has had R sided hemiparesis. The niece notes she has also had dysphagia and has been on pureed foods and thickened liquids. Minimally conversant at baseline. She has a PCA at home and requires dependence in all ADLs including transfers and feeding. In the ED, initial vitals: T ___ HR 85 BP 167/78 RR 20 O2 98% RA Labs notable for: WBC 8.1 Hgb 11.3 Plt 401 Cr 0.6 BUN 9 Na 144 Bicarb 25 Cl 106 Lactate 3.9, 3.7, 4.4 VBGx2 unremarkable Flu negative Imaging notable for: Comparison to ___. On today's examination, there is stable mild bilateral apical scarring and elevation of the right hemidiaphragm. Moreover, the heart is slightly enlarged and there is elongation of the descending aorta. However, there is no evidence of pneumonia, pulmonary edema or pleural effusions. No pneumothorax. Severe scoliosis with secondary degenerative vertebral changes. - Patient was given: IV Ampicillin-Sulbactam 3 g 2L IV LR On arrival to the floor, patient is minimally conversant and unable to provide a history. Past Medical History: - Atrial fibrillation, paroxysmal - Hypertension - Diabetes mellitus II - Asthma - Obesity - Graves Disease - Right knee DJD - Mild esophagitis seen on EGD ___ - history of UTI - Colitis thought to be ischemic colitis - Microcytic anemia - Total abdominal hysterectomy (for uterine prolapse) Social History: ___ Family History: noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: ___ Temp: 98.2 PO BP: 161/87 HR: 76 RR: 17 O2 sat: 96% O2 delivery: Ra GENERAL: Patient comfortable but non-verbal, lying in bed HEENT: atraumatic, PERRL. Preferetial rightward eye gaze but tracks to voice. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, Expiratory rhonchi throughout. Decreased breath sounds at RL base. 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: Not verbalizing so unable to assess orientation. PERRL, Preferential R eye gaze but tracks to all directions. Face symmetric at rest and with activation. Motor exam notable for at least ___ strength in left arm and leg but ___ strength in right arm. Increased tone in left upper arm with 1+ reflexes throughout. Unable to assess sensory function. Plantar reflexes bilaterally. SKIN: No significant rashes Discharge Exam ================== ___ ___ Temp: 98.0 PO BP: 164/84 L Lying HR: 69 RR: 18 O2 sat: 94% O2 delivery: Ra FSBG: 225 GENERAL: Patient comfortable, smiling, minimally-verbal HEENT: atraumatic, PERRL. Preferetial rightward eye gaze but tracks to voice. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, Expiratory rhonchi throughout. Decreased breath sounds at RL base. 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: AOx1.5 (self, knows in hospital but not which one) PERRL, Preferential R eye gaze but tracks to all directions. Face symmetric at rest and with activation. Motor exam notable for at least ___ strength in left arm and leg but ___ strength in right arm. Increased tone in left upper arm with 1+ reflexes throughout. Unable to assess sensory function. Plantar reflexes bilaterally. SKIN: No significant rashes Pertinent Results: Admission Labs ================== ___ 10:40AM BLOOD WBC-8.1 RBC-4.63 Hgb-11.3 Hct-37.1 MCV-80* MCH-24.4* MCHC-30.5* RDW-22.2* RDWSD-63.6* Plt ___ ___ 10:40AM BLOOD Neuts-78.0* Lymphs-15.3* Monos-5.5 Eos-0.6* Baso-0.1 Im ___ AbsNeut-6.33* AbsLymp-1.24 AbsMono-0.45 AbsEos-0.05 AbsBaso-0.01 ___ 06:23AM BLOOD ___ PTT-150* ___ 10:40AM BLOOD Plt ___ ___ 10:40AM BLOOD Glucose-272* UreaN-9 Creat-0.6 Na-144 K-5.5* Cl-106 HCO3-25 AnGap-13 ___ 10:40AM BLOOD ALT-22 AST-26 AlkPhos-83 TotBili-0.3 ___ 10:40AM BLOOD cTropnT-<0.01 proBNP-378 ___ 10:40AM BLOOD Albumin-3.1* Calcium-10.8* Mg-1.6 ___ 06:23AM BLOOD PTH-169* ___ 05:14AM BLOOD 25VitD-39 ___ 10:46AM BLOOD Lactate-3.9* Pertinent Labs -============ ___ 06:23AM BLOOD PTH-169* ___ 05:14AM BLOOD 25VitD-39 ___ 10:40AM BLOOD Albumin-3.1* Calcium-10.8* Mg-1.6 Imaging =========== CT CHEST W/O CONTRASTStudy Date of ___ 2:52 ___ IMPRESSION: Severe broncho centric and bronchiolar infection right lung, probably viral. Moderate, chronic generalized bronchial inflammation is more severe due to acute infection. Chronic mild to moderate thyromegaly. Possible anasarca. Reccs: Conventional chest radiograph now, repeated in 6 weeks, at which time any need for repeat chest CT scanning will be determined. Discharge Labs =================== ___ 05:14AM BLOOD WBC-6.2 RBC-4.67 Hgb-11.4 Hct-37.2 MCV-80* MCH-24.4* MCHC-30.6* RDW-22.4* RDWSD-63.3* Plt ___ ___ 05:14AM BLOOD Plt ___ ___ 05:14AM BLOOD Glucose-207* UreaN-8 Creat-0.4 Na-144 K-4.0 Cl-103 HCO3-29 AnGap-12 ___ 06:23AM BLOOD ALT-19 AST-16 LD(LDH)-241 AlkPhos-72 TotBili-0.4 ___ 05:14AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 2. Apixaban 5 mg PO BID 3. Benzonatate 100 mg PO TID 4. Bisacodyl ___AILY:PRN constipation 5. Ferrous GLUCONATE 324 mg PO DAILY 6. FLUoxetine 20 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 8. Methimazole 5 mg PO DAILY 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Senna 17.2 mg PO QHS 11. Diltiazem Extended-Release 90 mg PO DAILY 12. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN wheezing 13. MetFORMIN (Glucophage) 1000 mg PO BID 14. Vesicare (solifenacin) 10 mg oral daily 15. Atorvastatin 80 mg PO QPM 16. Amantadine 100 mg PO BID 17. Pantoprazole 40 mg PO Q24H 18. Carbidopa-Levodopa (___) 0.5 TAB PO TID Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth twice a day Disp #*9 Tablet Refills:*0 2. Azithromycin 250 mg PO DAILY Duration: 4 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2 Tablet Refills:*0 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 4. Amantadine 100 mg PO BID 5. Apixaban 5 mg PO BID 6. Atorvastatin 80 mg PO QPM 7. Benzonatate 100 mg PO TID 8. Bisacodyl ___AILY:PRN constipation 9. Carbidopa-Levodopa (___) 0.5 TAB PO TID 10. Diltiazem Extended-Release 90 mg PO DAILY 11. Ferrous GLUCONATE 324 mg PO DAILY 12. FLUoxetine 20 mg PO DAILY 13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN wheezing 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Methimazole 5 mg PO DAILY 17. Multivitamins W/minerals 1 TAB PO DAILY 18. Pantoprazole 40 mg PO Q24H 19. Senna 17.2 mg PO QHS 20. Vesicare (solifenacin) 10 mg oral daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Viral Bronchitis Aspiration pneumonia Urinary Tract Infection Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with history of cough, phlegm, fever at home// PNA? PNA? IMPRESSION: Comparison to ___. On today's examination, there is stable mild bilateral apical scarring and elevation of the right hemidiaphragm. Moreover, the heart is slightly enlarged and there is elongation of the descending aorta. However, there is no evidence of pneumonia, pulmonary edema or pleural effusions. No pneumothorax. Severe scoliosis with secondary degenerative vertebral changes. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Pneumonia, unspecified organism temperature: 98.0 heartrate: 85.0 resprate: 20.0 o2sat: 98.0 sbp: 167.0 dbp: 78.0 level of pain: 3 level of acuity: 2.0

Dear ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted out of concern for a pneumonia What was done for me while I was in the hospital? - We looked at your lungs with a cat scan, which showed you have bronchitis - We looked at your urine under a microscope, and we were concerned you had a bladder infection - We started you on antibiotics to treat your infections What should I do when I leave the hospital? - Please take your medications as prescribed - Please keep all of your appointments - continue your pureed diet with nectar thickened liquids Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tramadol / Abacavir Attending: ___. Chief Complaint: Positive blood culture. Major Surgical or Invasive Procedure: hemodialysis session on ___ History of Present Illness: Ms. ___ is a ___ year old woman with a history of HIV, HCV, end-stage renal disease on HD, and hypertension, who was found to have a positive gram positive blood culture taken during HD yesterday. . According to Ms. ___, she began to feel unwell yesterday during HD which prompted her to ask for a blood culture. After the HD session she had up to 30 episodes of non-bloody vomiting which was followed by severe, ___, epigastric abdominal pain that felt like a gnawing dullness. "It felt like pancreatitis." This morning, her primary care physician informed her by telephone that her blood culture had come back positive and advised her to go to the emergency department. . Her vital signs on presentation to the emergency department were: T 99.6, P 90, BP 192/114, RR 18, O2 Sat 100%. She was given 1 gram of IV Vancomycin for the positive blood culture, Zofran for nausea, and morphine for pain, and acetaminophen for a new onset headache while in the ED. Her labs were significant for a BUN 55, Cr 8.5, and a lactate that was initially 3.3 but then dropped to 2.1. She also received 1L of NS. Her vital signs on transfer to the floor were T 98.0, P 89, RR 14, BP 116/70, O2 Sat 100%. . Currently, she does not complain of pain or nausea. She had no sick contacts. She attributes the nausea and vomiting to having eaten at a restaurant where she previously developed a gi illness. She endorses having had developed a headache while in the emergency department that still persists. She denies shortness of breath, cough, diarrhea and constipation, urinary changes, fevers, night sweats, and chills. Past Medical History: End Stage Renal Disease on HD. (Dr. ___ is her nephrologist) Hepatitis C (has never had treatment for HCV) HIV (Diagnosed ___ years ago. CD4 299, Viral Load 55 per ___ labs) Hypertension ITP Right Subclavian Thrombosis Anxiety Depression Social History: ___ Family History: non-contributory. Physical Exam: On Admission: VS - Temp 98.8F, BP 116/70, HR 89, R 14, O2-sat 100% RA GENERAL - NAD, comfortable, appropriate HEENT - No head trauma. Extraocular movements are intact. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. NECK - supple, no thyromegaly, no carotid bruits, non-tender lymphadenopathy appreciated, no JVD. LUNGS - Clear to auscultation bilaterally. HEART - RRR, nl s1 and s2, no murmurs appreciated ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - Failed fistulas in her right and left upper extremity. Left sided tunneled drain with no purulous drainage or pus surrounding the site. SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, sensation grossly intact throughout At Discharge: AF, no abdominal pain, line appears clean without purulence or erythema Pertinent Results: Images: IMPRESSION: No evidence of acute cardiopulmonary disease. Labs on admission: . ___ 11:10AM BLOOD WBC-4.7 RBC-4.46 Hgb-13.7 Hct-43.0 MCV-96 MCH-30.7 MCHC-31.9 RDW-16.0* Plt ___ ___ 11:10AM BLOOD Neuts-72.8* ___ Monos-3.8 Eos-0.2 Baso-0.4 ___ 11:10AM BLOOD Plt ___ ___ 11:10AM BLOOD Glucose-100 UreaN-57* Creat-8.2* Na-133 K-GREATER TH Cl-87* HCO3-27 ___ 11:10AM BLOOD ALT-33 AST-76* AlkPhos-457* TotBili-0.7 ___ 11:10AM BLOOD Lipase-41 ___ 12:30PM BLOOD CK-MB-1 cTropnT-0.02* ___ 11:10AM BLOOD HoldBLu-HOLD ___ 11:17AM BLOOD Lactate-3.3* Microbiology: ___ CULTUREBlood Culture, Routine-FINAL {STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL . ___ CULTUREBlood Culture, Routine-FINAL {STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL . Labs on Discharge: ___ 06:45AM BLOOD WBC-5.8 RBC-3.89* Hgb-12.0 Hct-37.8 MCV-97 MCH-30.9 MCHC-31.8 RDW-16.1* Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-75 UreaN-73* Creat-10.2*# Na-133 K-5.5* Cl-87* HCO3-31 AnGap-21* ___ 12:00AM BLOOD CK(CPK)-36 ___ 12:00AM BLOOD CK-MB-1 cTropnT-0.02* ___ 06:45AM BLOOD Calcium-11.2* Phos-7.2*# Mg-2.0 ___ 06:45AM BLOOD PTH-3381* ___ 06:45AM BLOOD Vanco-23.2* Medications on Admission: Atazanavir 300mg po daily Ritonavir 400mg po BID Raltegravir 400mg po BID Emtricitabine 200mg q96hr (has not yet filled ___ prescription) Sulfamethoxazole-Trimethoprim 1 tab every other day. Lisinopril 40mg po daily Metoprolol Tartrate 100mg po BID Aspirin 81mg po daily Sevelamer 800mg with meals Nephrocaps 1mg capsule daily Lactulose 10 gram/15ml once daily as needed Acetaminophen 325mg q6h as needed Oxycodone 2mg per day for right shoulder pain per patient. Polyethylene glycol as needed per patient. Docusate as needed per patient. Senna as needed per patient. Discharge Medications: 1. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q96H (every 96 hours). 5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 11. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 12. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO once a day as needed for pain. 14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 0.5 to 1 gram Intravenous HD PROTOCOL (HD Protochol) for 2 weeks: If Vanc level < 15, give 1 gram If Vanc level ___, give 500 mg If Vanc level > 25, hold dose. Last dose to be given on ___. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Gram positive, coagulase negative staph bacteremia. Secondary Diagnosis: End Stage Renal Disease on Hemodialysis HIV HCV Hypertension ITP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Confirm bacteremia. Question pneumonia. COMPARISONS: Radiographs from ___. TECHNIQUE: Chest, AP upright and lateral views. FINDINGS: There is a dual-lumen dialysis catheter terminating in the uppermost part of the atrium, in an unchanged position. The heart is normal in size. The aortic arch is partly calcified. There is no pleural effusion or pneumothorax. The lungs appear clear aside from patchy right infrahilar opacity that appears unchanged and may be associated with minor chronic scarring or atelectasis. The appearance includes mildly dilated descending airways noting an element of slight bronchiectasis. There are similar degenerative changes which are incompletely characterized along the right shoulder. The bones appear sclerotic compatible with known renal osteodystrophy. IMPRESSION: No evidence of acute cardiopulmonary disease. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: EPISATRIC, N/V Diagnosed with BACTEREMIA NOS, END STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE temperature: 99.6 heartrate: 90.0 resprate: 18.0 o2sat: 100.0 sbp: 192.0 dbp: 114.0 level of pain: 10 level of acuity: 3.0

It was a pleasure to take care of you at the ___! You came to the hospital yesterday because you had a positive blood culture. You also had abdominal pain, nausea, and vomiting. You were treated in the emergency department with vancomycin, morphine, zofran, and acetaminophen. Your abdominal pain, nausea, and vomiting were relieved by the time you were transferred to the internal medicine floor. You received hemodialysis the following morning. During hemodialysis, you were given another dose of vancomycin. The blood culture from ___ grew a strain of organism that can be treated in the outpatient setting (coagulase negative staph). Hopefully, your line will not need to be changed in order for this strain to be treated. We ADDED Vancomycin (dosed at Hemodialysis) to your medication list -> you will continue vancomycin for 2 weeks - if there are questions about the dosing scheme, these can be directed to Dr. ___ office at ___ Otherwise your medication list is the same as that you had when you visited your primary care physician ___ ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / niacin Attending: ___. Chief Complaint: worsening leg edema Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of AVR s/p redo, CAD s/p CABG, CHB s/p pacer placement, CKD baseline cre 1.3, HTN p/w complaints of b/l ___ edema x 2 wks in the setting of now resolved upper respiratory symptoms (nonproductive cough, congestion). She wears stockings that she is now unable to pullup her thigh (only able to get up to mid calf now). However, she reports stable wt of 130. She states that she has minimal nocturia now despite taking nighttime lasix. She has been drinking less since noticing the swelling. She denies orthopnea, pnd. Does complain of some DOE. Feels that her legs are heavy and gets fatigued with walking short distances. No BRBPR, melena. No f/c/n/v/d/chest pain/baseline sob/flank pain. In the ED, initial VS were 98.6 59 132/44 16 99% ra. Exam was significant for 1+ pitting edema to mid shin. There was no stool present on rectal exam. Labs significant for Cr of 1.7 from baseline of 1.3 and HCT of 24 from normal baseline (although last value in our system from ___. BNP was in the 900s (no prior in our system). LDH elevated but normal tbili. Iron studies were suggestive of iron deficiency anemia. INR of 4.1. She had a CTAP which showed no evidence of bleed and a CXR. She was given no medications. Transfer VS were 98.5 64 104/38 16 96% On arrival to the floor, patient reports no pain, no change in bowel habits, a colonoscopy done by Dr. ___ in ___ which was "normal", a remote history of anemia that she takes folate/B12 for, no easy brusing, neuropahties or pain. She does note that for the last 2 months she has been chewing on ice which is not normal for her. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -ALLERGIC URTICARIA -ANEMIA, ACQUIRED HEMOLYTIC NOS -ANGINA PECTORIS -ATRIAL FIBRILLATION -ATRIOVENTRICULAR BLOCK s/p pacer -AVR -COUMADIN THERAPY -DISORDER, AORTIC VALVE -DIVERTICULOSIS -GERD -HOMOCYSTEINE ELEVATION -HYPERCHOLESTEROLEMIA -HYPERTENSION -PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA -SHOULDER PAIN -WRIST FX -GOUT -H/O AORTIC VALVE REPLACEMENT -H/O CLOSED HUMERUS, UPPER END, LEFT -H/O NQWMI -H/O OPHTHALMIC MIGRAINES Social History: ___ Family History: Father: MI at age ___, Paternal uncle: MI ___: MI at age ___ and ___ Mother: ___ cancer- in her ___, died in her ___. Sister: CVA in ___ Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.4, 122/84, 70, 18, 98RA GEN - Alert, oriented, no acute distress HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD, no LAD PULM - CTAB, no w/r/r CV - RRR, mechancial S1S2 with ___ early systolic murmur at the RSB ABD - obese soft, NT/ND, normoactive bowel sounds, no guarding or rebound EXT - WWP, trace ankle edema bilaterally, 2+ pulses palpable bilaterally NEURO - CN ___ intact, motor function grossly normal SKIN - no ulcers or lesions DISCHARGE PHYSICAL EXAM: VS - 98.4 ___ 16 97%RA ___ pain GEN - Alert, oriented, no acute distress HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD however difficult to assess given body habitus, no LAD PULM - CTAB, no w/r/r CV - RRR, mechancial S1, S2 with ___ early systolic murmur at the RSB ABD - obese, soft, NT/ND, normoactive bowel sounds, no guarding or rebound EXT - WWP, 1+ pitting edema to upper shins stable in comparison to yesterday, 2+ pulses palpable bilaterally NEURO - CN ___ intact, motor function grossly normal SKIN - no ulcers or lesions Pertinent Results: Admission Labs: ___ 04:25PM BLOOD ___ ___ Plt ___ ___ 04:25PM BLOOD ___ ___ ___ 04:25PM BLOOD ___ ___ ___ Tear ___ ___ 04:25PM BLOOD ___ ___ ___ 04:25PM BLOOD ___ ___ ___ 04:25PM BLOOD ___ LD(LDH)-347* ___ ___ ___ 04:25PM BLOOD ___ ___ 04:25PM BLOOD ___ ___ 04:25PM BLOOD ___ ___ 04:25PM BLOOD ___ . ___ 08:00PM URINE ___ Sp ___ ___ 08:00PM URINE ___ ___ ___ 08:00PM URINE ___ ___ . Discharge Labs: ___ 06:45AM BLOOD ___ ___ Plt ___ ___ 04:00PM BLOOD ___ ___ 06:45AM BLOOD ___ ___ ___ 06:45AM BLOOD ___ ___ . Imaging: ECG ___: Sinus bradycardia with marked first degree ___ delay. Left ___ block. Compared to the previous tracing of ___ the ___ interval is more prolonged and the sinus rate is slower. . CXR ___: No evidence of acute disease. . CT ABD/PELVIS ___: 1. No evidence of retroperitoneal hematoma. 2. Indeterminant renal cysts. Evaluation with ultrasound is recommended when clinically appropriate. 3. Moderate to large hiatal hernia. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY hold for SBP<100 2. Allopurinol ___ mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. Colchicine 0.6 mg PO DAILY 5. Metoprolol Tartrate 12.5 mg PO BID hold for HR<60 6. Ezetimibe 10 mg PO DAILY 7. Warfarin 4 mg PO 5X/WEEK (MO,WE,TH,SA) 8. Warfarin 3 mg PO 2X/WEEK (___) 9. Ranitidine 150 mg PO BID 10. Simvastatin 80 mg PO DAILY 11. Furosemide 40 mg PO BID hold for SBP<100 12. Clopidogrel 75 mg PO DAILY 13. potassium chloride *NF* 10 mEq Oral daily 14. Folic ___ B12 (Ca) *NF* ___ ___ Oral daily Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Furosemide 40 mg PO BID 5. Metoprolol Tartrate 12.5 mg PO BID 6. Warfarin 3 mg PO 2X/WEEK (___) 7. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 9. Ferrous Sulfate 325 mg PO TID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 10. Senna 1 TAB PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*60 Capsule Refills:*0 11. Colchicine 0.6 mg PO DAILY 12. potassium chloride *NF* 10 mEq Oral daily 13. Ranitidine 150 mg PO BID 14. Warfarin 4 mg PO 5X/WEEK (MO,WE,TH,SA) 15. Lisinopril 5 mg PO DAILY 16. Folic ___ B12 (Ca) *NF* ___ ___ 0 tab ORAL DAILY 17. Outpatient Lab Work Mechanical aortic valve Please measure INR week of ___ and fax results to Dr. ___ of ___ Fax: ___ Discharge Disposition: Home Discharge Diagnosis: Primary: Iron deficiency anemia Secondary: Chronic kidney disease, hypertension, coronary artery disease s/p stent placement, pacemaker, aortic valve repair x2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Bilateral lower extremity edema. COMPARISONS: ___. TECHNIQUE: Chest, PA and lateral. FINDINGS: The patient is status post aortic valve replacement and probably coronary artery bypass graft surgery. A dual-lead pacemaker/ICD device appears unchanged. The heart is moderately enlarged. The mediastinal and hilar contours appear unchanged. There is no pleural effusion or pneumothorax. The lungs appear clear. The bones are probably demineralized. Mild degenerative changes along the lower thoracic spine appear similar. IMPRESSION: No evidence of acute disease. Radiology Report CT OF THE ABDOMEN AND PELVIS HISTORY: Anemia and supratherapeutic INR. Question retroperitoneal hematoma. COMPARISONS: Chest CT is available from ___, but no prior dedicated CT imaging of the abdomen and pelvis. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained without oral or intravenous contrast. Sagittal and coronal reformations were also performed. FINDINGS: The patient is status post sternotomy. A dual-lead pacemaker/ICD device is in place. The heart is somewhat enlarged. Patchy basilar opacities suggest minor atelectasis. Along the lower pole of the left kidney there is a small moderately hyperdense focus measuring 8 mm in diameter, indeterminant although likely a hemorrhagic cyst). A small hypodense focus in the interpolar region of the right kidney of 8 mm in diameter is too small to characterize. A simple cyst along the left mid to lower pole measures 22 mm in diameter. The spleen is normal in size and appearance. The liver, pancreas and adrenal glands appear within normal limits. There is a moderate to large hiatal hernia with an air-fluid level. The stomach is otherwise unremarkable. There is moderate sigmoid diverticulosis. CT PELVIS: The uterus and adnexal regions appear within normal limits. There are no enlarged lymph nodes or ascites. The common iliac arteries are relatively small and substantial vascular disease is suspected, but not fully characterized. Patchy vascular calcifications are present. There is no aneurysm. No hematoma is identified. Dependent fluid in posterior subcutaneous tissues could be seen with some degree of fluid overload. A surgical clip is present in the left inguinal region. BONE WINDOWS: There are no suspicious lytic or blastic lesions. Moderate degenerative changes are present along lower lumbar facets. The bones appear demineralized. IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. Indeterminant renal cysts. Evaluation with ultrasound is recommended when clinically appropriate. 3. Moderate to large hiatal hernia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: LOWER EXTREMITY SWELLING Diagnosed with ANEMIA NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, CARDIAC PACEMAKER STATUS temperature: 98.6 heartrate: 59.0 resprate: 16.0 o2sat: 99.0 sbp: 132.0 dbp: 44.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you in the hospital. You were admitted for evaluation of anemia. You had imaging done that did not show any signs of bleeding. You had no signs of blood in your upper or lower gastrointestinal tract. You were found to be iron deficient and you should start taking iron supplements. You should also follow up with Dr. ___ Dr. ___ this. As we discussed while you were here, you may need IV iron to get your levels back to normal. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Please make sure to follow up with your outpatient providers as listed below. Please see the attached sheet for your updated medication list. As you know, iron supplements may cause constipation. Please do not stop taking them. Instead, add senna to your ___ medications. If you are still constipated, call Dr. ___ recommend other ___ medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right cerebellar mass Major Surgical or Invasive Procedure: ___ Right occipital craniotomy for tumor resection History of Present Illness: This is a ___ year old male who presents with outpatient MRI revealing a 3cm R cerebellar mass with mass effect on the ___ ventricle. Patient reports about a year ago he began to feel very fatigued and had difficult with short term memory as well as word finding difficulty. He was referred by his PCP at that time to a neurologist. He was started on CPAP machine with no improvement of symptoms. Subsequently he was trialed on a number of antidepressants with no improvement in symptoms. He was sent for an outpatient MRI with and without contrast of the brain by his PCP. Patient denies headache, weakness, numbness or tingling. He does report word finding difficulty and intermittent double vision. Past Medical History: Rosacea "eye condition that requires injection to eye Q6-8 wks" Social History: ___ Family History: Non-contributory Physical Exam: On admission: O: T:97.7 BP: 154/72 HR:95 R 16 O2Sats 100% on RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ EOMs intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Patient has trouble getting out some words with slowing and slurring until he arrives on the correct word. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift on the day of discharge: intact, no dysmetria Pertinent Results: MRI head at outside hospital: 3cm R cerebellar mass with mass effect on ___ ventricle Cardiovascular Report ECG Study Date of ___ Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of ___ there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 142 82 366/381 51 4 15 Pathology Report Tissue: BRAIN/MENINGES FOR TUMOR Procedure Date of ___ Report not finalized. Logged in only. PATHOLOGY # ___ BRAIN/MENINGES FOR TUMOR Radiology Report CHEST (PRE-OP PA & LAT) Study Date of ___ IMPRESSION: No acute cardiopulmonary process. Radiology Report MR HEAD W/ CONTRAST Study Date of ___ IMPRESSION: No significant interval change in enhancing right cerebellar lesion. No new enhancing lesions. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ IMPRESSION: Postoperative changes from right cerebellar lesion resection, within expected limits. No acute findings. Medications on Admission: ___ (pt does not know the name) Discharge Medications: 1. Minocycline 50 mg PO Q24H 2. Acetaminophen 325-650 mg PO Q6H:PRN pain 3. Bisacodyl 10 mg PO DAILY constipation 4. Dexamethasone 4 mg PO Q6H Duration: 48 Hours RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours Disp #*2 Tablet Refills:*0 5. Dexamethasone 3 mg PO Q6H Duration: 72 Hours RX *dexamethasone 1.5 mg 2 tablet(s) by mouth every six (6) hours Disp #*24 Tablet Refills:*0 6. Dexamethasone 2 mg PO Q6H Duration: 72 Hours RX *dexamethasone 2 mg 1 tablet(s) by mouth every six (6) hours Disp #*12 Tablet Refills:*0 7. Dexamethasone 2 mg PO Q8H Duration: 48 Hours RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8) hours Disp #*6 Tablet Refills:*0 8. Dexamethasone 2 mg PO Q12H Duration: 48 Hours RX *dexamethasone 2 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*4 Tablet Refills:*0 9. Dexamethasone 2 mg PO DAILY Duration: 48 Hours Tapered dose - DOWN RX *dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #*2 Tablet Refills:*0 10. Docusate Sodium 100 mg PO BID 11. Methocarbamol 500 mg PO TID RX *methocarbamol 500 mg 1 tablet(s) by mouth tid prn Disp #*40 Tablet Refills:*0 12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*40 Tablet Refills:*0 13. Senna 8.6 mg PO BID constipation 14. Outpatient Physical Therapy Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right cerebellar mass Discharge Condition: Improved AO3. WBAT BLE. Outpatient ___. ___, home OT, assistance w/IADLs. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W/ CONTRAST INDICATION: ___ year old man with new right cerebellar lesion. // Pre-operative planning. Pt to OR with Dr. ___ on ___. Please perform in early AM ___. TECHNIQUE: After administration of Gadavist intravenous contrast, axial imaging was performed with MPRAGE and T1 technique. MPRAGE images were re-formatted in sagittal and coronal orientations. COMPARISON: Prior MRI of the brain dated ___. FINDINGS: There has been no significant interval change in solitary enhancing right cerebellar lesion. Effacement of the fourth ventricle appears similar to prior study. The lateral and third ventricles are stable in size and configuration. There is no shift of midline. No new enhancing lesions are identified. There is no extra-axial collection. IMPRESSION: No significant interval change in enhancing right cerebellar lesion. No new enhancing lesions. Radiology Report INDICATION: ___ year old man with preop craniotomy . COMPARISON: None Available. TECHNIQUE Frontal and lateral view of the chest. FINDINGS: The cardiomediastinal silhouette is normal. There is no pleural effusion or pneumothorax. There is no focal lung consolidation. Degenerative changes are noted in the mid thoracic spine with anterior osteophytes. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old man with R tentorial lesion s/p resection // evaluate for post-operative change TECHNIQUE: MRI of the head without and with IV contrast COMPARISON: MRA of the head ___ FINDINGS: Status post resection of the previously noted right tentorial dural-based mass lesion. Postsurgical changes are noted adjacent with small amount of gas and fluid and blood products. Small foci of negative susceptibility are noted in the in the right cerebellar hemisphere, related to blood products. Increased DWI signal intensity medially in the right cerebellar hemisphere, can relate to blood products or ischemic/infarction changes. Limited assessment on diffusion sequences for ischemic changes due to the confounding effects of blood products. There is surrounding edema and mass effect on the right side of the fourth ventricle, similar to the prior CT study. Linear, slightly irregular enhancement in the right cerebellar hemisphere and tentorium, can relate to postoperative changes. No obvious nodular component of enhancement to suggest obvious residual tumor. Assessment can be limited due to the postoperative changes. Postsurgical changes are noted in the overlying soft tissues of the right occipital and upper cervical regions. Increased signal intensity in the left more than right parietal and temporal subcutaneous soft tissues of the scalp with swelling with a focal area of heterogeneous enhancement, can be correlated clinically. (se 11, im 14; se 13, im 16). This can relate to edema or inflammation with focal contusion/hematoma. The lateral and third ventricles and the extra-axial CSF spaces in the cerebral sulci are unremarkable, without significant change compared to the preoperative study. A few small FLAIR hyperintense foci are noted in the cerebral white matter, nonspecific in appearance. No abnormal enhancement is noted in these foci. The major intracranial arterial flow voids are noted on the T2 sequence, left vertebral artery is diminutive. The venous sinuses are unremarkable on the routine study. Near total empty sella. Tiny cystis focus in the pineal gland. The craniocervical junction region is otherwise unremarkable. Mild ethmoidal mucosal thickening. Small amount of fluid in the mastoid air cells on both sides. Sphenoid sinus major septation inserts on the left carotid groove. IMPRESSION: 1. Postsurgical changes, with interval resection of the previously noted right tentorial dural-based lesion. Foci of negative susceptibility in the right cerebellar hemisphere can relate to blood products. Surrounding edema and mass effect on the fourth ventricle, as before. Foci of increased DWI signal intensity in the medial aspect of the right cerebellar hemisphere can relate to blood products or ischemic/infarction related changes. Limited assessment on diffusion sequences for ischemic changes due to the confounding effects of blood products. Attention on close followup 2. Linear, slightly irregular enhancement in the right cerebellar hemisphere and tentorium, can relate to postoperative changes. No obvious nodular component of enhancement to suggest obvious residual tumor. Assessment can be limited due to the postoperative changes. 3. Postsurgical changes are noted in the overlying soft tissues of the right occipital and upper cervical regions. Increased signal intensity in the left more than right parietal and temporal subcutaneous soft tissues of the scalp with swelling with a focal area of heterogeneous enhancement, can be correlated clinically. (se 11, im 14; se 13, im 16). This can relate to edema or inflammation with focal contusion/hematoma. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: Right tentorial lesion resection. Evaluate for interval change. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. DOSE: DLP: 897.12 mGy-cm CTDI: 55.04 mGy COMPARISON: MRI ___, outside hospital MR head ___. FINDINGS: Status post right suboccipital craniotomy with resection of previously noted right tentorial mass. Expected trace fluid and small pneumocephalus, within expected limits. Trace edema around the resection cavity. Mild effacement of the fourth ventricle appears similar to preoperative scan. There is otherwise no intracranial hemorrhage, acute infarction, large mass or midline shift. There is no hydrocephalus. The ventricles and sulci are stable in size and configuration. The basal cisterns are patent and there is preservation of gray-white matter differentiation. The orbits are unremarkable. The visualized paranasal sinuses, middle ear cavities and mastoid air cells are clear. IMPRESSION: Postoperative changes from right tentorial mass lesion resection, within expected limits. No acute findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: NEURO EVAL Diagnosed with BRAIN CONDITION NOS temperature: 97.7 heartrate: 95.0 resprate: 16.0 o2sat: 100.0 sbp: 154.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

•You underwent surgery to remove a brain lesion from your brain. •You underwent a biopsy. A sample of tissue from the lesion in your brain was sent to pathology for testing. . •Please keep your incision dry until your sutures/staples are removed. •You may shower at this time but keep your incision dry. •It is best to keep your incision open to air but it is ok to cover it when outside. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •You may experience headaches and incisional pain. •You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. •You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. •Feeling more tired or restlessness is also common. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Malaise, SOB, myalgia, chest pressure Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular pacer, COPD on 2L at home (at night), CKD, asbestosis with known pleural plaques, AAA s/p repair who presented to the ED with a 4 day history of myalgia, SOB, and dull chest pain. He was in his usual state of health until ___ day, when he started to feel tired and achy all over. Per daughter, he began to sleep a lot and lost his appetite. He states that his cough worsened as well. He described the cough as productive of white phlegm, about a tablespoon a day. He says that he was around "a lot of people" during ___ and might have sat across from someone who had a cold. Denies nausea, vomiting, diarrhea. His daughter, ___, states that they went to a ___ clinic on either ___ or ___, where patient was started on erythromycin. They tried to call his PCP at the ___, but his previous PCP retired and his new PCP was on vacation. Patient states that over the past several weeks, he has been trying to lose weight by eating healthier food. He lives with his daughter ___, who is his caretaker. A few months ago, he presented to ___ with dark stools. An EGD was done, which reportedly showed no bleeding. Per patient's daughter, they did not do a colonoscopy because of his age and other medical issues. Neither the patient nor his daughter remembers whether he got the flu vaccine this year, as he receives his primary care at the ___. In the ED, he received 1x dose of azithromycin 500mg iv and ceftriaxone 1g iv. He also received 500cc of NS bolus. CXR showed a retrocardiac opacity that may be either atelectasis or pneumonia. Labs were notable for Hgb of 9.9, Cr 1.4, and proBNP of 4507. Upon arrival to the floor, the patient was breathing comfortably on 2L NC. He states that his appetite has improved since arriving in the ED. He also thinks that his cough is improving and his throat is not as sore anymore. He states that at home, he only uses his oxygen at night. However, he sometimes gets SOB and light-headed during the day, and this is his baseline. Past Medical History: CARDIAC HISTORY -CAD s/p CABG in ___ SVG -> R-PDA, SVG -> OM1 with skip to D1, SVG to LAD known to be occluded - Moderate-Severe AS - Infarct related cardiomyopathy s/p BiV ICD - Nonsustained VT OTHER PAST MEDICAL HISTORY - Diabetes - Hypertension - Dyslipidemia - Abdominal aortic aneurysm s/p repair - Asbestos exposure w/ pleural plaques known - Gout - GERD - CKD Stage III - Bilateral corneal transplant - Umbilical hernia repair Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission Physical exam: General: elderly man sitting up, NAD HEENT: ATNC CV: harsh systolic murmur with radiation to clavicles Resp: faint wheezing bilaterally, breathing comfortably on 2L NC GI: +BS, nontender Extr: Trace edema bilaterally Neuro: Alert, oriented, able to answer all questions appropriately Pertinent Results: ADMISSION LABS: ============ ___ 02:35PM BLOOD WBC-7.8# RBC-3.20* Hgb-9.9* Hct-32.3* MCV-101* MCH-30.9 MCHC-30.7* RDW-15.9* RDWSD-58.4* Plt ___ ___ 02:35PM BLOOD Neuts-73.3* Lymphs-14.4* Monos-7.6 Eos-4.1 Baso-0.3 Im ___ AbsNeut-5.72# AbsLymp-1.12* AbsMono-0.59 AbsEos-0.32 AbsBaso-0.02 ___ 02:35PM BLOOD Glucose-104* UreaN-51* Creat-1.4* Na-145 K-4.1 Cl-102 HCO3-30 AnGap-13 ___ 02:35PM BLOOD CK(CPK)-34* ___ 02:35PM BLOOD CK-MB-2 proBNP-4507* ___ 02:35PM BLOOD cTropnT-<0.01 ___ 06:41AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.9 ___ 06:41AM BLOOD VitB12-789 ___ 02:39PM BLOOD Lactate-1.0 ___ 06:41AM BLOOD ___ PTT-26.4 ___ DISCHARGE LABS: ============ ___ 06:10AM BLOOD WBC-6.7 RBC-3.21* Hgb-9.6* Hct-31.2* MCV-97 MCH-29.9 MCHC-30.8* RDW-15.3 RDWSD-54.4* Plt ___ ___ 06:10AM BLOOD Glucose-108* UreaN-55* Creat-1.6* Na-145 K-4.3 Cl-106 HCO3-29 AnGap-10 ___ 06:10AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0 MICRO: ===== ___ GRAM STAIN, CULTURE: CONTAMINATED ___ Culture, Routine-PENDING IMAGES: ======= CXR ___ 1. Interval increased retrocardiac opacity could be left lower lobe focal pneumonia in the appropriate clinical situation versus atelectasis. 2. Increased peribronchial wall thickening can be seen with small airways disease and chronic inflammation. 3. Extensive bilateral pleural plaques. 4. Cardiomegaly without edema or pleural effusion. No evidence of pneumothorax. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 3. Allopurinol ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Carvedilol 6.25 mg PO BID 7. Furosemide 60 mg PO DAILY 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Lisinopril 10 mg PO DAILY 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QHS 11. Benzonatate 100 mg PO TID 12. Ipratropium Bromide MDI 1 PUFF IH TID 13. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID Discharge Medications: 1. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Benzonatate 100 mg PO TID 8. Carvedilol 6.25 mg PO BID 9. Ipratropium Bromide MDI 1 PUFF IH TID 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QHS 12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID 13. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until speaking with your primary care doctor and having your kidney function tested Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Pneumonia COPD exacerbation Claudication Aortic Stenosis Secondary: CKD Chronic diastolic HF CAD Angina 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 chest pain. Evaluate for pneumonia or pneumothorax. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. Reference is made with a chest CT dated ___. FINDINGS: Left retrocardiac parenchymal opacity is new or more conspicuous since ___ and could be atelectasis and/or pneumonia in the appropriate clinical setting. Bilateral peribronchovascular thickening, particularly in the perihilar region and bilateral lower lobes is slightly more pronounced can be seen with bronchiolar inflammation and small airways disease. Extensive bilateral calcified pleural plaques are similar to the prior chest CT. No pleural effusion or pneumothorax. The patient has a left ACID in place. Median sternotomy wires and mediastinal clips are unchanged. The heart remains moderate to severely enlarged. Mediastinal contours are unchanged. Aortic knob calcifications are mild, unchanged. Degenerative changes in the bilateral AC joints are severe. Widening of the right AC joint is similar to the prior exam. Degenerative changes in the glenohumeral joints are moderate. Coarse calcification of the anterior longitudinal ligament. IMPRESSION: 1. Interval increased retrocardiac opacity could be left lower lobe focal pneumonia in the appropriate clinical situation versus atelectasis. 2. Increased peribronchial wall thickening can be seen with small airways disease and chronic inflammation. 3. Extensive bilateral pleural plaques. 4. Cardiomegaly without edema or pleural effusion. No evidence of pneumothorax. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Chest pain, Cough, ILI Diagnosed with Pneumonia, unspecified organism temperature: 97.6 heartrate: 73.0 resprate: 18.0 o2sat: 99.0 sbp: 110.0 dbp: 56.0 level of pain: 6 level of acuity: 3.0

Dear Mr. ___, You came to the hospital because you were not feeling well. You had a chest x-ray that may have showed pneumonia, though this was hard to tell because of your plaques. You finished a course of treatment for pneumonia with antibiotics and started to feel a lot better. You also got treatment for COPD exacerbation with steroids, which really helped you. When you go home, please work with a physical therapist. Please talk to your cardiologist and primary care doctor about the pain and fatigue in your legs because this may require further testing and treatment. Your lasix (water pill) amount was decreased. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs in one day or 5 lbs in one week. It was a pleasure caring for you and we wish you the best! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: low back, left leg pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with h/o hypertension and herniated lumbar disc with sciatica x 6 months presents with worsening low back pain radiating down left leg similar to previous sciatica. Pt reports overnight was turning in bed and felt "pop" and sudden onset pain left low back/buttock radiating down lateral leg. Has had intermittent numbness in left toe but otherwise no paresthesias or loss of bowel or bladder. Worse with movement. Has difficulty weight bearing but doesn't feel he has focal weakness. No fevers or chills. No difficulty urinating, subjective perianla anesthsia. No trauma. Oxycodone at home gave minimal relief. Has gotten cortisol injections x2, last one 3 weeks ago. Has trialed NSAIDs, flexiril, and oxycodone at home. Has not see a specialist yet. In the ED, he had the following vitals: pain 8, 98.6F, HR68, BP180/90, RR16, O2 100%RA. EXAM: no TTP along spinous processes, TTP mid-left buttock musculature, reflexes symmetric, downgoing babinski's bl,, sensation grossly intact to soft touch, motor- 4+/5 strenght LLE plantar flexion (?limited by pain), normal perianal sensation and rectal tone. Patient was given 5mg IV morphine, 5mg morphine sc, oxycodone 10mg PO, and diazepam 5mg. Plain film L spine done with arthrosis in lumbar and sacral areas, no subluxation. Currently, resting in bed in NAD. Family at bedside. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HTN Sciatica Alcohol use Social History: ___ Family History: No significant family history Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 97.3F, BP 170/83, HR 64, R 18, O2-sat 98% RA GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dry MM, OP clear NECK - supple, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/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, unable to elicit DTRs in bilateral LEs. Toes downgoing. Straight leg raise mildly positive in left leg. No saddle anesthesia DISCHARGE PHYSICAL EXAM: unchanged Pertinent Results: LABS: On admission: ___ 03:05PM BLOOD WBC-8.1 RBC-4.50* Hgb-14.9 Hct-42.8 MCV-95 MCH-33.1* MCHC-34.7 RDW-12.8 Plt ___ ___ 03:05PM BLOOD Neuts-79.1* Lymphs-13.1* Monos-4.8 Eos-2.4 Baso-0.6 ___ 03:05PM BLOOD Glucose-115* UreaN-26* Creat-0.8 Na-140 K-4.5 Cl-104 HCO3-23 AnGap-18 MICRO: none IMAGING: ___ Lumbo-sacral xray: FINDINGS: Frontal and lateral views of the lumbar spine were obtained. Five non-rib-bearing vertebral bodies are identified. No fracture is present and vertebral body heights are preserved. Multilevel lumbar spine degenerative changes are present, most severe at L4-5 and L5-S1, with moderate-to-severe facet arthrosis. No alignment abnormality. No focal lytic or sclerotic lesion. Chain sutures are present in the right lower quadrant. IMPRESSION: Multilevel degenerative change, worst in lower lumbar spine. ___ MRI Lumbar Spine: IMPRESSION: Underlying dextroscoliosis with associated alignment abnormalities, as well as congenitally abnormal spinal canal geometry and prominent epidural lipomatosis, result in: 1. L4-L5: Most severe spinal canal and left more than right subarticular zone stenosis with traversing L5 neural impingement; bilateral neural foraminal stenosis with exiting L4 neural impingement. 2. L3-L4: Multifactorial moderate canal stenosis with central crowding of the traversing nerve roots; right more than left neural foraminal stenosis with possible impingement upon the exiting right L3 nerve root. 3. L5-S1: Grade 1 anterolisthesis, likely spondylolytic, with bilateral neural foraminal narrowing and possible exiting L5 neural impingement, left more than right. 4. T11-T12: Disc degeneration with right paracentral/proximal foraminal protrusion which may impinge upon the exiting right T11 nerve root, incompletely imaged. COMMENT: Given the numerous findings, close correlation should be made with the nature, level and side of the patient's symptoms. In addition, comparison with any previous (outside) MR imaging study would be helpful. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Ibuprofen 800 mg PO Q8H 2. Lisinopril 10 mg PO DAILY 3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 4. Indomethacin 50 mg PO TID Discharge Medications: 1. Ibuprofen 800 mg PO Q8H RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp #*90 Tablet Refills:*0 2. Lisinopril 20 mg PO DAILY Hold for SBP <110 RX *lisinopril 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain Hold for RR <12 or sedation RX *oxycodone 5 mg 2 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #*120 Tablet Refills:*0 5. Outpatient Physical Therapy 722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy Evaluate and treat for lumbar radiculopathy from degenerative disc disease with disc herniation Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: L5 lumbar radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with lower back pain and radiculopathy. Evaluate for compression fracture. COMPARISONS: None. FINDINGS: Frontal and lateral views of the lumbar spine were obtained. Five non-rib-bearing vertebral bodies are identified. No fracture is present and vertebral body heights are preserved. Multilevel lumbar spine degenerative changes are present, most severe at L4-5 and L5-S1, with moderate-to-severe facet arthrosis. No alignment abnormality. No focal lytic or sclerotic lesion. Chain sutures are present in the right lower quadrant. IMPRESSION: Multilevel degenerative change, worst in lower lumbar spine. Radiology Report MR EXAMINATION OF LUMBAR SPINE WITHOUT CONTRAST, ___ HISTORY: ___ male with severe left back pain and radicular symptoms "down the left leg," and "MRI (six months ago) with herniated discs and stenosis, of unknown degree"; now with acute worsening (symptoms). TECHNIQUE: Routine ___ non-enhanced MR examination with supplemental sagittal STIR FSE sequence. FINDINGS: The reported OSH MR examination has not been obtained and uploaded to ___ for comparison. The sagittal STIR sequence is essentially unremarkable, with no finding to suggest acute vertebral compression injury. Other than a small right parapelvic cyst, the included paraspinal soft tissues are grossly unremarkable. Note that there is no significant fatty atrophy of the paraspinal musculature. The distal spinal cord is normal in caliber and intrinsic signal intensity, as is the conus medullaris, which is normal in morphology and terminates at the mid-S1 level. As on the recent radiographs of ___, there is a slight lumbar dextroscoliosis with associated minimal retrolisthesis of L3 on L4 and L4 on L5. The lumbar vertebrae are normal in height and demonstrate somewhat heterogeneous T1- and T2-hypointensity. There is multilevel degenerative disc, endplate and facet joint disease, as follows: There is degeneration of the T11-T12 disc, with a small right paracentral/proximal foraminal protrusion which may impinge upon the exiting right T11 nerve root; this is incompletely imaged, only in the sagittal plane. The T12-L1 and L1-L2 discs are preserved in height and signal intensity with normal intranuclear clefts and no significant bulge or focal herniation. The L2-L3 disc is also preserved in height and signal intensity with mild bulging, but no significant canal or foraminal compromise. There is more marked degeneration of the L3-L4 disc with vacuum phenomenon and mild-moderate bulging, eccentric to the right. There is a superimposed anular tear with accompanying protrusion. In combination with facet arthropathy and prominent dorsal epidural fat, and superimposed on congenitally short pedicles, this results in relative central crowding of the traversing nerve roots with loss of the normal CSF-signal within the thecal sac (2:11, 5:12). There is also caudal narrowing of the neural foramina, right more than left, with likely impingement upon the exiting right L3 nerve root. There is marked degeneration of the L4-L5 disc with ___ type 2 change in the adjacent vertebral endplates. There is moderately severe bulging with a superimposed broad-based central/left paracentral disc protrusion measuring roughly 11 mm (AP). In combination with the above factors, as well as congenitally narrow intralaminal angle, this again results in relatively severe canal stenosis and impingement upon the traversing L5 nerve roots in the subarticular zones. There is also severe bilateral neural foraminal narrowing with likely impingement upon the exiting L4 nerve roots. There is grade 1 anterolisthesis of L5 on S1, which appears related to bilateral spondylolysis, with expected relative widening of the AP dimension of the spinal canal. However, the redundant anulus and "rolled disc," in addition to L5 inferior endplate spondylosis, produces expected narrowing of both neural foramina with possible impingement upon the exiting L5 nerve roots, left more than right. There is also contact with the traversing S1 nerve roots in the subarticular zones. IMPRESSION: Underlying dextroscoliosis with associated alignment abnormalities, as well as congenitally abnormal spinal canal geometry and prominent epidural lipomatosis, result in: 1. L4-L5: Most severe spinal canal and left more than right subarticular zone stenosis with traversing L5 neural impingement; bilateral neural foraminal stenosis with exiting L4 neural impingement. 2. L3-L4: Multifactorial moderate canal stenosis with central crowding of the traversing nerve roots; right more than left neural foraminal stenosis with possible impingement upon the exiting right L3 nerve root. 3. L5-S1: Grade 1 anterolisthesis, likely spondylolytic, with bilateral neural foraminal narrowing and possible exiting L5 neural impingement, left more than right. 4. T11-T12: Disc degeneration with right paracentral/proximal foraminal protrusion which may impinge upon the exiting right T11 nerve root, incompletely imaged. COMMENT: Given the numerous findings, close correlation should be made with the nature, level and side of the patient's symptoms. In addition, comparison with any previous (outside) MR imaging study would be helpful. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: BACK PAIN Diagnosed with SCIATICA temperature: 98.6 heartrate: 68.0 resprate: 16.0 o2sat: 100.0 sbp: 180.0 dbp: 90.0 level of pain: 8 level of acuity: 3.0

Dear Mr ___, It was a pleasure being involved in your care at ___ ___. ___ were admitted to the hospital due to acute worsening of your chronic low back pain. An MRI showed that ___ have a herniated disc in your back that is starting to press on some nerves and causing your symptoms. There was no sign of infection or masses in the back. We started ___ on some pain medications to help control your symptoms. ___ should continue to take ibuprofen and tylenol scheduled around the clock, with oxycodone available as a stronger medicine when the pain is bad. Do not drink alcohol, drive or operate heavy machinery while taking oxycodone. Avoid doing any lifting or twisting motions that may worsen your symptoms. Physical therapy will be an important part of your recovery, so please bring this ___ prescription to your local physical therapy office to begin sessions. ___ also should make an appointment with a back surgeon for evaluation for possible surgery in case your symptoms continue unabated. Your lisinopril was also increased to 20mg to help better control your blood pressure.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: amino acids Attending: ___. Chief Complaint: admission for expedited stroke workup Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ right-handed man with past medical history significant for Hodgkin's lymphoma diagnosed in ___ with recurrences later that year in ___ and ___. He is status post full body radiation in ___ and a bone marrow transplant in ___ followed by another round of radiation. He then developed squamous cell carcinoma of the left mandible requiring modified radical neck dissection with resection of the left posterior mandible followed by a third radiation treatment. He presented to neurology clinic last week after CT earlier this year showed evidence of a frontal stroke. Earlier today, Mr ___ called the clinic to report several concerning episodes over the weekend. On ___, around noon he had 30- 60min of right hand numbness. He has had this sensation before (maybe ~6x in his life). Occasionally, it has been associated with weakness where he is unable to keep the hand lifted up. This time, it was associated with numbness of all the fingers as well as the palm but no weakness. He also reports a frontal headache around this time that he treated with Tylenol. At 3pm, he developed dysarthric speech. He knew what he wanted to say but the words coming out did not sound like the words he was trying to say. His wife was unable to understand what he was trying to say until he repeated it several times. This completely resolved within an hour. It was not associated with any other weakness, numbness, visual problems, or vertigo. Yesterday, he had a additional episode of right hand numbness (no weakness) lasting ___ minutes. He reports that he is currently back to his baseline. He denies any recent illnesses, infections, intoxications that could explain his symptoms. He had a full stoke workup ordered as an outpatient (scheduled to get MRI/MRA head and neck, carotid ultrasounds next ___, a week from today) but because of these recent episodes, he was instructed to come to the ED for admission and expedited workup. The patient had a long and complicated medical history since his diagnosis of Hodgkin's when he was ___ most significant for bone marrow transplant and whole body radiation x 3. mmediately after the bone marrow transplant, secondary to immunosuppression medications, he developed chronic kidney disease. This progressed into fulminant renal failure earlier this year (the exact cause unknown) requiring the placement of a peritoneal dialysis catheter in ___. During the time of his kidney failure, he developed severe generalized sharp headaches focused behind his eyes that would last approximately four hours a day but were relatively well treated with Tylenol and Percocet. Those headaches have since resolved as his metabolic and electrolyte disturbances have normalized with the use of the PD catheter. Earlier this year, in order to workup the severe headaches, he underwent a CT scan which showed a hypodensity in the left frontal region. On further questioning, he remembers having a facial droop in ___ that lasted about a month. In addition, he and his wife describe an episode of an abnormal heart rhythm during his hospitalization in ___ as SVT) which was associated with negative CE and unchanged EKG. During that hospitalization, he had CT Head which did not show the lesion leading us to believe that it occurred some time in the last ___ years although we are unable to determine a more exact date. He comes to clinic today for recommendations for further workup of this finding as well as secondary prevention recommendations. Review of Systems: Positive for headaches earlier this year which have almost entirely resolved, generalized numbness and weakness which has since resolved; chronic muscle cramps; easy fatigability; vertigo/nausea with any abrupt changes in his PD catheter which has since resolved; chronic speaking and swallowing difficulties related to his radical neck dissection; chronic insomnia; difficulty with maintaining his weight since his initial diagnosis. He denies loss of vision, blurred vision, diplopia, hearing difficulty. He reports difficulty of gait secondary to his gout. On general review of systems, he denies recent fever or chills. No night sweats. Denies cough, shortness of breath, chest pain, tightness, palpitations. Had intermittent nausea and vomiting with his headaches and when his PD catheter malfunctions, but otherwise this seems to have resolved. Chronic myalgias since his bone marrow transplant. Past Medical History: Past Medical History: - Hodgkin's lymphoma dx ___ - status post allogenic bone marrow transplant ___ - asplenic - basal cell carcinoma - squamous cell carcinoma - hyperlipidemia - history of orthostatic hypotension especially for several months following the radical neck dissection (___) - chronic renal failure now requiring peritoneal dialysis - chronic graft-versus-host disease Past Surgical History: - squamous cell carcinoma status post radical neck dissection (___) - bilateral hip replacement due to chronic osteonecrosis secondary to long-term prednisone use - splenectomy in ___ - numerous skin biopsies and resections for basal cell carcinoma - the placement of peritoneal dialysis catheter in ___. Social History: ___ Family History: His mother passed away at ___ from cervical cancer. His father is alive at ___ with dementia and prostate cancer. He has three sisters at ___, ___, ___ with ovarian cancer, arthritis, COPD. He has two brothers at ___ and ___ with hypertension and heart disease. He has three adopted children. A ___ daughter who is healthy, a ___ son with mental health issues and a son who passed away ___ from an overdose. Physical Exam: ADMISSION EXAM: T 97.8; HR 80; BP 137/118; RR 18 SpO2 100% RA General: Cachechtic, pleasant man sitting up in NAD. HEENT: Normocephalic. Post-surgical changes over left jaw, post-surgical tongue with minimal range of movement. Neck: Supple. Pulmonary: Normal work of breathing on room air. Vesicular breath sounds bilaterally, no wheezes or crackles appreciated. Cardiac: S1/S2 appreciated, RRR, no M/R/G. Abdomen: Surgical scars and peritoneal dialysis catheter noted. Soft, nontender, nondistended. Extremities: No lower extremity edema Skin: Wound over left great toe. Neurologic: -Mental Status: Alert, oriented x 3. Attentive to ___ backwards. Able to relate history without difficulty. Recalls what he had for breakfast. Language is fluent, intact to repetition, comprehension, naming high and low frequency objects. There was mild dysarthria, ligual and labial most prominent. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. Could not appreciate fundi. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch and temperature in all distributions. VII: R nasolabial fold flattening, but activation is symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. (the structure of the palatal arch appears somewhat altered ?postsurgical? but excursion is full and symmetric) XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes minimally due to post-surgical changes. -Motor: Normal bulk, increased tone throughout. R pronation without drift. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ 4+ ___ 5 5 5 5 R ___ ___ 4+ ___ 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 0 0 0 0 0 R 0 0 0 0 0 - Plantar response was withdrawal on the left, extensor on the right. -Sensory: No deficits to light touch, cold sensation, vibratory sense, or proprioception in upper extremities. Vibration sense decreased at the great toes bilaterally (6s), temperature decreased below the ankle. Proprioception intact. No extinction to DSS. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Antalgic, favoring left knee and ankle. Gait is slightly wide-based, normal stride and arm swing. Romberg absent. DISCHARGE EXAM: MS: alert and oriented x3, intact fluency and comprehension CN: pupils reactive bilaterally, eomi, intact light touch and facial strength bilaterally, vfftc, no visual extinction Motor: ___ strength of all four ext. Sensory: intact light touch and pp of all four ext. Reflexes: left toe down, right toe up Coord: intact fnf bilaterally Pertinent Results: ADMISSION LABS: ___ 08:52PM BLOOD WBC-7.0 RBC-3.43* Hgb-9.8* Hct-31.5* MCV-92 MCH-28.6 MCHC-31.1* RDW-15.8* RDWSD-52.2* Plt ___ ___ 08:52PM BLOOD Neuts-65.1 ___ Monos-8.0 Eos-1.7 Baso-0.4 Im ___ AbsNeut-4.53 AbsLymp-1.71 AbsMono-0.56 AbsEos-0.12 AbsBaso-0.03 ___ 08:52PM BLOOD ___ PTT-30.3 ___ ___ 08:52PM BLOOD Glucose-79 UreaN-50* Creat-8.1* Na-139 K-5.4* Cl-98 HCO3-29 AnGap-17 ___ 08:52PM BLOOD ALT-10 AST-17 AlkPhos-120 TotBili-0.1 ___ 07:00AM BLOOD Calcium-7.6* Phos-5.6* Mg-1.5* Stroke Risk Factors: Cholest-182 Triglyc-100 HDL-45 CHOL/HD-4.0 LDLcalc-117 T4-5.0 %HbA1c-5.3 eAG-105 Imaging: MRI Brain w/wo IMPRESSION: 1. Small cortical acute to early subacute infarction in the inferior left parietal lobe extending to the parieto-occipital sulcus. 2. Confluent elevated T2 signal in the deep and periventricular white matter of the cerebral hemispheres is compatible with sequela of chronic small vessel ischemic disease, prior medication toxicity, or prior brain radiation. 3. Linear foci of mildly high signal on the diffusion tracer sequence in the posterior frontal centrum semiovale, more conspicuous on the right than left, without associated signal abnormality on the ADC map, most likely represent T2 shine through, and less likely subacute infarcts. 4. Small area of encephalomalacia and gliosis in the superior left frontal lobe at the site of a prior hematoma, with several prominent adjacent superficial veins. Diagnostic considerations include prior hemorrhage which may be secondary to amyloid angiopathy or an underlying vascular malformation. No clear evidence for an underlying cavernous malformation is seen. This area is not included in the field of view of the MRA. 5. Left greater than right internal carotid artery origin atherosclerosis without evidence for flow-limiting stenosis by NASCET criteria. 6. No evidence for occlusion or flow-limiting stenosis of the major intracranial arteries. 7. 7 mm fusiform dilatation of the cavernous right internal carotid artery. No evidence for a saccular aneurysm. CTA Head/Neck ___: IMPRESSION: 1. No acute intracranial pathology. 2. 8 mm fusiform aneurysm of the right ICA cavernous segment. 6 mm fusiform aneurysm of the left ICA cavernous segment. No saccular aneurysms. 3. No significant stenosis of the extracranial circulation. 4. Post radiation changes the right lung with small bilateral pleural effusions. Multiple biapical lung nodules, better visualized on the prior dedicated CT chest. 5. A 1 cm left thyroid nodule for which a dedicated thyroid ultrasound can be performed. Carotid ultrasound ___: IMPRESSION: Bilateral mild heterogeneous atherosclerotic plaque in the ICAs resulting in less than 40% stenosis on both sides. Echocardiogram ___ Conclusions: The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. 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 leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate (___) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, the LVEF has decreased. MRI Cervical Spine ___: IMPRESSION: Mild cervical degenerative disease. Mild to moderate left C2-3 neural foraminal narrowing. No spinal canal narrowing. Normal appearance of the spinal cord. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Levothyroxine Sodium 25 mcg PO DAILY 3. Nystatin 100,000 UNIT PO Q8H 4. Lanthanum 1000 mg PO TID W/MEALS 5. Calcitriol 0.25 mcg PO 3X/WEEK (___) 6. Fluconazole 200 mg PO 2X/WEEK (MO,TH) Discharge Medications: 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Calcitriol 0.25 mcg PO 3X/WEEK (___) 3. Lanthanum 1000 mg PO TID W/MEALS 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Amlodipine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Atorvastatin 10 mg PO QPM RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 8. Fluconazole 200 mg PO 2X/WEEK (MO,TH) 9. Nystatin 100,000 UNIT PO Q8H Discharge Disposition: Home Discharge Diagnosis: ACUTE ISCHEMIC STROKE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with history of Hodgkins lymphoma diagnosed in ___ with recurrence in ___, status post fall body radiation in ___ and bone marrow transplant with additional radiation in ___. Also history of squamous cell carcinoma of the left mandible status post modified radical neck dissection in ___ and radiation. Now the patient demonstrates a left frontal hypodensity on head CT and TIA-like events, including slurred speech and right arm numbness which brought the patient to the emergency department on ___. Please evaluate for vessel stenosis or cutoff. Please evaluate for infarct. TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained. 3D time-of-flight MRA of the brain was obtained with multiplanar maximum intensity projection angiographic reformatted images. 2D time-of-flight MRA of the neck was obtained with multiplanar maximal intensity projection angiographic reformatted images. This report is based on interpretation of all of the above images. COMPARISON: Noncontrast head CT ___. FINDINGS: BRAIN MRI: There is a small cortical focus of slow diffusion in the inferior left parietal lobe extending to the parieto-occipital sulcus, images 13 and 14 of series 404 and 402. There is corresponding high signal on FLAIR images. There is no evidence for associated blood products on gradient echo images. In the centrum semiovale of bilateral posterior frontal lobes, there are linear foci of mildly high signal on the diffusion tracer sequence, more conspicuous on the right than left, without corresponding signal abnormality on the ADC map. FLAIR and T2 weighted images demonstrate confluent high signal in the centrum semiovale, corona radiata, other deep white matter, and periventricular white matter of the cerebral hemispheres, nonspecific but compatible with sequela of chronic small vessel ischemic disease, prior medication toxicity or prior brain radiation. In the setting, the mild signal abnormalities in the centrum semiovale on the diffusion tracer sequence are most likely related to T2 shine through, and less likely subacute infarcts. In the left middle frontal gyrus bordering the superior frontal gyrus, there is a small area of encephalomalacia with adjacent gliosis, which demonstrates extensive low signal on gradient echo images. There are several adjacent prominent superficial veins with preserved flow voids. Diagnostic considerations include prior hemorrhage which may be secondary to amyloid angiopathy or an underlying vascular malformation. No clear evidence for an underlying cavernous malformation is seen. Prior ischemic infarction with hemorrhagic transformation is less likely. There is mild parenchymal volume loss with associated prominence of the ventricles and sulci. There is mild partial bilateral mastoid air cell opacification. There is evidence of left lens replacement. NECK MRA: The aortic arch is not included on the 2D time-of-flight images. 2D time-of-flight technique limits evaluation of minimal stenoses due to stepping artifact. There are filling defects at the origins of bilateral internal carotid arteries, left greater than right, without evidence for flow-limiting stenosis by NASCET criteria. Visualized portions of bilateral vertebral arteries appear patent. Left vertebral artery is dominant. BRAIN MRA: There is ___ termination of the non dominant right vertebral artery without evidence for flow-limiting stenosis. Left vertebral artery, basilar artery, internal carotid arteries, and their major branches appear patent without evidence for flow-limiting stenosis. Cavernous right internal carotid artery demonstrates fusiform dilatation measuring 7 mm. There is no evidence for a saccular aneurysm. The area of prior hematoma in the superior left frontal lobe is not included in the field of view of the MRA. IMPRESSION: 1. Small cortical acute to early subacute infarction in the inferior left parietal lobe extending to the parieto-occipital sulcus. 2. Confluent elevated T2 signal in the deep and periventricular white matter of the cerebral hemispheres is compatible with sequela of chronic small vessel ischemic disease, prior medication toxicity, or prior brain radiation. 3. Linear foci of mildly high signal on the diffusion tracer sequence in the posterior frontal centrum semiovale, more conspicuous on the right than left, without associated signal abnormality on the ADC map, most likely represent T2 shine through, and less likely subacute infarcts. 4. Small area of encephalomalacia and gliosis in the superior left frontal lobe at the site of a prior hematoma, with several prominent adjacent superficial veins. Diagnostic considerations include prior hemorrhage which may be secondary to amyloid angiopathy or an underlying vascular malformation. No clear evidence for an underlying cavernous malformation is seen. This area is not included in the field of view of the MRA. 5. Left greater than right internal carotid artery origin atherosclerosis without evidence for flow-limiting stenosis by NASCET criteria. 6. No evidence for occlusion or flow-limiting stenosis of the major intracranial arteries. 7. 7 mm fusiform dilatation of the cavernous right internal carotid artery. No evidence for a saccular aneurysm. RECOMMENDATION(S): Recommend CTA of the head to exclude an arteriovenous malformation in the superior left frontal lobe. NOTIFICATION: The findings and recommendations were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:21. Radiology Report EXAMINATION: MRI CERVICAL SPINE WITHOUT CONTRAST INDICATION: ___ year old man with history of Hodgkins lymphoma diagnosed in ___ with recurrence in ___, status post fall body radiation in ___ and bone marrow transplant with additional radiation in ___. Also history of squamous cell carcinoma of the left mandible status post modified radical neck dissection in ___ and radiation. Now the patient demonstrates a left frontal hypodensity on head CT obtained for evaluation of TIA-like events, including slurred speech and right arm numbness which brought the patient to the emergency department on ___. Please evaluate for for myelopathy. TECHNIQUE: Sagittal T1 weighted, T2 weighted, and fat suppressed T2 weighted images of the cervical spine with axial gradient echo and T2 weighted images. COMPARISON: Concurrent brain MRI/ MRA and neck MRA from ___ is reported separately. Neck CT without contrast from ___ is available for correlation. FINDINGS: No concerning bone marrow signal abnormalities are seen. Vertebral body heights are preserved. Alignment is normal. The cerebellar tonsils are normally positioned. Concurrent brain MRI is reported separately. The cervical and included upper thoracic spinal cord demonstrates normal morphology and signal intensity. C2-3: Mild to moderate left neural foraminal narrowing by uncovertebral osteophytes. No spinal canal narrowing. C3-4: Small bilateral uncovertebral osteophytes. Minimal left neural foraminal narrowing. No spinal canal narrowing. C4-5: No spinal canal or neural foraminal narrowing. C5-6: Shallow broad-based central disc protrusion without spinal canal or neural foraminal narrowing. C6-7: A shallow left paracentral disc protrusion. Tiny bilateral uncovertebral osteophytes. No spinal canal or neural foraminal narrowing. C7-T1: No spinal canal or neural foraminal narrowing. This exam is not tailored for evaluation of the partially included soft tissues of the neck. There are changes related to prior left neck dissection in radiation. Plaque is seen at the common carotid arterial bifurcations, left greater than right. Concurrent neck MRA is reported separately. IMPRESSION: Mild cervical degenerative disease. Mild to moderate left C2-3 neural foraminal narrowing. No spinal canal narrowing. Normal appearance of the spinal cord. Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old man with history of head/neck radiation presenting with multpiple TIAs and CT scan concerning for L frontal infarct. Please evaluate carotids. TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has mild heterogeneous atherosclerotic plaque in the ICA and the CCA. The peak systolic velocity in the right common carotid artery is 75 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 56, 81, and 57 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 30 cm/sec. The ICA/CCA ratio is 1.0. The external carotid artery has peak systolic velocity of 105 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild heterogeneous atherosclerotic plaque in the ICA and the ECA. The peak systolic velocity in the left common carotid artery is 78 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 96, 88, and 84 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 38 cm/sec. The ICA/CCA ratio is 1.2. The external carotid artery has peak systolic velocity of 62 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: Bilateral mild heterogeneous atherosclerotic plaque in the ICAs resulting in less than 40% stenosis on both sides. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: ___ year old male status post radiation with episodes of hand numbness concerning stroke. Evaluate for infarct. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque350 intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP = 30.0 mGy-cm. 5) Spiral Acquisition 5.2 s, 41.2 cm; CTDIvol = 32.1 mGy (Head) DLP = 1,321.7 mGy-cm. Total DLP (Head) = 2,249 mGy-cm. COMPARISON: CT head from ___ and CT chest from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: No intra or extra-axial hemorrhage, mass effect, or shift of normally midline structures. Small the moderate chronic infarct in the left frontal lobe. Small focus of low attenuation beneath the left basal ganglia likely represents a prominent perivascular space versus chronic lacunar infarct. Mild low attenuation in the periventricular white matter is nonspecific, but likely relates to chronic microangiopathic ischemia. No CT evidence for acute, major vascular territorial infarction. Mild prominence of the ventricles, sulci, and cisterns appears proportional. Left lens replacement. Dental implants with partial erosion of the mandibular condyles. \ CTA HEAD: Fusiform aneurysm arise involving the right ICA cavernous segment, measuring up to 8 mm, compared with 5 mm in the proximal petrous segment. Mild fusiform dilatation of the left ICA cavernous segment measuring up to 6 mm, compared with 5 mm more proximally. Otherwise, bilateral intracranial internal carotid arteries, middle cerebral arteries, and anterior cerebral arteries enhance normally. The anterior communicating artery is patent. Small right posterior communicating artery. Left posterior communicating artery is either absent or hypoplastic. Left vertebral artery is dominant. Right vertebral artery largely terminates as the right posterior inferior cerebellar artery. Basilar artery, visualized cerebellar arteries, and posterior cerebral arteries enhance normally. CTA NECK: Mild to moderate calcified atherosclerotic plaque surrounds the right carotid bifurcation. The right common, internal, and external carotid arteries otherwise enhance normally. Moderate calcified atherosclerotic plaque surrounds the left carotid bifurcation. Mild narrowing of the left ICA origin. The left common, internal, and external carotid arteries otherwise enhance normally. The vertebral arteries enhance normally. The left vertebral artery is dominant. 3 vessel arch configuration. OTHER: There are small partially visualized bilateral pleural effusions. There is a stable right upper lobe lung nodule measuring 6 x 5 mm, series 5, image 29. An additional 1 cm right upper lobe nodule with central hypoattenuation is seen, slightly more prominent in comparison to the prior CT. There is a right upper lobe pleural parenchymal scarring with associated bronchiectasis. Debris is seen within the trachea. A stable 0.5 cm left upper lobe lung nodule is seen, series 5, image 33. A 1 cm left thyroid nodule is seen. IMPRESSION: 1. No acute intracranial pathology. 2. 8 mm fusiform aneurysm of the right ICA cavernous segment. 6 mm fusiform aneurysm of the left ICA cavernous segment. No saccular aneurysms. 3. No significant stenosis of the extracranial circulation. 4. Post radiation changes the right lung with small bilateral pleural effusions. Multiple biapical lung nodules, better visualized on the prior dedicated CT chest. 5. A 1 cm left thyroid nodule for which a dedicated thyroid ultrasound can be performed. RECOMMENDATION(S): Nonurgent thyroid ultrasound. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: R Arm numbness, Slurred speech Diagnosed with TRANS CEREB ISCHEMIA NOS temperature: 97.8 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 137.0 dbp: 118.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of right hand numbness, difficulty speaking, and headache resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. We incidentally found aneurysms in your MCAs which should be evaluated by Neurosurgery in outpatient clinic. Please call tomorrow to make an appointment in their clinic. 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: History of Radiation and Cancer High Cholesterol High Blood pressure We are changing your medications as follows: 1. START Aspirin 81mg daily 2. START Atorvastatin 10mg at bedtime 3. START Amlodipine 5 mg daily Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine / Restoril / Demerol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ with h/o dementia on asa 81, no other anticoagulation, transferred with questionable traumatic SAH s/p unwitnessed fall today. Pt is delirious and cannot provide history. Per ___ note, pt lives with family, found down. Initial eval showed normal EKG, troponins negative. Vitals benign exam non focal Labs notable for cr 2.0 (unk baseline), negative troponin. CT head with bilateral frontal intraparenchymal calcifications but negative for hemorrhage. ___ RN NOTE and corroborated by HCP: Pt was discharged from ___ on ___ after admission for AMS. Pt had wandered to neighbors house who called police and per daughter w/u was negative. Followed at home by ___ ___ last home visit was ___ and has declined at home over this weekend with generalized weakness and c/o of her back/neck/knee pain which is chronic. Fell at home and was estimated to be on the floor for appx 30 min. Pt was ambulatory up until ___ and has been having decreased PO's for several days. In the ___, initial vitals were: 98.4 80 125/72 16 97% 2L NC. Initial Labs were largely unremarkable and showed WBC 10.9, Hgb/Hct 11.2/35.1, Plt 245, U/A negative leuks/negative nitrites, few bacteria, BUN/Cr 47/1.9. A CK was eelvated to 632 and downtrended to ___ s/p 2L NS bolus. Lactate was WNL at 1.6 and trop < 0.01. Pt given IV Haloperidol 1 mg for delirium. Imaging CT head w/o contrast: Stable bifrontal intraparenchymal hemorrhage without appreciable mass effect. No fracture is identified.; CXR was negative for acute cardiopulmonary process. Left knee xray was negative for fracture or dislocation. On the floor, pt is NAD but AOx0. Pt's HCP daughter is present and corroborates ___ story. Pt is purported to be off her baseline in terms of mental status. Pt denies any fevers, chills, chest pain, dyspnea, abd pain, nausea, vomiting, diarrhea, dysuria. Past Medical History: 1. HTN - poorly controlled 2. Depression 3. Hyperlipidemia 4. Frequent falls 5. Arthritis - needs knee replacements but hold due to poor BP control 6. s/p hysterectomy 7. GERD 8. Vertigo 9. Essential tremor 10. s/p L cataract repair - awaiting R side to be repaired as well. 11. Insomnia 12. Anxiety Social History: ___ Family History: Daughter died of likely metastatic breast cancer in her ___. Physical Exam: ADMISSION: Vital Signs: 98.3 138/68 84 18 98% RA General: Alert, AOx0, 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, 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: 98.6 160/67-191/76 ___ 18 95% RA GEN: AOx1, sad, in tears, poor eye contact HEENT: atruamatic, conjunctiva pink, sclera anicteric, MMM NECK: supple, FROM, no LAD, JVP<10 CV: RRR, no m/r/g LUNG: CTAP b/l ABD: benign EXT: wwp, no c/c/e NEURO: grossly intact, cognition impaired, insight poor Pertinent Results: ADMISSION: ___ 11:41PM BLOOD WBC-10.8 RBC-3.81* Hgb-11.2* Hct-35.1* MCV-92 MCH-29.5 MCHC-32.0 RDW-12.5 Plt ___ ___ 11:41PM BLOOD Neuts-79.8* Lymphs-11.7* Monos-7.4 Eos-0.9 Baso-0.3 ___ 11:41PM BLOOD Plt ___ ___ 11:41PM BLOOD Glucose-170* UreaN-47* Creat-1.9* Na-145 K-4.4 Cl-104 HCO3-21* AnGap-24* ___ 11:41PM BLOOD CK(CPK)-632* ___ 11:41PM BLOOD cTropnT-<0.01 ___ 07:45AM BLOOD cTropnT-<0.01 ___ 11:54PM BLOOD Lactate-1.6 DISCHARGE: ___ 07:23AM BLOOD WBC-5.5 RBC-3.51* Hgb-10.6* Hct-31.4* MCV-90 MCH-30.2 MCHC-33.7 RDW-12.7 Plt ___ ___ 07:23AM BLOOD Plt ___ ___ 07:23AM BLOOD Glucose-120* UreaN-24* Creat-1.1 Na-143 K-4.0 Cl-112* HCO3-21* AnGap-14 ___ 07:23AM BLOOD ALT-103* AST-73* CK(CPK)-207* AlkPhos-140* TotBili-0.3 ___ 07:23AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8 ___ 06:30AM BLOOD calTIBC-185* Ferritn-209* TRF-142* ___ 06:30AM BLOOD TSH-0.67 CT HEAD W/O CONTRAST: IMPRESSION: Stable bifrontal subcortical calcification. No fracture is identified. Note that there is no evidence of hemorrhage. NOTIFICATION: A revised report indicating with the frontal lobe hyperintensities are calcification rather than acute hemorrhage for was discussed by telephone by Dr. ___ with the attending covering the ___ at 09:40 on ___ CXR: no acute cardiopulmonary process KNEE PLAIN FILM: IMPRESSION: No acute fracture or dislocation. Moderate tricompartmental osteoarthritis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Lorazepam 1 mg PO TID 4. Venlafaxine XR 75 mg PO BID 5. Losartan Potassium 100 mg PO DAILY 6. HydrALAzine 25 mg PO BID 7. Vitamin D 1000 UNIT PO DAILY 8. Simvastatin 40 mg PO QPM 9. Zolpidem Tartrate 10 mg PO QHS 10. Omeprazole 20 mg PO BID 11. OxycoDONE (Immediate Release) 10 mg PO Q6H 12. Gabapentin 100 mg PO TID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Gabapentin 100 mg PO BID RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. HydrALAzine 25 mg PO BID 4. Lorazepam 0.5 mg PO TID RX *lorazepam 0.5 mg 1 by mouth three times a day Disp #*90 Tablet Refills:*0 5. Losartan Potassium 100 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Omeprazole 20 mg PO BID 8. OxycoDONE (Immediate Release) 5 mg PO Q6H RX *oxycodone 5 mg 1 tablet(s) by mouth q6 Disp #*30 Tablet Refills:*0 9. Simvastatin 40 mg PO QPM 10. Venlafaxine XR 37.5 mg PO BID RX *venlafaxine 37.5 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 11. Vitamin D 1000 UNIT PO DAILY 12. Citalopram 10 mg PO DAILY RX *citalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: - Toxic-metabolic encephalopathy - Acute renal failure - Recurrent falls - Elevated LFTs NOS Secondary: - Dementia NOS - Bifrontal subcortical calcifications secondary to traumatic frontal ICH (___) - Hypertension - Anxiety and Depression - Osteoarthritis w/ chronic pain - GERD - Vertigo - S/P hysterectomy - S/P L cataract repair Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT INDICATION: History: ___ with IPH s/p fall and L knee pain // evidence of fracture or worsening bleed TECHNIQUE: 3 views of the left knee. COMPARISON: None available. FINDINGS: There is no fracture or dislocation. Moderate tricompartmental degenerative changes are noted, most severe in the patellofemoral compartment with joint space narrowing and subchondral sclerosis. A well ossified fragment along the superior aspect of the patella likely represents a loose body or prior trauma. No focal lytic or sclerotic lesion is identified. No gross joint effusion. No soft tissue calcification or radio-opaque foreign body is seen. IMPRESSION: No acute fracture or dislocation. Moderate tricompartmental osteoarthritis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with hypoxia COMPARISON: ___ FINDINGS: AP portable upright view of the chest. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. Degenerative changes of the AC joint again noted. IMPRESSION: No acute intrathoracic process Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, Transfer Diagnosed with ALTERED MENTAL STATUS , FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 98.4 heartrate: 80.0 resprate: 16.0 o2sat: 97.0 sbp: 125.0 dbp: 72.0 level of pain: 13 level of acuity: 2.0

Dear Ms. ___: You were admitted to ___ after a fall. The cause of your fall was likely related to not eating and drinking enough. You were found to have an acute kidney injury and we gave you fluids to treat this. We also decreased some of your home medications which are known to cause altered mental status. You were seen by geriatricians who think your altered mental status was related to worsening dementia. You were seen by a geriatrician who recommended starting a new medicine called citalopram and going down on your home venlafaxine. Changes to your medications: (1) start citalopram 10mg daily (2) decreased gabapentin to 100mg twice daily (3) decreased ativan to 0.5mg three times daily (4) decrease oxycodone to 5mg every 6 hours as needed (5) decrease venlafaxine to 37.5 mg daily (6) STOP ambien You should take all of the rest of your home medications as you were before. All the best for a speedy recovery! Sincerely, ___ Treatment Team

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Amiodarone Attending: ___. Chief Complaint: Generalized weakness Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Overall patient is an ___ yo man with h/o ESRD on HD, Afib on coumadin, HTN, CHF with EF 48% p/w generalized weakness. Patient reports 3 days of generalized fatigue and weakness on morning of admission esp in LEs with inability to get out of bed to walk short distence. Some concern for left sided weakness initially, although patient now states that at baseline uses LUE less due to old injury and LLE w/ heel ulcer, thus less concern for left sided weakness. Patient recently admitted with UTI for which completed course of ceftaz on ___ and he continues to get neomycin bladder flush and dwell q2 days. Denies any change in quality of urine. Patient denies chest pain, palpiations, orthostasis, cough, fever, chills, abdominal pain, nausea, vomiting, diarrhea, shortness of breath, orhopnea, PND, leg swelling, parestesias, dysathria, dysphagia. Overnight noted to have peaked TW on EKG w/ elevated K. He was given one dose of kayelxelate and transfered to HD this morning as he missed HD session on ___. At the time of my exam, patient states feeling back to baseline and is eager to go home. Has no complaints. Past Medical History: T2DM - now resolved s/p weight loss, A1c<5% in ___, not on treatment ESRD- most likely multifactorial from hypertensive and obstructive nephropathy. On dialysis since ___. Atrial fibrillation- Pt is anticoagulated on coumadin. Hypertension CHF outpatient TTE ___ with LVEF ___ and subsequent recovery with EF 48% on office study ___. Obesity Gout PVD Anemia of chronic disease- Secondary to renal dysfunction. Sleep apnea Autonomic dysfunction, remitted (no longer on midodrine and fludrocort); persistent volume-sensitive BP regulation Social History: ___ Family History: His grandparents and father have hypertension and diabetes. Physical Exam: ADMISSION EXAM Vitals: 97.4, 125/78, 72, 20, 96% RA General: elderly male, NAD, AAOx3 HEENT: MM dry, EOMI, Neck: no JVD Lungs: CTAB CV: RRR no m/r/g Abdomen: soft, NT, ND NABS Ext: 2+ pulses, no edema Skin: no rashes; pressure ulcer under left heel with fibrinous exudate, not infected-appearing Neuro: CN2-12 intact. stength ___ in UE bilaterally except for 4+/5 with left triceps and 4+/5 with right biceps. biceps appears to be limited by pain from IV in wrist. unable to make strong grip, worse on left, due to bilateral baseline extension of fingers which patient says is chronic. ___ strength ___ bilat. LTSI. DISCHARGE EXAM Vitals: 97.0 139/88 87 20 97% RA 97.4kg General: AAOx3, sitting in bed eating in NAD HEENT: MMM, EOMI Neck: no JVD Lungs: CTABL CV: irreg irreg, no mrg Abdomen: soft, NT, ND NABS Ext: no edema Skin: left heel ulcer not examined Neuro: CN2-12 intact. strength 4+ to ___ bil upper and lower extremities. sensation to soft touch grossly intact. Pertinent Results: ADMISSION LABS ___ 02:15PM BLOOD WBC-7.8 RBC-3.60* Hgb-10.8* Hct-34.8*# MCV-97 MCH-29.9 MCHC-31.0 RDW-16.7* Plt ___ ___ 02:15PM BLOOD ___ PTT-42.5* ___ ___ 02:15PM BLOOD Glucose-107* UreaN-70* Creat-7.1*# Na-138 K-5.7* Cl-101 HCO3-19* AnGap-24* ___ 02:15PM BLOOD ALT-11 AST-21 CK(CPK)-37* AlkPhos-215* TotBili-0.3 ___ 02:15PM BLOOD Lipase-132* ___ 02:15PM BLOOD CK-MB-2 cTropnT-0.07* ___ 02:15PM BLOOD Albumin-3.9 Calcium-8.3* Phos-3.8 Mg-2.3 INTERVAL LABS ___ 07:00AM BLOOD TSH-6.0* ___ 07:25AM BLOOD T4-6.1 Free T4-1.3 DISCHARGE LABS ___ 07:25AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.4* Hct-33.2* MCV-95 MCH-29.7 MCHC-31.4 RDW-16.9* Plt ___ ___ 07:25AM BLOOD ___ PTT-42.2* ___ ___ 07:25AM BLOOD Glucose-89 UreaN-39* Creat-5.6*# Na-139 K-4.3 Cl-101 HCO3-27 AnGap-15 IMGAING CXR ___ IMPRESSION: 1. Moderate size right pleural effusion, similar compared to the prior exam, with trace left pleural effusion. 2. Bibasilar airspace opacities could reflect compressive atelectasis but infection is not excluded. 3. Interval improvement in mild pulmonary edema. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Cinacalcet 30 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Finasteride 5 mg PO DAILY 5. Furosemide 80 mg PO 4X/WEEK (___) 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Metoprolol Succinate XL 150 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. Pantoprazole 40 mg PO Q12H 10. Paricalcitol 6 mcg IV QHD 11. sevelamer CARBONATE 1600 mg PO TID W/MEALS 12. Sucralfate 1 gm PO TID 13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 14. Allopurinol ___ mg PO DAILY 15. Warfarin 2 mg PO EVERY OTHER DAY 16. Warfarin 3 mg PO EVERY OTHER DAY 17. Polyethylene Glycol 17 g PO DAILY:PRN constipation 18. Neomycin-Polymyxin B GU 1 mL / 1000 ml SW ___ Q48H Each 1000mL bottle contains 1mL of Neosporin GU Irrigant. please leave 25 cc of neosporin in bladder dwell between flushes Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Cinacalcet 30 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Finasteride 5 mg PO DAILY 5. Furosemide 80 mg PO 4X/WEEK (___) 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Metoprolol Succinate XL 150 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. Pantoprazole 40 mg PO Q12H 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. sevelamer CARBONATE 1600 mg PO TID W/MEALS 12. Sucralfate 1 gm PO TID 13. Warfarin 2 mg PO EVERY OTHER DAY 14. Warfarin 3 mg PO EVERY OTHER DAY 15. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 16. Paricalcitol 6 mcg IV QHD 17. Allopurinol ___ mg PO DAILY 18. Neomycin-Polymyxin B GU 1 mL / 1000 ml SW ___ Q48H please leave 10 cc of neosporin in bladder dwell between flushes 19. Collagenase Ointment 1 Appl TP DAILY RX *collagenase clostridium hist. [Santyl] 250 unit/gram As directed once a day Disp #*1 Each Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Generalized weakness Volume depletion Hypothyroidism ESRD 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: Weakness. TECHNIQUE: Upright AP and lateral views of the chest. COMPARISON: ___. FINDINGS: Heart size is difficult to determine given the presence of a moderate size right pleural effusion, which appears relatively unchanged compared to the prior exam. There is mild pulmonary edema, slightly improved compared to the previous exam. Streaky left basilar opacity may reflect atelectasis, with a right basilar opacity also likely reflective of compressive atelectasis. A small left pleural effusion appears to be present. There is no pneumothorax. Assessment of the lung apices is somewhat obscured due to the patient's chin projecting over this region. No acute osseous abnormalities are present. IMPRESSION: 1. Moderate size right pleural effusion, similar compared to the prior exam, with trace left pleural effusion. 2. Bibasilar airspace opacities could reflect compressive atelectasis but infection is not excluded. 3. Interval improvement in mild pulmonary edema. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: WEAKNESS Diagnosed with OTHER MALAISE AND FATIGUE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM NOS temperature: 96.8 heartrate: 83.0 resprate: 18.0 o2sat: 94.0 sbp: 122.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

Mr. ___, It was a pleasure taking care of you at the ___ ___ ___. You were admitted to the hospital because of generalized weakness. It is possible that this was caused in part by dehydration. You were given some fluids IV and you improved. You missed a dialysis session on ___ so had dialysis on ___ in the hospital. Following the dialysis you were feeling back to baseline. You had another dialysis session on ___ and were discharged home. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. You were also found to have mildly low thyroid levels. We are going to check some additional test and your PCP, ___ let you know whether any changes to your thyroid medications are necessary.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Morphine / Compazine / Gluten / Reglan Attending: ___ Chief Complaint: Nausea Concern for Dobhoff tube migration Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ with history of anorexia nervosa presenting from Radius LTS with nausea. ___ staff concerned that pt pt's J-tube had migrated into stomach, and that pt needs higher level of care so transferred her back to ___ with all of her belongings. Of note, pt was recently discharged on ___ from ___ to ___. Last hospital course was notable for prolonged stay secondary to anorexia nervosa. Initial VS in the ED:97.8 74 113/75 15 100%. Labs notable for unremarkable lytes accept slightly elevated phos. CBC shows crit of 34.9 at baseline Imaging notable for KUB dobhoff is clearly still in the right place. VS prior to transfer: 97.8 74 113/75 15 100% Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, Denies sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Medical History: 1. Celiac Sprue - Diagnosed via biopsy several years ago. Managed with diet, but with frequent complaints abdominal pain. 2. History of laxative, diet pill, and diuretic abuse 3. Osteoporosis - complicated by ankle fracture from stressrrelated to overexercising, and rib fracture s/p fall from blackout. On calcium and Vit D supplements 4. Chronic anemia - patient pancytopenic in past 5. Migraines 6. Chronic Arthritis in L Knee with a h/o 7 operations on L knee for torn meniscus - injury related to running. Last operation in ___. Past psychiatric history: 1. Anorexia Nervosa - per patient, diagnosed ~ ___ years ago. Lowest weight was "around 80 lbs" on her 5'2" frame (thinks she has lost ~ 0.5 inches of height). Amenorrheic in the past. AN c/b severe osteoporosis & h/o fractures and and h/o leukopenia in the past. Patient has been hospitalized > 10 times for her eating disorder, including past treatment at ___, most recently in the ___ and prior to that a nearly 3 month hospitalization there in the ___. Has h/o requiring tube feeds. Patient has also had treatment at a facility in ___ and at ___ in the past. Eating disorder behavior is primarily restricting, although patient has a h/o abuse of laxative, diuretics and diet pills and a h/o over-exercising. She denied any h/o binging behavior. 2. Unipolar Depression - Has a h/o previous inpatient psychiatric admissions, including a stay at ___ in ___ during which she was treated with ECT, which pt says was not helpful. Was discharged from ___ to the eating disorders program at ___, where she stayed for three months. 3. Self-injurious behavior and suicide attempts - Patient has a h/o one suicide attempt by attempted self-electrocution (use of a hair dryer while standing at a sink with water--nothing happened, later told her therapist), but the circumstances around this episode remain hazy (although the report of the attempt has been consistent over the years). She estimated that this attempt was approximately ___ years ago. Also has a h/o cutting, used to cut arms to "relieve pain," has req'd stitches in the past. Reported that she last cut over ___ years ago. Psychiatrist- Referred to new psychiatrist on discharge from ___ but pt and PCP have not heard back from new psychiatrist after multiple outreach attempts and pt feels she will likely need a new referral. Therapist- ___, ___ ___ (pastoral counselor, ___. Pt reports both are 'great' and that she's been seeing ___ since ___, though pt notes that she hasn't seen her very frequently ___ to frequent hospitalizations. Medication trials: Med trials have included sertraline, fluoxetine, amitriptyline, mirtazepine, duloxetine, olanzapine, aripiprazole and quetiapine. Social History: Guardian- Temporary court-appointed ___, ___. Court date for permanent guardianship pending. Sisters were guardians previously. B/R- ___ Family/Support- Primary supports include best friend ___, friend/boyfriend of ___ years, his mother, and church community. Mother is deceased. Father, 3 sisters live in the area. Patient is able to drive, but has transportation assistance through DMH. Housing- Lives w/ sister and brother-in-law, feels this is a supportive environment, feels safe. Employment- SSDI for psychiatric illness. No work since ___. Reports she is hoping to get back to work soon. Previously worked as ___ and in ___ and a ___ lab. Education- HS Spiritual- Identifies as ___. Reads bible regularly. Feels supported by church community. Trauma/Abuse- Endorses h/o sexual/physical/emotional abuse in teens/___. Firearms- Denies access. Family History: Mother - deceased age ___ from ___ Father - alive and well; history of depression. Physical Exam: PHYSICAL EXAMINATION: VITALS: 5'2", 41 kg, 98.3, 104/70, 64, 24, 97RA GENERAL: cachectic appearing, comfortable aox3 HEENT: PERRL, EOMI NECK: no carotid bruits, JVD LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, slightly tender in LUQ, NABS, no organomegaly EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3 Pertinent Results: Admission Labs: ___ 11:45PM BLOOD WBC-4.5# RBC-3.60* Hgb-11.6* Hct-34.9* MCV-97 MCH-32.2* MCHC-33.3 RDW-13.7 Plt ___ ___ 11:45PM BLOOD Neuts-66.1 ___ Monos-5.8 Eos-2.8 Baso-0.8 ___ 11:45PM BLOOD ___ PTT-26.4 ___ ___ 11:45PM BLOOD Glucose-91 UreaN-9 Creat-0.6 Na-137 K-4.3 Cl-99 HCO3-30 AnGap-12 ___ 11:45PM BLOOD Calcium-9.6 Phos-5.6*# Mg-1.9 Discharge Labs: Microbiology: none Imaging: KUB ___: FINDINGS: Dobbhoff tube ends beyond the ligament of Treitz in the proximal jejunum, in appropriate position. Nonspecific bowel gas pattern, no evidence of obstruction. No free air. Medications on Admission: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Dulcolax Stool Softener] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. HydrOXYzine 25 mg PO Q6H:PRN anxiety 5. Multivitamins 1 TAB PO DAILY 6. Pantoprazole 40 mg PO Q12H before breakfast and dinner 7. Psyllium 1 PKT PO TID 8. Ranitidine 300 mg PO HS 9. traZODONE 100 mg PO HS:PRN insomnia 10. Vitamin D 400 UNIT PO DAILY 11. Venlafaxine XR 225 mg PO DAILY 12. Sumatriptan Succinate 50 mg PO QID:PRN headache do not exceed 200mg/24hours 13. Senna 1 TAB PO BID:PRN constipation RX *sennosides [Senna Laxative] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*1 14. Ondansetron 4 mg PO Q6H:PRN nausea 15. Lorazepam 0.5 mg PO BID:PRN anxiety 16. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily Disp #*30 Capsule Refills:*1 17. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth / rectum daily Disp #*60 Tablet Refills:*1 18. Calcium Carbonate 500 mg PO TID 19. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*1 20. DiCYCLOmine 20 mg PO QID RX *dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp #*40 Tablet Refills:*1 21. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN GI discomfort RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 5 mL by mouth four times a day Disp #*5 Bottle Refills:*1 22. Lorazepam 0.5 mg PO Q8H:PRN nausea, anxiety RX *lorazepam 0.5 mg one tablet by mouth three times per day Disp #*60 Tablet Refills:*1 Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN indegestion 4. Docusate Sodium 100 mg PO BID 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. HydrOXYzine 25 mg PO Q6H:PRN anxiety 7. Lorazepam 0.5-1 mg PO TID hold for sedation 8. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN GI discomfort 9. Multivitamins 1 TAB PO DAILY 10. Pantoprazole 40 mg PO Q12H before breakfast and dinner 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Psyllium 1 PKT PO TID 13. Ranitidine 300 mg PO HS 14. Sumatriptan Succinate 50 mg PO QID:PRN headache do not exceed 200mg/24hours 15. Vitamin D 400 UNIT PO DAILY 16. Venlafaxine XR 225 mg PO DAILY 17. Senna 1 TAB PO BID:PRN constipation 18. Ondansetron 4 mg PO Q6H:PRN nausea 19. Lubiprostone 24 mcg PO BID RX *lubiprostone [___] 24 mcg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills:*2 20. OLANZapine 2.5 mg PO HS RX *olanzapine 2.5 mg 1 tablet(s) by mouth bedtime Disp #*30 Tablet Refills:*1 21. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*2 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - anorexia Secondary: - Anxiety - Chronic abdominal pain - Orthostatic hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___. Please assess Dobhoff position. TECHNIQUE: Supine and upright radiographs of the abdomen. COMPARISON: KUB from ___. FINDINGS: Dobbhoff tube ends beyond the ligament of Treitz in the proximal jejunum, in appropriate position. Nonspecific bowel gas pattern, no evidence of obstruction. No free air. Radiology Report HISTORY: Dobbhoff tube. FINDINGS: Tip of the Dobbhoff tube lies in the jejunum. Radiology Report HISTORY: Dobbhoff tube. FINDINGS: In comparison with earlier study of this date, the Dobbhoff tube now lies within the third portion of the duodenum. Radiology Report HISTORY: Dobbhoff placement. FINDINGS: The Dobbhoff tube is now in the upper stomach. Little change in the appearance of the heart and lungs. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: NAUSEA Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ANOREXIA NERVOSA temperature: 97.8 heartrate: 74.0 resprate: 15.0 o2sat: 100.0 sbp: 113.0 dbp: 75.0 level of pain: 13 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You came to the hospital out of concern for misplacement of your Dobhoff feeding tube. This was found to be in the correct location. We made the following changes to your medications: 1. Lubiprostone 24 mcg twice a day 2. Olanzapine 2.5 mg at nighttime 3. Tramadol (Ultram) 50 mg every 6 hours as needed for pain Please stop the following medications: 1. Bentyl 20mg QID 2. Trazadone 100mg at nighttime Please continue to take your other medications. Please follow-up with your providers as listed below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: antihistamines / decongestants / Amitriptyline / Adhesive Bandage / IV Dye, Iodine Containing Contrast Media / ACE Inhibitors Attending: ___. Chief Complaint: spinal abscess Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with PMH of MRSA infections (notably left knee PJI, T6-T7 discitis requiring T4-T9 fusion in ___, also hx of L3-L5 fusion laminectomy in ___ who is referred to ED for after abnormal MRI (available through ATRIUS) with right L2-L3 paracentral fluid collection concerning for abscess. Per PMD, patient has had longstanding back pain, which is currently unchanged. She is being referred for admission for biopsy, spine surgery and ID consults. - In the ED, initial vitals were: T 97.5 HR 97 BP 168/67 RR 17 O2 97% RA 320 - Exam was notable for: Neuro intact Diffuse midline lower back tenderness Rectal tone - Labs were notable for: 137 103 92 AGap=15 ------------<235 4.2 19 1.7 13.4 18.1>---<168 42.1 CRP: 217.8 - The patient was given: ___ 22:55 IVF LR ___ 00:59 PO/NG Gabapentin 600 mg ___ 00:59 PO/NG HYDROmorphone (Dilaudid) 2 mg ___ 00:59 PO/NG Methadone 5 mg ___ 02:00 IVF LR 1000 mL ___ 02:18 SC Insulin - Ortho was consulted, who recommended medicine admission and ID consult for IV antibiotics. On arrival to the floor, the patient confirms the history as above. Feels that her back pain is at baseline. Does have occasional shooting left leg pain, which is persistent. Does also note some significant left shoulder pain after having a cortisone injection on ___. Past Medical History: Prior hx of spinal osteomyelitis and discitis as above, h/o foot osteomyelitis s/p amputation CKD Stage III Insulin dependent type 2 diabetes Hypertension Obesity Ischemic colitis Hypertlipidemia Hypothyroidism Migraines GERD Social History: ___ Family History: No history of immunodeficiency. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: 98.3 PO 149 / 75 L Lying 79 20 93 Ra GENERAL: Alert and interactive. In no acute distress. HEENT: Sclera anicteric and without injection. MMM. NECK: No appreciable JVD CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: TTP in lower ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Left shoulder TTP at joint line, limited ROM due to pain. SKIN: No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: ======================== VITALS: ___ 0734 Temp: 98.0 PO BP: 149/69 HR: 71 RR: 20 O2 sat: 100% O2 delivery: Ra FSBG: 110 HEENT: MMM. NECK: No appreciable JVD CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: TTP in lumbar spine. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Left shoulder no significant tenderness. Improved ROM, able to reach across body, abduct past 90 degrees. L hallux s/p amputation. SKIN: Warm. NEUROLOGIC: AOx3. ___ strength in L foot dorsiflexion, remainder ___ throughout. Reports tingling to light touch on LLE to mid-calf. Pertinent Results: ADMISSION LABS =============== ___ 08:30PM BLOOD WBC-18.1* RBC-4.39 Hgb-13.4 Hct-42.1 MCV-96 MCH-30.5 MCHC-31.8* RDW-14.1 RDWSD-49.8* Plt ___ ___ 08:30PM BLOOD Glucose-308* UreaN-95* Creat-1.9* Na-135 K-4.5 Cl-99 HCO3-20* AnGap-16 ___ 04:39AM BLOOD ALT-29 AST-49* AlkPhos-119* TotBili-0.3 ___ 04:39AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.1 Mg-1.9 ___ 11:03PM BLOOD CRP-217.8* ___ 08:47PM BLOOD ___ pO2-42* pCO2-56* pH-7.19* calTCO2-22 Base XS--8 DISCHARGE LABS =============== ___ 06:36AM BLOOD WBC-9.0 RBC-3.85* Hgb-11.7 Hct-36.1 MCV-94 MCH-30.4 MCHC-32.4 RDW-14.2 RDWSD-48.1* Plt ___ ___ 06:36AM BLOOD Glucose-79 UreaN-38* Creat-0.8 Na-141 K-4.2 Cl-107 HCO3-22 AnGap-12 ___ 06:36AM BLOOD ALT-29 AST-37 AlkPhos-104 TotBili-0.4 ___ 06:36AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.6 ___ 06:36AM BLOOD CRP-87.9* ___ 03:18AM BLOOD ___ pO2-56* pCO2-33* pH-7.30* calTCO2-17* Base XS--8 MICRO ====== ___ 11:09 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Susceptibility testing requested per ___ ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___ MD (___) ON ___ AT 20:35. IMAGING ======== L SHOULDER XRAY ___ Moderate left glenohumeral joint degenerative changes and joint space narrowing. Mild AC joint degenerative changes. L SHOULDER US ___ No evidence of fluid collection within the left shoulder. SECOND OPINION MRI L-SPINE W & W/O CONTRAST ___. Study is degraded by motion and spinal fusion hardware artifact. 2. Postsurgical changes from L3-5 laminectomy and posterior fusion. 3. Approximately 5 mm T2 hyperintense, rim enhancing lesion in the right lateral recess at L2. While findings suggestive of suggestive of a discal cyst, differential considerations of infectious or inflammatory etiologies are not excluded on the basis examination. Recommend follow-up imaging to resolution. 4. Nonspecific paraspinal soft tissue edema centered at L4-5 persists, though is decreased from prior. 5. Multilevel lumbar spondylosis as described, most pronounced at L2-3, where there is moderate vertebral canal, mild left and moderate right neural foraminal narrowing. 6. Limited imaging of the kidneys demonstrate right at least partially cystic structures, incompletely characterized. RECOMMENDATION(S): Approximately 5 mm T2 hyperintense, rim enhancing lesion in the right lateral recess at L2. While findings suggestive of suggestive of a discal cyst, differential considerations of infectious or inflammatory etiologies are not excluded on the basis examination. Recommend follow-up imaging to resolution. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Methadone 5 mg PO TID 5. Minocycline 50 mg PO Q12H 6. Omeprazole 20 mg PO DAILY 7. Pregabalin 50 mg PO TID 8. Rosuvastatin Calcium 5 mg PO QPM 9. Sertraline 125 mg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. irbesartan 75 mg oral Q24H 13. Furosemide 20 mg PO DAILY 14. Tresiba FlexTouch U-100 (insulin degludec) 46 units subcutaneous QAM Discharge Medications: 1. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate 2. Minocycline 100 mg PO Q12H 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Methadone 5 mg PO TID 8. Omeprazole 20 mg PO DAILY 9. Pregabalin 50 mg PO TID 10. Rosuvastatin Calcium 5 mg PO QPM 11. Sertraline 125 mg PO DAILY 12. Tresiba FlexTouch U-100 (insulin degludec) 46 units subcutaneous QAM 13. Vitamin D 1000 UNIT PO DAILY 14. HELD- irbesartan 75 mg oral Q24H This medication was held. Do not restart irbesartan until instructed by your doctor Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis ================= Suspected spinal abscess Acute kidney injury Secondary diagnosis =================== Osteoarthritis Diabetes Hypertension Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA LEFT INDICATION: ___ year old woman with significant left shoulder pain// ?fraction TECHNIQUE: Three views of the left shoulder COMPARISON: No priors for comparison FINDINGS: The bones are demineralized. There is no acute displaced fracture or dislocation involving the glenohumeral or AC joint. Moderate degenerative changes are noted within the glenohumeral joint. There is moderate joint space narrowing of the glenohumeral joint. Mild AC joint degenerative changes. No suspicious lytic or sclerotic lesions are identified. No periarticular calcification or radio-opaque foreign body is seen. Thoracic posterior fusion hardware is partially visualized. IMPRESSION: Moderate left glenohumeral joint degenerative changes and joint space narrowing. Mild AC joint degenerative changes. Radiology Report EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE LEFT INDICATION: ___ year old woman with spinal abscess, now with severe shoulder pain// evaluate for effusion TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the left shoulder. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the left shoulder. There is no evidence of fluid collection or joint effusion. IMPRESSION: No evidence of fluid collection within the left shoulder. Radiology Report EXAMINATION: SECOND OPINION MR NEURO PSO4 MR INDICATION: ___ year old woman ___ year old female with PMH of MRSA infections (notably left knee PJI, T6-T7 discitis requiring T4-T9 fusion in ___, also hx of L3-L5 fusion laminectomy in ___, IDDM, HTN, CKD, hypothyroidism who is coming in for evaluation and treatment of suspected spinal abscess.// second opinion on back abscess second opinion on back abscess TECHNIQUE: Second opinion read on MRI ___ with and without contrast performed at outside institution. COMPARISON: MR ___ dated ___. FINDINGS: Study is degraded by motion and spinal fusion hardware artifact. For the purposes of numbering, the lowest rib bearing vertebral body was designated the T12 level. There is minimal anterolisthesis of L4 on L5, unchanged, as well as levoscoliosis of the lumbar spine. The patient is status post L3-5 laminectomy and posterior transpedicular fusion, with disc spacers noted at L3-4 and L4-5. T1 and T2 hypointensity along the inferior endplate of L2 and the superior endplate of L3 is also similar to prior, suggestive of degenerative sclerosis. Question STIR hyperintensity of the vertebral bodies of L2 and L3 versus hardware artifact. The visualized portion of the spinal cord is grossly preserved in signal and caliber, with the conus medullaris terminating at L1-2. There is loss of intervertebral disc space and loss of disc signal intensity at T12-L1 and L5-S1. STIR hyperintensity within the L2-3 and L3-4 disc spaces is similar to slightly decreased from most recent prior. Within the right lateral recess at L2, there is a 5 mm T2 hyperintense, rim enhancing focus (08:13, 2:9, 9:7) with questioned extension from the L2-3 intervertebral disc. Posterior disc bulge at L2-3 and uncovertebral hypertrophy contribute to moderate spinal canal narrowing and moderate right and mild left neural foraminal narrowing. Multilevel facet joint hypertrophy is noted throughout the lumbar spine. There is no definite vertebral canal narrowing or neural foraminal narrowing at T12-L1 or L1-L2. Evaluation of the neural foramen at L3-4, L4-5 and L5-S1 is limited due to hardware artifact. OTHER: Nonspecific L3 through sacrum paraspinal soft tissue probable edema is again seen, minimally decreased from prior exam. Nonspecific probable dependent edema is noted in the dorsal lumbar soft tissues. The partially imaged abdomen is notable for a right renal lesion which is at least partially cystic, though incompletely imaged, measuring at least 1.0 cm. IMPRESSION: 1. Study is degraded by motion and spinal fusion hardware artifact. 2. Postsurgical changes from L3-5 laminectomy and posterior fusion. 3. Approximately 5 mm T2 hyperintense, rim enhancing lesion in the right lateral recess at L2. While findings suggestive of suggestive of a discal cyst, differential considerations of infectious or inflammatory etiologies are not excluded on the basis examination. Recommend follow-up imaging to resolution. 4. Nonspecific paraspinal soft tissue edema centered at L4-5 persists, though is decreased from prior. 5. Multilevel lumbar spondylosis as described, most pronounced at L2-3, where there is moderate vertebral canal, mild left and moderate right neural foraminal narrowing. 6. Limited imaging of the kidneys demonstrate right at least partially cystic structures, incompletely characterized. RECOMMENDATION(S): Approximately 5 mm T2 hyperintense, rim enhancing lesion in the right lateral recess at L2. While findings suggestive of suggestive of a discal cyst, differential considerations of infectious or inflammatory etiologies are not excluded on the basis examination. Recommend follow-up imaging to resolution. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Back pain Diagnosed with Intraspinal abscess and granuloma temperature: 97.5 heartrate: 97.0 resprate: 17.0 o2sat: 97.0 sbp: 168.0 dbp: 67.0 level of pain: 8 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for a spinal abscess WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were seen by infectious disease and radiology and it was determined that your abscess was too small for drainage - You received IV antibiotics for your infection WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - You decided to leave against medical advice as we have not placed a PICC or set up home antibiotic infusions with vancomycin. We will try to schedule this once you leave the hospital, but this will be difficult and you will likely miss several doses of your vancomycin. Since you understand the risks of death, septic shock, recurrent bacteremia, we are discharging you against medical advice. - Please come to the emergency room if you develop fevers, worsening back pain, numbness or weakness, lightheadedness, or any other symptoms that concern you as it may be a sign that your infection is back. *** It is very important that you attend your appointments as listed below, especially your appointment with infectious disease. *** We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Penicillins / Remicade Attending: ___ Chief Complaint: lower extremity weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ M with a h/o multiple spinal surgeries following spinal cord accident in early ___, s/p cervical spine fusion, lumbar spinal fusion, cauda equine syndrome s/p decompression/fusion (___) with chronic lumbar spinal pain (on fentanyl and hydrocodone), h/o multiple MRSA infection incl. bacteremia, chronic diverticulitis, Crohn's and RA (on immunosuppression), and CVL who p/w acute on chronic back pain with b/l lateral lower extremity pain, saddle paranesthesias, inability to void, and bilateral lower extremity weakness following a minor fall at 14:30 on ___. The patient reports that he was in usual state of health until 14:30 on ___ when he stopped a gasstation on his way to visit family in the ___ area, tripped and fall on his back and head. Minor head strike to occiput. No LOC. He was able to stand and walk but noticed an intense pain shooting down his lateral legs b/l to the level of knees and on the left down to his lateral foot. This was followed by numbness and tingling sensations in the same location (L>R). He was able to walk back to his car. His symptoms felt similar to the symptoms he had when he had cauda equine syndrome and he noted that he was unable to void so he drove himself to the local ED at ___. At ___ he had a Foley catheter placed yielding about 900cc of urine. He was transferred to ___ for further care. A code cord was activated and he had several imaging studies done as summarized below. Of note the patient reports having being hospitalized at ___ in ___ 3 weeks ago for transient neurological symptoms, possibly a stroke. He seems to remember receiving TPA and was admitted to the hospital for 2 days. He is not on aspirin or AC. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. He denies difficulties producing or comprehending speech. On ___ review of systems, the pt reports having several days of diarrhea with lower abdominal pain (c/w CD flare vs diverticulitis). No fevers or chills. No blood in stool or urine. He acknowledges an about 10 lbs unintentional weight loss over the last 4 weeks. He has chronic arthralgias. Past Medical History: RA IBD (Crohn's) HTN Spinal surgeries (2 cervical, 3 lumbar) - most recent ___ GERD Chronic lower back pain Social History: ___ Family History: Non-contributory Physical Exam: PHYSICAL EXAM ============= Vitals: Temp: 96.9 HR: 89 BP: 145/89 Resp: 16 O2 Sat: 97 room air Normal ___: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused Abdomen: soft, tender in RLQ and supra Extremities: No cyanosis, clubbing or edema bilaterally. Tenderness over mid thoracic and lumbar spine. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3->2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 4* 4* 4* 4* 4* 4* 4* 4* 0 0 0 0 0 R 5 ___ 5 ___ 5 5 5 5 5 *unclear if giving away weakness -Sensory: Sensation to light touch, pain, proprioception intact in both upper extremities. Sensory deficit with no sensation in LLE below the level of L1. Perianal sensation decreased. Sphincter tonus decreased per ED team. -DTRs: Bi Tri ___ Pat Ach L 4+* 4+ 4+* 4+ 1+ 1+ R 3+ 3+ 3+ 4+ 1+ 2+ *several beats of clonus Plantar response was flexor on the right. No movement appreciated on the left. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF. Unable to perform heel to shin. -Gait: deferred Pertinent Results: ADMISSION LABS =============== ___ 09:20PM BLOOD WBC-5.9 RBC-3.73* Hgb-9.7* Hct-31.1* MCV-83 MCH-26.0 MCHC-31.2* RDW-16.0* RDWSD-48.2* Plt ___ ___ 09:20PM BLOOD Neuts-74.7* Lymphs-12.8* Monos-9.7 Eos-1.4 Baso-0.7 Im ___ AbsNeut-4.37 AbsLymp-0.75* AbsMono-0.57 AbsEos-0.08 AbsBaso-0.04 ___ 09:20PM BLOOD Plt ___ ___ 09:20PM BLOOD ___ PTT-29.4 ___ ___ 09:20PM BLOOD Glucose-98 UreaN-9 Creat-0.8 Na-147 K-4.3 Cl-109* HCO3-23 AnGap-15 ___ 09:20PM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2 IMAGING ======= CT C-SPINE W/O CONTRAST IMPRESSION: 1. Postoperative changes spine. 2. No fractures. 3. Degenerative changes. CT ABD & PELVIS WITH CO IMPRESSION: 1. No acute CT findings in the abdomen or pelvis to correlate with patient's reported symptoms. Specifically, no evidence of fracture in the lumbosacral spine. 2. Hepatic steatosis. CT HEAD W/O CONTRAST IMPRESSION: 1. No acute intracranial abnormalities. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fentanyl Patch 25 mcg/h TD Q72H 2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Frequency is Unknown 3. Metoprolol Tartrate 25 mg PO BID 4. Pravastatin 20 mg PO QPM Discharge Medications: 1. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - Severe DOSE FREQUENCY UNKNOWN, NOT VERIFIED BY HOME PHARMACY 2. Fentanyl Patch 25 mcg/h TD Q72H NOT VERIFIED BY HOME PHARMACY 3. Metoprolol Tartrate 25 mg PO BID 4. Pravastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: left lower extremity weakness urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: *** CODE CORD *** History: ___ with fall injury// fractures TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.5 cm; CTDIvol = 48.9 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: CT head without contrast from ___ FINDINGS: There is no evidence of acute major vascular territorial infarction,hemorrhage,edema,or mass. Mild brain parenchymal atrophy.. No evidence of midline shift. The basilar cisterns are patent. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post lens resections IMPRESSION: 1. No acute intracranial abnormalities. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: *** CODE CORD *** History: ___ with fall injury// fractures fractures 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 5.5 s, 21.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 493.9 mGy-cm. Total DLP (Body) = 494 mGy-cm. COMPARISON: CT C-spine without contrast from ___ FINDINGS: Please note that the exam is limited due to streak artifact from fusion hardware which limits assessment of adjacent structures. No evidence of prevertebral soft tissue swelling. Normal alignment. No acute fractures are identified. Anterior C4-C6 vertebral levels with interbody spaces, screws, solid fusion across vertebral bodies.. C4-C6 laminoplasty. Mild degenerative changes cervical spine. Probably mild central canal narrowing C3-C4 level. Multilevel foraminal narrowing. There is no evidence of infection or neoplasm. The visualized lung apices appear unremarkable. The thyroid gland is normal. Port-A-Cath in place. IMPRESSION: 1. Postoperative changes spine. 2. No fractures. 3. Degenerative changes. Radiology Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: ___ year old man with sx concerning for cauda equina // r/o fracture; please include sacral spine. 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 6.8 s, 53.8 cm; CTDIvol = 23.7 mGy (Body) DLP = 1,276.0 mGy-cm. Total DLP (Body) = 1,276 mGy-cm. COMPARISON: CT abdomen pelvis with contrast from ___ FINDINGS: LOWER CHEST: Mild atelectasis is seen in the lung bases. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous low attenuation throughout, compatible with hepatic steatosis. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. A 1.4 hypodense lesion is seen in the interpolar region of the right kidney, compatible with simple cyst. A subcentimeter hypodense lesion is seen in the left lower renal pole, too small to characterize. No hydronephrosis bilaterally. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not seen. PELVIS: The urinary bladder is decompressed by a Foley catheter there is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. 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 near complete fusion of the L4-L5 vertebral level. There is evidence of prior laminectomies. Mild retrolisthesis is seen at the L4-5 to S1 vertebral level. No definite fracture is identified. SOFT TISSUES: Note is made of a right fat containing inguinal hernia. There is evidence of prior anterior hernia mesh repair. Otherwise, the abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute CT findings in the abdomen or pelvis to correlate with patient's reported symptoms. Specifically, no evidence of fracture in the lumbosacral spine. 2. Hepatic steatosis. Gender: M Race: WHITE Arrive by HELICOPTER Chief complaint: Back pain, L Leg numbness Diagnosed with Low back pain, Fall on same level, unspecified, initial encounter, Crohn's disease, unspecified, without complications temperature: 96.9 heartrate: 89.0 resprate: 16.0 o2sat: 97.0 sbp: 145.0 dbp: 89.0 level of pain: 8 level of acuity: 2.0

Dear Mr. ___, It was a pleasure caring for you at the ___ ___. You came to the hospital because you developed weakness and changes in sensation in your legs. You chose to leave the hospital against medical advice prior to the completion of your workup. We recommend that you return to an emergency room if your symptoms worsen. Please continue to take your medications as prescribed and follow-up with your doctors as ___. We wish you all the best, Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Latex / Levaquin Attending: ___. Chief Complaint: palpitations, fever Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: The patient is a ___ year old male with a PMHx of metastatic RCC (papillary vs clear cell) to lungs & L pleural effusions s/p multiple chemo regimens (most recently cycle 10 of bevacizumab + erlotinib on ___, presents after a recent admission to ___ for PNA now with fevers, hypotension. The patient was recently admitted from ___ to ___ for similar symptoms. He was started on a 14-day course of unasyn & doxycycline but was ultimately discharged on augmentin. He did not, however, complete a 14-day course; opting to stop antibiotics on ___ in hopes of being considered for a clinical trial. He was screened for a clinical trial for a novel anti-PDL1 antibody that required him to hold his tarceva for 3 weeks. During this time, he appears to have clinically deteriorated. Most recently, he was admitted from ___ - ___ for respiratory failure due to post obstructive pneumonia and progressive metastatic disease to the lungs, as well as the pleural effusion. He was given vanc/cefepime switched to Levofloxacin for a total of ___T scan showed mild colitis affecting the distal descending and sigmoid colon. Stool studies were negative for C. Diff, he was empirically treated with Flagyl and completed a 2 week course of treatment. In the ED inital vitals were, 98.5 168 126/66 25 100% RA. He was triggered on arrival to ED for HR in 160s, SBP 125 initially then 88/69, got 2L IVF. CXR which shows large effusion ? similar to prior, difficult to tell if new/old PNA, treated with levofloxacin and vanc. He had a questionable allergic rxn to levo (hives on arms, got benadryl) so planned to give vanco / cefepime / gent / azithro, but only got cefepime and levofloxacin. His BP was down in ___ for approximately 40 min and he was admitted to the ICU for close monitoring. Patient did not want CVL or pressors in ED, lactate 3.3, had 2 18G PIVs (but pt requested one be d/c'd), HR down to 110s, not febrile in ED, EKG showed sinus tach. In the ICU, he remained stable not requiring pressors. On ___ he no longer required IVF boluses to maintain his BP. His other VS also remained stable. On the floor, he reports no problems. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Past Oncologic History: - Renal Cell Carcinoma ---> ___: Microscoping hematuria ---> CT A/P: 4.5 cm L adrean & periadrenal mass ---> MRI: L periaortic mass 4.6 cm ---> PET CT: lingular nodule, RP lesion adjacent to L adrenal - ___: underwent resection of mass & L adrenal nodule ---> Pathology revealved metastatic adenocarcinoma of unknown origin ---> Prominent papillary architecture w abundant eosinophilic or clear cytoplasm & high-grade nuclear features - PET ___: interval increase in size & update of pulmonary nodules - ___: 6 cycles carboplatin & Taxotere ---> PET CT: improvement in L lung lesions - ___: Enrolled in phase 1 trial of MET/ALK inhibitor ---> PET CT: Progression of disease in L adrenalectomy bed & lungs ---> Taken off trial - THEROS CancerType ID molecular classification test revealed 90.9% probability that cancer is of kidney origin based on 92 gene expression profile - ___: Sunitinib ---> Post-CT: Partial regression of adrenal bed lesion & stability in pulmonary nodules. ---> Progressed after 6 cycles of sunitinib - ___: Everolimus - ___: Taken off everolimus for disease progression - ___: Cyberknife radiation for mass invading psoas muscle ---> Recovery c/b severe pain ___ inflammation ---> Fevers to 100-102, SOB, R-sided CP. - ___: Bronch revealed malignant cell ---> No ABPA - ___: Started pazopanib - ___: Disease progression; taken off pazopanib - ___: s/p 10 cycles bevacizumab & erlotinib . Past Medical History: - Nephrolithiasis (bilateral) - Mitral valve prolapse - Colon polyp - Dysplastic nevus x3 - Necrotic LN in left neck (never biopsied/cultured) Social History: ___ Family History: - Father: Died in his ___ from brain aneurysm. Hypoplastic kidney - Mother: Alive in her ___. - All 3 sisters healthy. Physical Exam: On Admission: VS: 98.6 128/62 92 16 97% RA; ___ pain GEN: No apparent distress, resting comfortably in bed HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, ___ motor function globally DERM: no lesions appreciated On Discharge: VS: 98.1 128/80 102 17 98% on RA GEN: No apparent distress, resting comfortably in bed HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, ___ motor function globally DERM: no lesions appreciated Pertinent Results: ADMISSION ___ 10:05AM BLOOD WBC-10.4 RBC-4.14* Hgb-10.2* Hct-34.5* MCV-83 MCH-24.6* MCHC-29.5* RDW-18.3* Plt ___ ___ 10:05AM BLOOD Neuts-88.4* Lymphs-8.1* Monos-3.0 Eos-0.1 Baso-0.4 ___ 10:05AM BLOOD ___ PTT-35.2 ___ ___ 10:05AM BLOOD Glucose-121* UreaN-11 Creat-0.9 Na-130* K-4.7 Cl-93* HCO3-25 AnGap-17 ___ 10:05AM BLOOD ALT-271* AST-252* AlkPhos-439* TotBili-0.7 ___ 10:05AM BLOOD Albumin-2.9* Calcium-9.3 Phos-2.6* Mg-1.6 ___ 10:12AM BLOOD Lactate-3.3* PERTINENT ___ 10:05AM BLOOD ALT-271* AST-252* AlkPhos-439* TotBili-0.7 ___ 08:00PM BLOOD ALT-271* AST-296* LD(___)-319* AlkPhos-398* TotBili-0.6 ___ 02:47AM BLOOD ALT-227* AST-216* LD(LDH)-256* AlkPhos-339* TotBili-0.6 ___ 02:47AM BLOOD Cortsol-11.6 ___ 10:12AM BLOOD Lactate-3.3* CXR FINDINGS: A persistent patchy opacification in the left mid and lower lung fields, unchanged from the prior exam. The right lower lung aeration has improved from the prior exam with resolution of the previously seen opacity. On discharge: Multiple small nodules are seen bilaterally, consistent with the patient's known history of metastatic renal cell carcinoma. No new opacifications are present. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal. IMPRESSION: 1. Improvement in right lower lobe aeration with resolution of previously seen opacity. 1. Persistent left mid and lower lung opacification. 2. Multiple pulmonary nodules, consistent with known history of metastatic renal cell carcinoma. ABD U/S ___ FINDINGS: The liver shows no focal or textual abnormalities. The gallbladder is normal, without evidence of stones. No intra- or extra-hepatic biliary duct dilatation. The CBD measures 0.4 cm. Normal appearance of the pancreas. Note is made to multiple lymph nodes around the celiac axis. Both right and left kidneys are normal without hydronephrosis or stones. The right kidney measures 13.2 cm and the left kidney measures 14.5 cm. Spleen is unremarkable measuring 12.2 cm. The aorta is of normal caliber throughout. The visualized portion of the inferior vena cava appears normal. No ascites is detected. COLOR DOPPLER AND SPECTRAL WAVEFORM ANALYSIS: The RHV, MHV, and LHV are patent, showing normal flow direction. The MPV, RPV, and LPV are patent, showing normal flow direction and normal spectral waveform. The hepatic artery is patent, showing normal spectral waveforms with RI of 0.7. Normal flow is seen in the splenic vein. IMPRESSION: 1. Normal appearance of the liver with no focal or textural abnormalities. 2. The bile ducts are not dilated. 3. Normal liver vasculature. 3. Enlarged lymph nodes around the celiac axis consistent with the patient's known lymphadenopathy. Discharge: ___ 06:50AM BLOOD WBC-4.8 RBC-3.91* Hgb-9.7* Hct-32.2* MCV-82 MCH-24.8* MCHC-30.1* RDW-18.9* Plt ___ ___ 06:50AM BLOOD ___ PTT-29.9 ___ ___ 06:50AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-138 K-4.6 Cl-97 HCO3-27 AnGap-19 ___ 06:50AM BLOOD ALT-121* AST-85* LD(LDH)-262* AlkPhos-221* TotBili-0.4 ___ 06:50AM BLOOD Albumin-2.6* Calcium-9.8 Phos-3.4 Mg-1.8 ___ 06:45AM BLOOD Cortsol-24.3* ___ 06:50AM BLOOD WBC-4.8 RBC-3.91* Hgb-9.7* Hct-32.2* MCV-82 MCH-24.8* MCHC-30.1* RDW-18.9* Plt ___ ___ 06:50AM BLOOD ___ PTT-29.9 ___ ___ 06:50AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-138 K-4.6 Cl-97 HCO3-27 AnGap-19 ___ 06:50AM BLOOD Albumin-2.6* Calcium-9.8 Phos-3.4 Mg-1.8 ___ 06:45AM BLOOD Cortsol-24.3* Medications on Admission: axitinib [Inlyta] 5 mg one Tablet by mouth twice daily erlotinib [Tarceva] 150 mg 1 Tablet by mouth once a day lorazepam 1 mg 1 Tablet by mouth every four hours as needed for nausea oxycodone 5 mg ___ Tablets by mouth ___ hours as needed for pain zinc oxide-cod liver oil [Diaper Rash] 40% Ointment apply to affected area prn Discharge Medications: 1. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* 2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Inlyta 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 8. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Metastatic renal cell carcinoma Fevers Hypotension Abdominal Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Tachycardia. History of renal cell carcinoma. COMPARISONS: Chest radiograph ___. CTA chest ___. FINDINGS: A persistent patchy opacification in the left mid and lower lung fields, unchanged from the prior exam. The right lower lung aeration has improved from the prior exam with resolution of the previously seen opacity. Multiple small nodules are seen bilaterally, consistent with the patient's known history of metastatic renal cell carcinoma. No new opacifications are present. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal. IMPRESSION: 1. Improvement in right lower lobe aeration with resolution of previously seen opacity. 1. Persistent left mid and lower lung opacification. 2. Multiple pulmonary nodules, consistent with known history of metastatic renal cell carcinoma. Radiology Report REASON FOR THE EXAMINATION: This is a ___ man with metastatic RCC with elevated liver enzymes and epigastric pain; the request is to perform right upper quadrant examination with Dopplers to evaluate for source of elevated liver enzymes. COMPARISON: CT torso from ___. FINDINGS: The liver shows no focal or textual abnormalities. The gallbladder is normal, without evidence of stones. No intra- or extra-hepatic biliary duct dilatation. The CBD measures 0.4 cm. Normal appearance of the pancreas. Note is made to multiple lymph nodes around the celiac axis. Both right and left kidneys are normal without hydronephrosis or stones. The right kidney measures 13.2 cm and the left kidney measures 14.5 cm. Spleen is unremarkable measuring 12.2 cm. The aorta is of normal caliber throughout. The visualized portion of the inferior vena cava appears normal. No ascites is detected. COLOR DOPPLER AND SPECTRAL WAVEFORM ANALYSIS: The RHV, MHV, and LHV are patent, showing normal flow direction. The MPV, RPV, and LPV are patent, showing normal flow direction and normal spectral waveform. The hepatic artery is patent, showing normal spectral waveforms with RI of 0.7. Normal flow is seen in the splenic vein. IMPRESSION: 1. Normal appearance of the liver with no focal or textural abnormalities. 2. The bile ducts are not dilated. 3. Normal liver vasculature. 3. Enlarged lymph nodes around the celiac axis consistent with the patient's known lymphadenopathy. Gender: M Race: OTHER Arrive by UNKNOWN Chief complaint: PALPATATIONS Diagnosed with PALPITATIONS, HYPOTENSION NOS, VERTIGO/DIZZINESS, SEPTICEMIA NOS, SEPTIC SHOCK, SEVERE SEPSIS , ACCIDENT NOS temperature: 98.5 heartrate: 168.0 resprate: 25.0 o2sat: 100.0 sbp: 126.0 dbp: 66.0 level of pain: 13 level of acuity: 1.0

Dr. ___, ___ was a pleasure taking care of you at ___. You were admitted to the hospital due to fevers and hypotension. You initially went to the ICU and were given IV fluids and IV antibiotics. Your blood pressure rapidly improved and you remained afebrile. As the clinical suspicion for recurrent pneumonia was low, your antibiotics were stopped. You were also started on steroids for your cancer as well. You also had abdominal pain during this admission and were started on long-acting pain medications. You also underwent an EGD which showed no abnormalities. CHANGES to your medications: START prednisone 40mg by mouth daily START OxyconTIN 10mg by mouth twice daily START gabapentin 300mg by mouth three times daily START omeprazole 20mg by mouth daily

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old ___ man with CAD s/p PCI with chronic anginal symptoms, symptomatic bradycardia status post pacer placement at ___ several months prior, malignant melanoma and other skin cancers s/p multiple resections and CLL here for evaluation of atraumatic lower back pain. Patient reports he awoke 2 days prior with mid back pain that has been worsening in severity and is now radiating to his right flank. The pain is exacerbated with movement. He does report intermittent anginal symptoms over this time however he does have these at baseline, and was recently started on isosorbide dinitrate (he also uses SL nitro occasionally in the evening). He denies dysuria, leg weakness/numbness/tingling, urinary fecal incontinence, fevers, chills, night sweats, abdominal pain, nausea, vomiting, diarrhea. He uses a cane at baseline, and is independent in his ADLs except for the past few days as he was limited by pain. Denies any skin rash or history of zoster. Past Medical History: --CLL: He is RAI stage I on the basis of his lymphadenopathy, without hepatosplenomegaly. His Binet staging is unclear given the unknown extent of lymphadenopathy. His WBC is overall stable. His hemoglobin, platelet count are stable and his symptoms remain unchanged during ___ ___ onc evaluation --numerous, nonmelanoma skin cancers, as well as a melanoma on the right shin, 0.4 mm, no mitoses and nonulcerated (___) s/p multiple surgeries for removal of skin cancers PMH/PSH: 1. Coronary artery disease status post stent in ___. 2. Hypertension. 3. Basal and squamous cell skin cancers. 4. Prostate cancer, previously on Lupron, managed by urology. 5. Osteoporosis. 6. History of blepharitis. - Malignant melanoma - CLL as above - TMJ left-sided mass (likely benign salivary tumor, previously followed at ___ - Bilateral cataract repair - ? stroke vs TIA (head MRI ___ without any e/o acute infarct) Social History: ___ Family History: No known family history of cancer Physical Exam: ADMISSION PHYSICAL EXAM: 98.2, 125/53, 61, 18, 95%RA GEN: NAD HEENT: PER and minimally reactive (2mm b/l), EOMI, MMM, oropharynx clear, no cervical ___. L jaw nodular mass not TTP Resp: slight bibasilar crackles, no wheezes or rhonchi CV: RRR without m/r/g, nl S1 S2. JVP<7cm Chest: left upper chest wall with well healed incision from PPM placement. ABD: normal bowel sounds, non-tender, not distended EXTR: Warm, well perfused. No edema. 2+ pulses. NEURO: alert and orientedx3, CN ___ grossly intact, ___ motor grossly intact. Downgoing babinski's bilaterally. patellar reflexes 1+ equal b/l. Back: +TTP of thoracic/ upper lumbar spine. No paraspinal tenderness. No CVA tenderness. DISCHARGE PHYSICAL EXAM: VS: 98 97.7 113-132/53-70 60-66 ___ 95/RA GEN: NAD, sleeping in bed HEENT: L jaw nodular mass not TTP and mobile, no JVD Resp: CTAB, no wheezes or rhonchi CV: RRR with ___ SEM throughout pericordium, no r/g, nl S1 S2. Chest: left upper chest wall with well healed incision from PPM placement. ABD: normal bowel sounds, non-tender, not distended EXTR: Warm, well perfused. No edema. 2+ pulses. NEURO: ___ and ___ motor grossly intact. Back: Dark red papules diffuse across his back with underlying erythema. pain with palpation at T11 region. No paraspinal tenderness. No CVA tenderness. Pertinent Results: ADMISSION LABS: ___ 03:48PM BLOOD WBC-21.5* RBC-3.82* Hgb-11.5* Hct-35.5* MCV-93 MCH-30.1 MCHC-32.4 RDW-14.0 Plt ___ ___ 03:48PM BLOOD Neuts-33* Bands-0 Lymphs-63* Monos-3 Eos-0 Baso-1 ___ Myelos-0 ___ 03:48PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07:25AM BLOOD ___ PTT-28.8 ___ ___ 03:48PM BLOOD Glucose-108* UreaN-24* Creat-1.0 Na-135 K-4.1 Cl-102 HCO3-25 AnGap-12 ___ 07:25AM BLOOD ALT-13 AST-57* LD(LDH)-216 CK(CPK)-604* AlkPhos-47 TotBili-0.5 TROPONINS: ___ 04:48AM BLOOD CK-MB-6 cTropnT-2.19* ___ 03:37AM BLOOD CK-MB-30* MB Indx-7.2* cTropnT-1.04* ___ 01:20PM BLOOD CK-MB-56* MB Indx-9.3* cTropnT-1.06* ___ 05:50PM BLOOD cTropnT-0.18* ___ 03:48PM BLOOD cTropnT-0.18* DISCHARGE LABS: ___ 07:00AM BLOOD WBC-18.5* RBC-3.40* Hgb-10.4* Hct-30.8* MCV-91 MCH-30.7 MCHC-33.8 RDW-13.8 Plt ___ ___ 07:00AM BLOOD ___ PTT-59.6* ___ ___ 05:25AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-135 K-3.8 Cl-100 HCO3-24 AnGap-15 BONE SCAN Study Date of ___ INTERPRETATION: Whole body images of the skeleton obtained in anterior and posterior projections show intense, linear tracer uptake at the T11 vertebral body compatible with compression fracture. Incidental note is made of focal tracer uptake at the left 3rd rib end anteriorly compatible with prior trauma. There is residual tracer in the bowel from a sestamibi cardiac perfusion study the day before. The kidneys and urinary bladder are visualized, the normal route of tracer excretion. IMPRESSION: Intense linear tracer uptake at T11 vertebral body compatible with compression fracture. CARDIAC PERFUSION PHARM Study Date of ___ INTERPRETATION: The image quality is adequate but limited due to soft tissue and left arm attenuation. Left ventricular cavity size is increased. Rest and stress perfusion images reveal a fixed, moderate reduction in photon counts involving the distal anterior wall, distal septum, distal inferior wall and the apex. There is also a fixed, severe reduction in photon counts involving the distal lateral wall and the mid and distal inferior and inferolateral walls. Gated images reveal akinesis of the apex, distal lateral wall and the mid inferior and inferolateral walls. There is hypokinesis of the distal anterior wall, distal septum, distal inferior wall, and the basal inferior and inferolateral walls The calculated left ventricular ejection fraction is 38% with an EDV of 147 ml. IMPRESSION: 1. Fixed, medium sized, moderate severity perfusion defect involving the LAD territory. 2. Fixed, large, severe perfusion defect involving the LCx territory. 3. Increased left ventricular cavity size. Moderate systolic dysfunction with multiple wall motion abnormalities as described above. Stress Study Date of ___ INTERPRETATION: This ___ year old man with h/o HTN, HLD, sCHF, AS, and stable angina; s/p MI ___, PPM in ___, and possible PCI in ___ was referred to the lab for CAD evaluation. The patient was admininstered 0.142 mg/kg/min of Persantine over four minutes. The patient presented with low/mid back discomfort constant over the last week. No other chest, neck, back, or arm discomforts were reported by the patient throughout the study. In the presence of baseline ventricular pacing, the ST segments are uninterpretable for ischemia. The rhythm was intermittent A-V paced and sinus with ventricular pacing. Several, isolated APBs, one VPB, and an 11 beat run of atrial tachycardia was noted after aminophylline. Appropriate hemodynamic response to the infusion. Post-MIBI, the Persantine was reversed with 125 mg of Aminophylline IV. IMPRESSION: Non-anginal type symptoms. Uninterpretable ST segments for ischemic in the presence of ventricular pacing. Rhythm as noted. Nuclear report sent separately. ECG Study Date of ___ 4:56:32 ___ Atrial and ventricular sequential pacing. Compared to the previous tracing of ___ there is no significant change. Portable TTE (Complete) Done ___ at 3:50:06 ___ The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with infero-lateral, apical and distal septal hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate (___) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, the LVEF has decreased and regional LV systolic dysfunction is much more extensive ECG Study Date of ___ 10:41:08 AM Probable A-V sequentially paced rhythm. Atrial spikes are difficult to discern. Compared to the previous tracing of ___ pacemaker rhythm is unchanged. However, T waves are now inverted in the anterolateral precordial leads, although difficult to interpret. Cannot rule out underlying myocardial ischemia. Clinical correlation is suggested. CHEST (PA & LAT) Study Date of ___ 5:18 ___ FINDINGS: Dual-lead pacer is unchanged. The heart remains mildly enlarged. Since the CT torso, there has been no significant change with mild bibasilar atelectasis again noted. Gaseous distention of bowel in the upper abdomen noted without signs of free air. CTA CHEST W&W/O C&RECONS, NON-CORONARY, CTA Abd&Pelv Study Date of ___ 5:02 ___ IMPRESSION: 1. No acute aortic abnormality or pulmonary embolus. 2. A 3.2 x 2.3 cm anterior mediastinal mass with internal calcifications the upper portion of which was partially visualized on prior CTA neck. Differential includes lymphoma, thymoma, thyroid lesion or germ cell tumor. Scattered prominent but nonenlarged mediastinal lymph nodes. 3. 1-cm left lower lobe nodule and 6-mm right lower lobe nodule. Given size, short-term followup is recommended as these lesions are suspicious for metastases. 4. 1 cm intermediate density lesion in the right interpolar kidney which may represent a cyst or solid lesion. Consider ultrasound to further characterize. 5. Top normal caliber of large bowel with air-fluid levels without wall thickening or pericolonic fat stranding is nonspecific, it could be suggestive of a mild enteritis. 6. Trace ascites. 7. Small-to-moderate hiatal hernia. 8. Enlarged prostate. 9. Cholelithiasis without evidence for cholecystitis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 2.5 mg PO DAILY 2. Doxazosin 8 mg PO HS 3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 4. Simvastatin 40 mg PO QPM 5. Senna 8.6 mg PO BID:PRN constipation 6. Docusate Sodium 100 mg PO DAILY:PRN constipation 7. Dipyridamole-Aspirin 1 CAP PO BID 8. Lisinopril 40 mg PO DAILY 9. Isosorbide Dinitrate 30 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL PRN chest pain 11. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Dipyridamole-Aspirin 1 CAP PO BID 3. Docusate Sodium 100 mg PO DAILY:PRN constipation 4. Doxazosin 8 mg PO HS 5. Isosorbide Dinitrate 30 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Senna 8.6 mg PO BID:PRN constipation 8. Acetaminophen 650 mg PO TID 9. Atorvastatin 80 mg PO DAILY 10. Bisacodyl ___AILY:PRN constipation 11. Lidocaine 5% Patch 1 PTCH TD QPM 12. Metoprolol Tartrate 6.25 mg PO BID 13. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 14. Nitroglycerin SL 0.4 mg SL PRN chest pain 15. Omeprazole 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary diagnoses: - NSTEMI - T11 compression fracture - Mediastinal mass Secondary diagnoses: - Lung nodules, kidney nodule - CLL - Hypertension - Coronary artery disease - Prostate cancer 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 ___. ___ and CTA torso from ___. CLINICAL HISTORY: Back pain, question fluid overload. FINDINGS: Dual-lead pacer is unchanged. The heart remains mildly enlarged. Since the CT torso, there has been no significant change with mild bibasilar atelectasis again noted. Gaseous distention of bowel in the upper abdomen noted without signs of free air. Radiology Report HISTORY: Mid back pain radiating to the right flank with some associated chest pain. Evaluate for thoracic or abdominal aortic aneurysm. COMPARISON: Chest radiograph, ___. TECHNIQUE: Axial helical MDCT images were obtained of the chest, abdomen and pelvis after the administration of IV contrast in the arterial phase. Multiplanar reformats were generated in the coronal and sagittal planes as well as thin section maximum intensity oblique images. DLP: 1128.55 mGy-cm. FINDINGS: CTA CHEST: Thyroid is unremarkable. Heart is enlarged with dense coronary artery calcifications. Left-sided pacer with dual leads are in place. The thoracic aortic arch is normal in caliber, without focal aneurysmal segment or dissection. The main pulmonary artery is top normal in caliber, and there is no pulmonary embolus to the subsegmental level. There are several calcified mediastinal lymph nodes. There is a partially calcified anterior mediastinal mass, measuring 3.2 x 2.3 cm (2:37) with internal calcification. There is no supraclavicular, axillary, hilar or mediastinal lymphadenopathy by CT size criteria, although there are few scattered top normal prominent mediastinal lymph nodes. There is posterior dependent atelectasis bilaterally. There is a 1-cm pulmonary nodule at the left lung base (2:61). There is a 6-mm ___ nodule in the right lower lobe (2:50). Lungs are otherwise clear. Pleural surfaces are clear without effusion or pneumothorax. CTA ABDOMEN: The liver enhances homogeneously without focal lesion, intra- or extra-hepatic biliary ductal dilatation. The portal vein is patent. There are several large gallstones measuring up to 2.5 cm without evidence for cholecystitis. The spleen, pancreas and adrenal glands are unremarkable. Several subcentimeter renal hypodensities bilaterally are too small to fully characterize, but likely represent cysts. There is a roughly 1 cm rounded area of intermediate density in the right interpolar kidney of slightly different enhancement pattern than the remainder of the kidney. The kidneys otherwise present symmetric nephrograms without pelvicaliceal dilatation or perinephric abnormalities. There is a small-to-moderate sliding hiatal hernia. The stomach, duodenum and remainder of the small bowel is otherwise grossly unremarkable. The colon is top normal in caliber with some air-fluid levels, with fluid opacification seen proximally but otherwise without wall thickening or pericolonic fat stranding. Atherosclerotic calcifications are seen along a normal caliber abdominal aorta without aneurysm or dissection. The celiac axis, SMA, bilateral renal arteries and ___ are grossly patent. There is no mesenteric or retroperitoneal lymphadenopathy by CT size criteria. There is no pneumoperitoneum. There is trace ascites. There is a small fat-containing umbilical hernia. CTA PELVIS: The bladder, rectum, and seminal vesicles are unremarkable. The prostate is enlarged. There is a fat-containing left-sided inguinal hernia. There is no inguinal or pelvic sidewall adenopathy by CT size criteria. OSSEOUS STRUCTURES: Well-circumscribed sclerotic focus in the right sacral ala is compatible with a bone island. There are no focal blastic or lytic lesions in the visualized osseous structures concerning for malignancy. IMPRESSION: 1. No acute aortic abnormality or pulmonary embolus. 2. A 3.2 x 2.3 cm anterior mediastinal mass with internal calcifications the upper portion of which was partially visualized on prior CTA neck. Differential includes lymphoma, thymoma, thyroid lesion or germ cell tumor. Scattered prominent but nonenlarged mediastinal lymph nodes. 3. 1-cm left lower lobe nodule and 6-mm right lower lobe nodule. Given size, short-term followup is recommended as these lesions are suspicious for metastases. 4. 1 cm intermediate density lesion in the right interpolar kidney which may represent a cyst or solid lesion. Consider ultrasound to further characterize. 5. Top normal caliber of large bowel with air-fluid levels without wall thickening or pericolonic fat stranding is nonspecific, it could be suggestive of a mild enteritis. 6. Trace ascites. 7. Small-to-moderate hiatal hernia. 8. Enlarged prostate. 9. Cholelithiasis without evidence for cholecystitis. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Back pain Diagnosed with BACKACHE NOS, HYPERTENSION NOS temperature: 98.3 heartrate: 80.0 resprate: 16.0 o2sat: 95.0 sbp: 149.0 dbp: 64.0 level of pain: 7 level of acuity: 3.0

Dear Mr. ___, It was our pleasure participating in your care here at ___. You were admitted on ___ with back pain and found to have damage to your heart based on your lab work, despite not having any chest pain. You underwent testing called a stress test that showed you would not likely benefit from another cardiac catheterization. You also had imaging of your chest and abdomen. This imaging showed you had nodules in your lungs and kidney as well as a mass in your chest that may be a cancer. You will have follow-up with thoracic surgery and may need to have a biopsy. You will also likely need to have further imaging as an outpatient. Your main concern was back pain. You had a special study called a bone scan that showed you had a fracture in one of your vertebrae. If you have worsening back pain, you may benefit from wearing a special brace when you walk. If you have chest pain, worsening back pain, shortness of breath, or any other concerning symptoms, please let your doctor know right away. Again, it was our pleasure participating in your care. We wish you the very best, -- Your ___ Medicine Team --

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history significant for obesity s/p Roux-en-Y gastric bypass done (___) who presents to the ED as a transfer from ___ for concern of abdominal abscess versus pancreatic pseudocyst. Patient describes a 3-week history of left-sided abdominal discomfort and pain. Symptoms have been constant with intermittent worsening in nature where she describes a crampy ___ abdominal pain. Symptoms not associated with any nausea, vomiting or diarrhea. She did not have medical insurance so did not go to hospital. This morning, pain was much worse so she presented to ___. Patient denies any shortness of breath or chest pain. Otherwise no recent illness. States she has not had an appetite and is only being able to eat a little soup and grapes. Denies any dysuria or hematuria. No vaginal bleeding or discharge. Patient is a daily drinker drinking about a box of wine daily. Last ingestion 5 AM this morning. No history of alcohol withdrawal seizures. Does not feel like she is withdrawing. Patient went to ___ had a CT scan done which show a large complex cystic mass occupying much of the left upper quadrant extending to the upper left pelvis which may represent multiple pseudocyst formation from prior pancreatitis. An abscess is also possible. She also had lab work done which were pertinent for a white count of 9.2 with a hematocrit 32.6. AST 63, ALT 26, alk phos of 241. Lipase of 542. Given CT findings abnormal lab results, patient transferred here for further eval. She received 1 L of normal saline, morphine and Zofran. Also given Ativan. Then transferred here for further care. In the ED: VS: Tmax 99.8, P 94, BP 120-140/70-84, RR ___, 94-96% on RA ECG: QTc 383 PE: benign cardiopulmonary, abdominal and neuro exam Labs: Lipase 291, AST 62, ALT 23, ALP 229, Tbili 0.6, Albumin 2.9, Utox pos opiates but otherwise all negative Imaging: RUQUS with borderline dilated CHD, no cholelithiasis, no evidence of biliary obstruction on OSH CT, second opinion read of CT at OSH with likely pancreatic pseudocyst, reactive segmental colitis Impression: Pancreatitis, EtOH withdrawal Interventions: LR @ 250, Ativan 0.5mg IV, dilaudid 0.5mg IV x 6, valium 20mg, valium 10mg x3, thiamine/folate/MVI, 2 gm MgSulf Consults: Bariatric surgery consulted, recommended NPO, IVF, nutrition labs and admission to medicine for pancreatitis. they reviewed imaging with radiology noting peripancreatic fluid collections, no abscess, no necrosis On arrival to the floor patient requested valium for alcohol withdrawal. She complained of persistent periumbilical pain which she states has been constant for the past 2 weeks. She also reported feeling anxious and very shaky with difficulty holding a cup because of the tremors. She states she was feeling like she was malnourished and questioned why she couldn't eat anything by mouth. She denies active nausea or vomiting, she denied fevers or chills. States she was given jello and broth earlier today which she tolerated fine. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Anxiety Allergic Rhinitis Alcohol Use Disorder / Alcohol Dependence LTBI s/p INH History of Roux-en-Y Gastric Bypass - ___ History of breast augmentation Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION VITALS: reviewed in POE, ___ GENERAL: Alert, anxious, tremulous EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, somewhat tender to palpation in periumbilical and lower quadrants without guarding or rebound. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly symmetric SKIN: No obvious rashes or ulcerations noted on cursory skin exam NEURO: tremulous, alert, oriented, face symmetric, speech fluent but with lag in answering time, moves all limbs PSYCH: anxious, somewhat difficult to engage, answering in short sentences with some impairment in attention span and memory recall but difficult to gauge whether or not this was volitional. DISCHARGE VS: ___ 0021 Temp: 98.2 PO BP: 102/67 HR: 74 RR: 18 O2 sat: 97% O2 delivery: RA Gen - sitting up in bed, comfortable appearing Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft, nontender to deep palpation; no rebound/guarding; normal bowel sounds Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses Neuro - AOx3, moving all extremities Psych - appropriate Pertinent Results: ADMISSION ___ 11:57PM BLOOD WBC-8.8 RBC-3.02* Hgb-9.4* Hct-29.4* MCV-97 MCH-31.1 MCHC-32.0 RDW-17.1* RDWSD-60.5* Plt ___ ___ 11:57PM BLOOD Glucose-81 UreaN-4* Creat-0.4 Na-139 K-4.2 Cl-101 HCO3-22 AnGap-16 ___ 11:57PM BLOOD ALT-25 AST-68* AlkPhos-231* TotBili-0.5 ___ 11:57PM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.4 Mg-1.6 Iron-48 ___ 09:40AM BLOOD ASA-NEG Ethanol-NEG Tricycl-NEG SECOND OPINION CT TORSO 1. Large complex peripancreatic collection most likely a pancreatic pseudocyst. Difficult to exclude a component of pancreatic necrosis though overall volume of the pancreas appears preserved. 2. Segmental colitis along the mid transverse and splenic flexure likely reactive with, given contact by adjacent pancreatic pseudocyst. 3. Nonspecific peritoneal nodularity along the anterolateral right abdominal wall, attention on follow-up. 4. Hepatic steatosis 5. Postsurgical changes from Roux-en-Y gastric bypass without evidence of obstruction. 6. The appendix is normal. LIVER OR GALLBLADDER US 1. Borderline dilated common hepatic duct. On outside hospital CT, the common hepatic duct and common bile duct taper gradually toward the ampulla without evidence of obstruction. 2. Peripancreatic fluid collections as assessed on outside hospital CT 1 day prior. 3. No cholelithiasis. DISCHARGE ___ 05:06AM BLOOD WBC-4.3 RBC-3.10* Hgb-9.6* Hct-30.7* MCV-99* MCH-31.0 MCHC-31.3* RDW-16.9* RDWSD-60.4* Plt ___ ___ 05:06AM BLOOD Glucose-82 UreaN-3* Creat-0.5 Na-143 K-4.4 Cl-103 HCO3-25 AnGap-15 ___ 05:06AM BLOOD ALT-25 AST-53* AlkPhos-175* TotBili-0.4 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cetirizine 10 mg PO DAILY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 2. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 3. Cetirizine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Acute alcohol pancreatitis # Pancreatic pseudocyst # Transaminitis # Alcohol abuse complicated by withdrawal # Peripheral neuropathy 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: ___ with pancreatitis 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. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace perihepatic ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 8 mm. On outside hospital CT, the common hepatic duct and common bile duct taper gradually toward the ampulla without evidence of obstruction. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. And peripancreatic fluid better assessed on outside hospital CT. Irregularly marginated hypoechoic fluid in the left upper quadrant appears similar to the outside hospital CT scan obtained 1 day prior. SPLEEN: Normal echogenicity. Spleen length: 11.1 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Borderline dilated common hepatic duct. On outside hospital CT, the common hepatic duct and common bile duct taper gradually toward the ampulla without evidence of obstruction. 2. Peripancreatic fluid collections as assessed on outside hospital CT 1 day prior. 3. No cholelithiasis. Radiology Report EXAMINATION: SECOND OPINION OF CT ABDOMEN AND PELVIS INDICATION: ___ female with pancreatitis. Evaluate fluid collection. TECHNIQUE: Not available as this study was completed at an outside hospital. DOSE: Not available as this study was completed at an outside hospital. COMPARISON: None available. FINDINGS: LOWER CHEST: There is mild dependent atelectasis in the bilateral lower lobes and subsegmental atelectasis in the right lower lobe. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates low attenuation, compatible with hepatic steatosis. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: There is significant peripancreatic stranding and peripancreatic fluid. There is a complex multiloculated peripancreatic collection which encases the pancreatic tail, contacts the splenic flexure of the colon anterolaterally, extends inferiorly along the anterior pararenal fascia and lateral conal fascia and extends medially along the anterior body of the pancreas tracking along the transverse mesocolon. This collection is irregular and poorly defined, its approximate measurement is 13.0 x 10.6 x 26.0 cm (ap x tv x cc: 2:31 and 601:63). The overall volume of the pancreas appears preserved. The splenic vein is attenuated and encased by the peripancreatic collection though appears patent. There is no convincing evidence of significant pancreatic necrosis. There is no main ductal dilatation. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Postsurgical changes from Roux-en-Y gastric bypass are noted. Oral contrast is seen to the ileum. The stomach is otherwise unremarkable. The small bowel is unremarkable without evidence of obstruction. The appendix is normal. There is wall thickening of the colon extending from the splenic flexure to the distal descending colon, which abuts the complex peripancreatic fluid collection. Subtle peritoneal nodularity is seen along the right anterolateral body wall best seen on series 4, image 206, of unclear etiology, attention on follow-up advised. PELVIS: There is mild wall thickening of the bladder. There is low volume minimally complex free fluid in the pelvis. (2:78) REPRODUCTIVE ORGANS: The uterus is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Bilateral breast prosthesis are noted. There is a fat containing ventral hernia.. IMPRESSION: 1. Large complex peripancreatic collection most likely a pancreatic pseudocyst. Difficult to exclude a component of pancreatic necrosis though overall volume of the pancreas appears preserved. 2. Segmental colitis along the mid transverse and splenic flexure likely reactive with, given contact by adjacent pancreatic pseudocyst. 3. Nonspecific peritoneal nodularity along the anterolateral right abdominal wall, attention on follow-up. 4. Hepatic steatosis 5. Postsurgical changes from Roux-en-Y gastric bypass without evidence of obstruction. 6. The appendix is normal. Radiology Report EXAMINATION: MRCP INDICATION: ___ year old woman with pancreatitis and pancreatic pseudocyst, unclear if alcohol vs stone related; CT with high density material within the lumen of a dilatedgallbladder// better characterize biliary tree for signs of stones or sequelae of recent obstruction to explain pancreatitis TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: Prior CT abdomen done ___ FINDINGS: Lower Thorax: Trace left-sided pleural effusion. No pericardial effusion. No confluent airspace consolidation. Bilateral breast prostheses in situ. Liver: Severe hepatic steatosis with a fat fraction of 25%. No focal suspicious hepatic lesions. No intrahepatic bile duct dilatation. Biliary: The CBD is mildly dilated measuring 9 mm diameter. It tapers smoothly towards the ampulla. No gallstones. No CBD stones. Pancreas: Decreased T1 signal intensity of the body and tail of the pancreas in keeping with acute edematous pancreatitis. No nonenhancing areas seen to suggest pancreatic parenchymal necrosis. Again noted are complex rim enhancing, multiloculated fluid collection which encases the pancreatic tail, contacts the splenic flexure of the colon anterolaterally, extends inferiorly along the anterior pararenal fascia and lateral conal fascia. It also extends medially along the anterior body of the pancreas tracking along the transverse mesocolon. The collection is also seen superior to the tail of the pancreas extending medial to the spleen tracking inferiorly via the posterior pararenal space. Spleen: No focal splenic lesions. Small accessory spleen. Adrenal Glands: The adrenals appear normal. Kidneys: The kidneys appear normal. No hydronephrosis. Gastrointestinal Tract: Post surgical anatomy after gastric bypass. Edematous appearance of the splenic flexure is most likely secondary to adjacent inflammation from the pancreas. The patient is status post Roux-en-Y gastric bypass without evidence of obstruction. Lymph Nodes: A couple of small reactive mesenteric lymph nodes. Vasculature: The major peripancreatic vessels are patent. Osseous and Soft Tissue Structures: No suspicious bony lesions. Small foci of susceptibility in the anterior abdomen is non specific, likely from prior surgery. IMPRESSION: 1. Findings in keeping with acute pancreatitis involving the body and tail of the pancreas. No pancreas non enhancement to suggest pancreatic necrosis. 2. Extensive peripancreatic fluid collections as described above. Appearing well circumscribed, they may represent acute necrotizing collections vs walled-off necrosis, the former more likely given the reported ___ weeks of symptoms. 3. No gallstones or CBD stones to suggest gallstone pancreatitis. 4. The major vessels surrounding the pancreas appears patent. 5. Severe hepatic steatosis. No suspicious focal hepatic lesions. 6. Please note that the previously described right anterior omental soft tissue nodules is not included in the MRI scan volume and reference is made to prior CT report dated ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Abscess, Transfer Diagnosed with Acute pancreatitis without necrosis or infection, unsp, Left lower quadrant pain temperature: 98.8 heartrate: 94.0 resprate: 18.0 o2sat: 95.0 sbp: 120.0 dbp: 70.0 level of pain: 7 level of acuity: 3.0

Ms. ___: It was a pleasure caring for you at ___. You were admitted with abdominal pain and found to have pancreatitis and a fluid collection in your pancreas ("pancreatic pseudocyst"). You were seen by GI specialists and surgeons and underwent additional testing. You improved and are now able to be discharged home. It will be important to avoid all alcohol, as this can cause your pancreatitis to occur again.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Shoulder Pain Major Surgical or Invasive Procedure: ___ I&D SHOULDER RIGHT ARTHROSCOPY History of Present Illness: ___ PMH of AFib (on Xarelto), OA, Metastatic Prostate cancer (c/b bone mets, s/p chemotherapy now on clinical trial pembrolizumab/radium) who presented to the ED with R shoulder pain and lightheadedness Patient noted that he has had weeks of right shoulder pain, which feels like sharp stabbing, that is better with rest, worse with movement, ___ at times, not a/w shoulder swelling/erythema. He noted that oxycontin/oxycodone help but he tries not to take the short acting as he feels that it makes his thought process clouded. He was seen ___ the ED on ___ for such pain where Xray revealed mild inferior subluxation of the right shoulder without definite findings of dislocation and no fracture or suspicious osseous lesions. He was presumed to have adhesive capsulitis so was discharged with orthopedics f/u which he attempted to go to today, but was sent to his PCP once ortho team identified that he had low BP + orthostatic symptoms. PCP then sent patient to ED for evaluation. With regard to lightheadedness, patient noted that it is only with movement, and is absent at rest. He noted that he feels very fatigued when exerting himself, and occasionally slightly short of breath, but denied chest pain/discomfort. He noted that he was without any blood ___ his urine or stool. No melena. Noted that such symptoms were subacute over the past few weeks, which he thought was related to overdiuresis so he decreased torsemide from 40 to 20mg daily. He noted that his lower extremity edema has been minimal on torsemide but that his RUE has had increased edema ___ last week or two. Past Medical History: PAST ONCOLOGIC HISTORY: -___ Prostate cancer diagnosed: adenocarcinoma ___ 3 cores, right mid-medial ___ 4+3 involving 40%, right base lateral ___ 4+3 involving 75%, and right base medial ___ 4+4 involving 70%, extensive prostate tumor ___ the anterior gland with extracapsular extension and invasion of the inferior bladder wall, bilateral peripheral zone tumors, and bilateral sidewall lymphadenopathy, cT3aN1M0 -___ initiated leuprolide and bicalutamide -___ - external beam radiation, stop bicalutamide -___ - completed ___ years of leuprolide therapy -___ - large rise ___ PSA (15.9). Underwent restaging and his bone scan showed two new lesions at T9 and L4. Therefore, he was restarted on Lupron. Seen by Dr. ___ 10 fractions of XRT to his spine and femur as prophylactic therapy -___ - PSA increased to 7.5 from 0.8-1.7. Started enzalutamide. Denosumab x 1 dose. -Docetaxel C1D1 ___ :c/b infection, leg swelling, cough, diarrhea and was hospitalized with neutropenia. -Docetaxel C2D1 ___ -Docetaxel C3D1 ___ + neulasta onbody -Docetaxel C4D1 ___ + neulasta onbody -Docetaxel C5D1 ___ + neulasta onbody + Lupron - ___: Progression of known bony metastatic disease - ___: Screened for protocol ___ - ___: CT-guided bone biopsy Social History: ___ Family History: Mother died of colon cancer at ___ Father died ___ ___ of unclear causes Physical Exam: Admission Exam: =============== GENERAL: Pleasant man, ___ no distress, sitting ___ bed comfortably. EYES: Anicteric, PERLL HENT: OP clear. MMM, supple neck CARDIAC: RRR, normal distal perfusion, trace peripheral edema ___ legs LUNG: Appears ___ no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. normal RR ABD: Soft, non-tender, non-distended, normal bowel sounds EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. RUE unable to be lifted off bed but has normal strength ___ forearm, wrists, and fingers. Specifically has problems with abduction. Patient has improved ROM with passive movement, but is limited by extreme pain with minor adjustments. Has tenderness both at AC joint and coracoid process, no effusion or erythema. Left shoulder normal. NEURO: A&Ox3, good attention and linear thought. Sensation to light touch intact. SKIN: No significant rashes. ACCESS: PORT with dressing c/d/i Discharge Exam: =============== GENERAL: Sitting ___ chair, no apparent distress CARDIAC: RRR, no murmurs LUNG: CTAB, no wheezes or crackles ABD: BS+. Soft, non-tender, non-distended. EXT: Warm, well perfused. Pain with active/passive motion of Right shoulder. Right shoulder tender to palpation NEURO: A&Ox3. SKIN: No significant rashes ACCESS: PORT with dressing c/d/i Pertinent Results: Admission Labs: =============== ___ 12:35PM BLOOD WBC-2.5* RBC-1.99* Hgb-5.6* Hct-17.5* MCV-88 MCH-28.1 MCHC-32.0 RDW-18.0* RDWSD-57.1* Plt Ct-44* ___ 12:35PM BLOOD Glucose-129* UreaN-15 Creat-0.6 Na-129* K-4.2 Cl-88* HCO3-25 AnGap-16 ___ 04:52AM BLOOD Calcium-7.8* Phos-4.0 Mg-2.1 ___ 07:35PM BLOOD ALT-47* AST-65* LD(LDH)-320* AlkPhos-283* TotBili-1.1 Reports: ======= Us left upper extremity ___: IMPRESSION: No evidence of deep vein thrombosis ___ the right upper extremity. CXR ___: IMPRESSION: Left costophrenic angle not fully included on the image. Given this, no large pleural effusion or focal consolidation. Likely mild basilar atelectasis CT Left upper extremity: IMPRESSION: 1. Fluid collection with peripheral hyper enhancement ___ the right subscapularis muscle is likely tracking from the joint space into the subscapularis recess consistent with a moderately large effusion. Similar appearing fluid ___ the subacromial subdeltoid bursa is likely tracking volar via a full-thickness rotator cuff tear however this would be better evaluated with an MRI of the shoulder. Tiny locules of air within the fluid collection are presumed related to prior intervention. 2. Moderate degenerative changes at the right glenohumeral joint. 3. Multiple sclerotic foci involving the right distal clavicle, several vertebral bodies, and second right rib. Appearances are highly concerning for metastatic disease, given the patient's history of prostate cancer, recommend further evaluation with bone scan if it will alter clinical management.. 4. Replacement of the normal fatty marrow ___ the right humerus is nonspecific ___ appearance on CT imaging and could reflect red marrow reconversion, particularly ___ a patient receiving chemotherapy. This could also be better evaluated with a shoulder MRI. 5. Nonvisualization of the proximal portion of the long head of the biceps tendon and fluid within at the level of the myotendinous junction suspicious for a tear. 6. New enlarged right paratracheal lymph node, recommend dedicated chest imaging to better evaluate. 7. Multiple small pulmonary nodules, likely unchanged when compared to the prior study allowing for slight differences ___ imaging technique. Continued attention on followup recommended Unilateral Upper extremity vein: ___ IMPRESSION: No evidence of deep vein thrombosis ___ the right upper extremity, however portions of the subclavian vein are not visualized. Micro: ___ 2:20 pm SWAB Site: SHOULDER RIGHT. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Susceptibility testing performed on culture # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 3:07 pm JOINT FLUID Source: right shoulder. **FINAL REPORT ___ GRAM STAIN (Final ___: THIS IS A CORRECTED REPORT ( ___. Reported to and read back by ___. ___ ___ 10:45AM. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. PREVIOUSLY REPORTED AS (___). 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Discharge Labs: ============== ___ 07:20PM BLOOD WBC-1.2* RBC-2.50* Hgb-7.3* Hct-21.5* MCV-86 MCH-29.2 MCHC-34.0 RDW-16.4* RDWSD-50.6* Plt Ct-30* ___ 04:55AM BLOOD Neuts-67 Bands-6* Lymphs-14* Monos-5 Eos-3 Baso-0 Atyps-1* ___ Myelos-3* Promyel-1* NRBC-3* AbsNeut-0.66* AbsLymp-0.14* AbsMono-0.05* AbsEos-0.03* AbsBaso-0.00* ___ 04:55AM BLOOD Glucose-97 UreaN-10 Creat-0.4* Na-132* K-3.6 Cl-89* HCO3-34* AnGap-9* ___ 05:15AM BLOOD ALT-37 AST-60* LD(LDH)-358* AlkPhos-215* TotBili-0.6 ___ 04:55AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.8 ___ 07:10AM BLOOD CRP-GREATER TH ___ 04:12AM BLOOD CRP-212.3* ___ 03:07PM JOINT FLUID ___ Polys-90* ___ Macro-9 ___ 03:07PM JOINT FLUID Crystal-NONE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. Gabapentin 600 mg PO BID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. LORazepam 1 mg PO QHS:PRN insomnia 6. Metoprolol Succinate XL 125 mg PO BID 7. Omeprazole 20 mg PO NOON 8. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 9. Pravastatin 40 mg PO QPM 10. Rivaroxaban 20 mg PO DAILY 11. Senna 8.6 mg PO BID:PRN Constipation - First Line 12. Tamsulosin 0.4 mg PO QHS 13. Torsemide 40 mg PO DAILY 14. Asmanex Twisthaler (mometasone) 110 mcg (30 doses) inhalation QHS 15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral NOON 16. Docusate Sodium 200 mg PO DAILY 17. Leuprolide Acetate 11.25 mg IM Q3MO 18. Polyethylene Glycol 17 g PO DAILY 19. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. CeFAZolin 2 g IV Q8H 2. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush RX *heparin lock flush (porcine) 10 unit/mL 5 mL IV daily and PRN Disp #*10 Vial Refills:*0 3. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port RX *heparin lock flush (porcine) 100 unit/mL 5 mL IV PRN Disp #*2 Vial Refills:*0 4. Lidocaine 5% Patch 1 PTCH TD QPM 5. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild Hold for sedation or RR<12 RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*12 Tablet Refills:*0 10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H Hold for sedation or RR<12 RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*8 Tablet Refills:*0 11. Torsemide 20 mg PO DAILY 12. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 13. Asmanex Twisthaler (mometasone) 110 mcg (30 doses) inhalation QHS 14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral NOON 15. Docusate Sodium 200 mg PO DAILY 16. Fluticasone Propionate NASAL 2 SPRY NU DAILY 17. Gabapentin 600 mg PO BID 18. Levothyroxine Sodium 75 mcg PO DAILY 19. LORazepam 1 mg PO QHS:PRN insomnia RX *lorazepam 1 mg 1 mg by mouth QHS PRN Disp #*6 Tablet Refills:*0 20. Metoprolol Succinate XL 125 mg PO BID 21. Omeprazole 20 mg PO NOON 22. Polyethylene Glycol 17 g PO DAILY 23. Pravastatin 40 mg PO QPM 24. Senna 8.6 mg PO BID:PRN Constipation - First Line 25. Tamsulosin 0.4 mg PO QHS 26. HELD- Rivaroxaban 20 mg PO DAILY This medication was held. Do not restart Rivaroxaban until your doctor says it is ok and your platelet count has recovered Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: ================== Infectious Arthritis Secondary Diagnosis: =================== Prostate Cancer Hypothyroidism Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ year old man with R hand swelling// ?DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the right subclavian vein. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with febrile neutropenia// evidence of PNA? TECHNIQUE: Single frontal view of the chest COMPARISON: ___ FINDINGS: Right-sided Port-A-Cath terminates in the low SVC without evidence of pneumothorax. The patient is rotated somewhat to the left. Cardiac and mediastinal silhouettes are stable. The left costophrenic angle is not fully included on the image; given this, no large pleural effusion is seen. No focal consolidation is seen. There is no evidence of pneumothorax. IMPRESSION: Left costophrenic angle not fully included on the image. Given this, no large pleural effusion or focal consolidation. Likely mild basilar atelectasis. Radiology Report EXAMINATION: Right shoulder CT with contrast. INDICATION: ___ PMH of AFib (on Xarelto), OA, Metastatic Prostate cancer (c/b bone mets, s/p chemotherapy now on clinical trial pembrolizumab/radium) who presented to the ED with R shoulder pain, for which Xray negative but would like CT to assess for metastatic lesion vs fracture vs adhesive capsulitis// ___ PMH of AFib (on Xarelto), OA, Metastatic Prostate cancer (c/b bone mets, s/p chemotherapy now on clinical trial pembrolizumab/radium) who presented to the ED with R shoulder pain, for which Xray negative but would like CT to assess for metastatic lesion vs fracture vs adhesive capsulitis TECHNIQUE: Right shoulder CT with bone reformats. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.0 s, 26.1 cm; CTDIvol = 30.6 mGy (Body) DLP = 777.2 mGy-cm. Total DLP (Body) = 777 mGy-cm. COMPARISON: Chest CT from ___. Right shoulder radiograph from ___. FINDINGS: There is fluid seen extending into the subscapularis recess and subscapularis muscle measuring 3.9 x 4.9 cm. This is likely contiguous with the glenohumeral joints with fluid tracking into the subscapularis recess of the joint space. Peripheral enhancement is noted. There is additional rim enhancing fluid seen within the subacromial subdeltoid bursa. This is also likely contiguous with the glenohumeral joint the a probable full-thickness rotator cuff tear of the supraspinatus tendon (09:38). This not be could be better evaluated with an MRI of the shoulder. There are tiny locules of air seen within the subacromial subdeltoid bursa (03:21) and in the subcoracoid recess (03:38) presumed to be related to prior intervention/aspiration. There are moderate severe degenerative changes at the glenohumeral joint. No osteolysis or periostitis to suggest osteomyelitis. There is nonvisualization of the distal portion of the long head of the biceps tendon in the intertubercular groove, suspicious for a tear. There is fluid seen close to the myotendinous junction of the long head of biceps (4:61) measuring 3.3 x 1.4 x 2.3 cm, likely tracking from the glenohumeral joint space. Moderate degenerative changes at the acromioclavicular joint with fragmented osteophytes seen along superior joint margin. There is no acute fracture or dislocation. There is moderate fatty atrophy of the supraspinatus muscle. There is scattered replacement of the fatty marrow in the humerus with soft tissue density material, this is nonspecific in appearance on CT imaging and could reflect red marrow or a neoplastic process. This could be better evaluated with MRI. Multiple foci of sclerosis are noted, including involving the distal clavicle, T2 vertebral body, T4, T6 and T7 suspicious for metastatic lesions. An area sclerosis is also seen in the right fifth rib (9:71) as well as the right third rib (9:95). Fusion hardware is seen in the low cervical spine. In the visualized portions of the right lung there are multiple small nodules seen. A right middle lobe nodule measures 6 mm (6:99), unchanged compared to the prior study. A cluster of 3 small nodules each measuring 4 mm (6:96) and a perifissural nodule measuring 4 mm (6:91) are noted. Allowing for differences in imaging technique these are likely unchanged when compared to the prior study but continued attention on follow-up CT chest is recommended. There is a new enlarged right paratracheal node measuring 1.4 cm in short axis (6:81). IMPRESSION: 1. Fluid collection with peripheral hyper enhancement in the right subscapularis muscle is likely tracking from the joint space into the subscapularis recess consistent with a moderately large effusion. Similar appearing fluid in the subacromial subdeltoid bursa is likely tracking volar via a full-thickness rotator cuff tear however this would be better evaluated with an MRI of the shoulder. Tiny locules of air within the fluid collection are presumed related to prior intervention. 2. Moderate degenerative changes at the right glenohumeral joint. 3. Multiple sclerotic foci involving the right distal clavicle, several vertebral bodies, and second right rib. Appearances are highly concerning for metastatic disease, given the patient's history of prostate cancer, recommend further evaluation with bone scan if it will alter clinical management.. 4. Replacement of the normal fatty marrow in the right humerus is nonspecific in appearance on CT imaging and could reflect red marrow reconversion, particularly in a patient receiving chemotherapy. This could also be better evaluated with a shoulder MRI. 5. Nonvisualization of the proximal portion of the long head of the biceps tendon and fluid within at the level of the myotendinous junction suspicious for a tear. 6. New enlarged right paratracheal lymph node, recommend dedicated chest imaging to better evaluate. 7. Multiple small pulmonary nodules, likely unchanged when compared to the prior study allowing for slight differences in imaging technique. Continued attention on followup recommended. RECOMMENDATION(S): 1. Evaluation of the fluid around the right shoulder region could be better performed with an MRI of the right shoulder, including assessment of any full-thickness rotator cuff tear and the biceps tendon. NOTIFICATION: Findings and recommendations discussed with Dr. ___ by telephone at 18:20 on ___ by Dr. ___, approximately 6 hours after discovery of the findings Radiology Report EXAMINATION: INJ/ASP MAJOR JT W/FLUORO INDICATION: ___ PMH of AFib, OA, metastatic Prostate cancer (c/bbone mets) who admitted for w/u of acute R. shoulder pain + lightheadedness with T101.1F on ___, no longer febrile, not on Abx.// Seen by Ortho, recommendation for ___ R. shoulder joint tap with Gram stain, Cx, crystals, cell count to R/O septic joint. Plt 24, we will plan on giving plt before procedure. If okay with procedure, please page us (___) about procedure time. Also page if concern about plts or need for repeat plt count after transfusion. COMPARISON: Right shoulder CT with contrast ___ 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. 5 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent fluoroscopic guidance, a 18-gauge spinal needle was advanced into the right glenohumeral joint. No fluid could be aspirated with initial aspiration attempt. The needle was repositioned 3 times without aspiration of fluid. Appropriate position within the joint space was confirmed by injection of intra-articular contrast. Contrast was seen to track into the subscapularis recess. Attempted aspiration at this point still did not yield any fluid therefore 10 cc of normal saline was injected into the joint and 15 cc of opaque yellow fluid was the re-aspirated. Samples were sent for culture and sensitivity, cell count and crystal analysis as requested. The needle was removed, hemostasis achieved, and a sterile bandage applied. The patient tolerated the procedure well and left the department in good condition. There were no immediate complications or complaints. FINDINGS: Degenerative changes are noted in the acromioclavicular joint and glenohumeral joint. Injection of iodinated contrast opacified the joint space with tracking into the subscapularis recess, presumed to correspond to the fluid collection seen on the prior CT. IMPRESSION: 1. Imaging Findings- as above. 2. Procedure - Technically successful reaspiration of right glenohumeral joint. I Dr. ___ ___ supervised the Resident/Fellow during the key components of the above procedure and I have reviewed and agree with the Resident/Fellow findings/dictation. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ year old man with metastatic prostate cancer admitted for septic R. shoulder joint growing coag-positive Staph aureus.// Duplex of tunneled line to r/o possible subclavian clot that could be superinfected iso septic R. shoulder joint. ___ MD at ___ if any questions about order. TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: No prior imaging for comparison. FINDINGS: The visualized right subclavian vein is patent with antegrade flow, however portions of the vein are not seen due to overlying dressing. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity, however portions of the subclavian vein are not visualized. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dizziness Diagnosed with Anemia, unspecified temperature: 97.4 heartrate: 109.0 resprate: 20.0 o2sat: 97.0 sbp: 128.0 dbp: 63.0 level of pain: 10 level of acuity: 2.0

====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, It was a pleasure caring for you at ___. WHY WAS I ___ THE HOSPITAL? - You were ___ the hospital for lightheadedness and right shoulder pain. WHAT HAPPENED TO ME ___ THE HOSPITAL? - You had an infection ___ your right shoulder joint. You were started on antibiotics for the infection and had a procedure done to wash the infected joint out. - We gave you pain medications to help control your right shoulder pain. - We gave you blood and platelet transfusions, because your blood and platelet counts were low. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. We wish you the ___! 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: cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ yo F with history of infiltrating ductal breast cancer (triple +, s/p mastectomy and reconstructive surgery, s/p Cytoxan and Adriamycin followed by Taxol and Herceptin as well as tamoxifen) who presented to the ED on ___ with four weeks of cough. She was seen at ___ Urgent Care on ___ with 3.5 weeks of cough with scant sputum and occasional dyspnea with climbing stairs. CXR with hyperinflation w/o infiltrate. She was discharged home with 5 days of prednisone (40 mg) and an albuterol inhaler. She re presented to urgent care on ___ and vital signs were notable for HR 121 and O2 sat of 91% on room air. O2 was 90% with ambulation. CXR was notable for mild bronchial wall thickening at the lung bases. She was given dose of azithromycin and transferred to ___ ED. -In the ED, initial VS were: 98.4 97 107/70 20 95% RA -Labs showed: WBC 12.9, CK MB and trop negative, urine w/small leuks and few bact, flu negative -Imaging showed: --CXR: Bronchitis at the lung bases. --CTA: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral ___ opacities and more nodular opacities at the left lung base in combination with bronchial wall thickening and mucous plugging is suggestive of a multifocal infectious process. 3. Calcified left hilar lymph nodes and calcified granulomas in the left lung are suggestive of prior granulomatous infection. -Consults: None -Patient received: -- 1.5 L NS, 2 grams IV ceftriaxone, ipratropium neb, albuterol neb, azithromycin (at urgent care) -Transfer VS were: 102.0 101 116/62 18 96% RA On arrival to the floor, patient reports that she developed a cough about four weeks ago. Initially accompanied by sore throat. She also had chills, muscle aches, mild congestion and runny nose as well as ear discomfort. She felt as though it was a cold, but her sx did not improve. Two weeks ago had red eyes that improved with OTC drops. Has been taking nyquil and advil very frequently. Did not have any fevers at home. Went to urgent care on ___ and was given prednisone and albuterol, which did not improve her sx. Returned to urgent care on ___ since sx were not improving. Cough has persisted and has become productive-gray to white sputum. Also notes shortness of breath with exertion and the sensation of wheezing during these episodes. No associated CP, n/v, diaphoresis with dyspnea. Has never had dyspnea prior to this episode. Denies fevers, n/v, abdominal pain, diarrhea, constipation, dysuria, change in urinary frequency, leg swelling, CP, palpitations, skin changes, new lumps/bumps. Endorses decreased PO intake and decreased appetite. She works at ___ so has been exposed to sick people and also has a ___ yo nephew that she spends time with as well. REVIEW OF SYSTEMS: See above Past Medical History: BREAST CANCER - Dx ___: L 1.8 cm grade 2 infiltrating ductal CA with clean lymph nodes, ER positive, PR positive, HER-2/neu positive. Rx AC, taxol, herceptin. On tamoxifen since ___. Reconstruction (B implants). HYPERLIPIDEMIA OSTEOPENIA POSTMENOPAUSAL BLEEDING ON TAMOXIFEN Social History: ___ Family History: Mother: CAD, MI Father: Lung cancer ___ aunt: breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: 100.0 121 / 73 96 18 94 Ra GENERAL: Well appearing female, no acute distress HEENT: MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Wheezing noted in L middle lobe, otherwise clear to auscultation b/l without wheezing, rhonci or crackles ABDOMEN: NABS, non distended, non tender in all four quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally DISCHARGE PHYSICAL EXAM: VS: Temp: 99.1 (Tm 100.0), BP: 123/74 (121-123/73-74), HR: 84 (84-96), RR: 18, O2 sat: 94%, O2 delivery: Ra GENERAL: Well appearing female, no acute distress HEENT: MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Wheezing noted in L middle lobe, otherwise clear to auscultation b/l without wheezing, rhonci or crackles ABDOMEN: NABS, non distended, non tender in all four quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally Pertinent Results: ADMISSION LABS -------------- ___ 01:00PM BLOOD WBC-12.9* RBC-3.82* Hgb-11.2 Hct-34.6 MCV-91 MCH-29.3 MCHC-32.4 RDW-13.1 RDWSD-43.4 Plt ___ ___ 01:00PM BLOOD Neuts-78.4* Lymphs-13.7* Monos-7.0 Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.14* AbsLymp-1.77 AbsMono-0.90* AbsEos-0.01* AbsBaso-0.03 ___ 01:00PM BLOOD Glucose-104* UreaN-16 Creat-1.0 Na-135 K-3.9 Cl-95* HCO3-31 AnGap-9* ___ 01:00PM BLOOD CK-MB-<1 cTropnT-<0.01 proBNP-227* ___ 06:50AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1 ___ 01:00PM BLOOD Lactate-0.9 DISCHARGE LABS -------------- ___ 06:50AM BLOOD WBC-12.2* RBC-3.87* Hgb-11.4 Hct-35.3 MCV-91 MCH-29.5 MCHC-32.3 RDW-13.4 RDWSD-45.3 Plt ___ ___ 06:50AM BLOOD Glucose-93 UreaN-11 Creat-0.9 Na-142 K-4.2 Cl-103 HCO3-25 AnGap-14 IMAGING ------- ___ CTA CHEST 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral ___ opacities and more nodular opacities at the left lung base in combination with bronchial wall thickening and mucous plugging is suggestive of a multifocal infectious process. 3. Calcified left hilar lymph nodes and calcified granulomas in the left lung are suggestive of prior granulomatous infection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Venlafaxine XR 75 mg PO DAILY Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 2. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 3. Multivitamins 1 TAB PO DAILY 4. Venlafaxine XR 75 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ----------------- Acute bacterial bronchitis SECONDARY DIAGNOSES ------------------- #HISTORY OF BREAST CANCER #DEPRESSION 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 worsening cough of almost 4 weeks and sob// r/o pna TECHNIQUE: PA and lateral views of the chest COMPARISON: ___ FINDINGS: Mild bronchial wall thickening at the lung bases could reflect bronchitis. No dense infiltrate The cardio-mediastinal silhouette is unremarkable. No significant pleural effusion or pneumothorax. IMPRESSION: Bronchitis at the lung bases. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with hx of breast cancer and hypoxia on exertion// evaluate 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 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP = 6.1 mGy-cm. 2) Spiral Acquisition 4.1 s, 32.3 cm; CTDIvol = 5.7 mGy (Body) DLP = 183.9 mGy-cm. Total DLP (Body) = 190 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: Hilar lymph nodes are prominent but not enlarged, and are likely reactive. No mediastinal lymphadenopathy. Calcified left hilar lymph nodes are noted, and in combination with calcified granulomas in the lung likely reflect prior granulomatous disease. No mediastinal mass. The esophagus is patulous. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: ___ opacities in the bilateral lower lobes, with more focal nodular consolidation primarily at the left lung base is most consistent with infection. Additionally, there is mucous plugging and bronchial wall thickening at the bilateral lung bases, suggestive of small airways inflammation. The upper lobe airways are patent to the subsegmental level. BASE OF NECK: 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. Bilateral subpectoral breast implants are noted. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral ___ opacities and more nodular opacities at the left lung base in combination with bronchial wall thickening and mucous plugging is suggestive of a multifocal infectious process. 3. Calcified left hilar lymph nodes and calcified granulomas in the left lung are suggestive of prior granulomatous infection. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ILI Diagnosed with Pneumonia, unspecified organism temperature: 98.4 heartrate: 97.0 resprate: 20.0 o2sat: 95.0 sbp: 107.0 dbp: 70.0 level of pain: 5 level of acuity: 3.0

Dear Ms ___, It was a pleasure taking care of you at ___! Why was I admitted to the hospital? - you had worsening cough and shortness of breath - imaging of you lungs showed signs of an infection of your lower airways, likely with bacteria - you were given medications (antibiotics) to treat the infection - your breathing improved during your hospital stay and you were safe to complete the treatment at home What should I do after discharge? - please continue taking the antibiotics as prescribed - please follow up with you primary care physician as detailed below All the best, Your ___ care team!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ male chef here for work from ___ reports having starting on ___ he began to have terrible epigastric pain. The pain was located in the epigastric region but then radiated diffusely throughout the upper abdomen. He also had nausea, but no vomiting initially. The pain continued in waves intermittently for a few days and was initially present after eating but then became present all the time and would get worse with eating or drinking. He on ___ began to have more nausea and tried taking ___ but the taste was so horrible that he vomited. Since then he has had nausea and vomiting with trying to eat and feels that there is "like a ball" in the epigastric region. He has not been moving his bowels for the past few days but previously no issues, no weight loss, no diarrhea. He denies fevers, had a low grade temp in the ED. He is very thirsty at this time and report poor urine outpt in teh past 2 days. He reports an episode of horrible epigastric pain that occured 2 days after he had what he though was bad fish in ___ of this year and a similar episode of again a few days of abd pain about ___ years ago. With the 2 previous episodes the pain was no terrible he thought that he was going to die. He came to medical attention this time before it became so bad. He does not have a hx of abd pain after eating. He does not usually see MDs, is otherwise healthy. Is helping a friend with a restaurant, here in town for about 2 weeks and was feeling well until this happened. 10 systems reviewed and are negative except where noted in the HPI above Past Medical History: none per the pt Social History: ___ Family History: no family hx of pancreatitis or gallstones Physical Exam: physical exam most notable for: Afeb VSS Cons: NAD, lying in bed Eyes: E___, no scleral icterus ENT: MMM Neck: nl ROM, no goiter Lymph: no cervical LAD Cardiovasc: rrr, no murmur, no edema Resp: CTA B GI: +hypoactive bs,soft, nd, no significant epigastric pain with palp. MSK: no significant kyphosis Skin: no rashes Neuro: no facial droop Psych: normal range of affect Pertinent Results: ___ 08:31PM GLUCOSE-96 UREA N-16 CREAT-1.0 SODIUM-137 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17 ___ 08:31PM ALT(SGPT)-12 AST(SGOT)-19 ALK PHOS-30* TOT BILI-2.3* ___ 08:31PM LIPASE-416* ___ 08:31PM ALBUMIN-5.1 ___ 08:31PM WBC-8.7 RBC-5.18 HGB-15.6 HCT-43.5 MCV-84 MCH-30.0 MCHC-35.8* RDW-13.5 ___ 08:31PM NEUTS-56 BANDS-0 ___ MONOS-8 EOS-2 BASOS-0 ATYPS-3* ___ MYELOS-0 ___ 08:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:23PM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 Discharge Labs: ___ 07:20AM BLOOD WBC-7.1 RBC-4.37* Hgb-12.9* Hct-36.7* MCV-84 MCH-29.6 MCHC-35.2* RDW-13.6 Plt ___ ___ 07:20AM BLOOD Neuts-58.7 ___ Monos-5.6 Eos-2.9 Baso-0.3 ___ 07:20AM BLOOD Glucose-89 UreaN-15 Creat-1.0 Na-142 K-4.0 Cl-107 HCO3-26 AnGap-13 ___ 07:20AM BLOOD ALT-10 AST-13 AlkPhos-22* TotBili-2.0* DirBili-0.4* IndBili-1.6 ___ 07:20AM BLOOD Lipase-31 ___ 07:20AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.1 Mg-1.9 ___ 07:20AM BLOOD Lipase-31 U/S RUQ: FINDINGS: The liver demonstrates normal echogenicity. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. Common bile duct measures 4 mm. The portal vein is patent. The gallbladder is normal without evidence of stones or gallbladder wall thickening. The pancreas is unremarkable without evidence of focal lesions or pancreatic duct dilatation. The spleen measures 8.2 cm and has a homogeneous echotexture. Visualized portions of the right kidney are within normal limits. IMPRESSION: Normal abdominal ultrasound. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Epigastric abdominal pain and vomiting. Elevated lipase. Assess for cholecystitis. COMPARISON: None available. FINDINGS: The liver demonstrates normal echogenicity. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. Common bile duct measures 4 mm. The portal vein is patent. The gallbladder is normal without evidence of stones or gallbladder wall thickening. The pancreas is unremarkable without evidence of focal lesions or pancreatic duct dilatation. The spleen measures 8.2 cm and has a homogeneous echotexture. Visualized portions of the right kidney are within normal limits. IMPRESSION: Normal abdominal ultrasound. Gender: M Race: BLACK/AFRICAN Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ACUTE PANCREATITIS, VOMITING temperature: 100.1 heartrate: 74.0 resprate: 18.0 o2sat: 100.0 sbp: 117.0 dbp: 77.0 level of pain: 6 level of acuity: 3.0

Mr. ___, You were admitted to ___ for pancreatitis and dehydration. your lab work returned to normal and your symptoms resolved with hydration with IV fluids. At this point, it is not clear why you had pancreatitis. I have made an appointment for you with a new primary care physician to further investigate this concern. Please keep the appointments as listed below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Neck pain/C2 fracture Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ year old male with a history of multiple falls out of bed. At 3am this morning he fell out of bed and struck the left side of his head/ear on a metal bedrail. He felt immediate pain in his neck and went back to sleep for ___ hours and woke with worsened neck pain. He called ___ and was transported to ___ where he was found to have a C2 fracture on C-spine CT that passes bilaterally through the transverse foramen and was transferred to ___ for further evaluation. Neurosurgery service is being consulted for evaluation of cervical fracture. He takes gabapentin at home for BUE numbness/tingling/pain extending from hands up bilateral forearms secondary to carpal tunnel which he only experiences during certain activities such as playing the guitar. Denies LOC, dizziness, decreased sensation in all extremities, loss of bowel/bladder control. Past Medical History: #COPD ___ years, last major hospitalization was last year, never previously intubated, on tiotropium/steroid/albuterol inhalers): GOLD stage I, PFTs ___ with mild obstructive defect #HCV (had acute hepatitis at ___, multiple negative hepatitis C viral loads at BID, consistent with self-limited infection) #Anemia #Anxiety #Dysphagia #HLD #PPD Positive treated with INH ___ years #Substance Abuse: history of IVDU and PSA, now on methadone 160mg #Tobacco Abuse #Baseline Creatinine 1.2-1.3 Social History: ___ Family History: Mother with ___ MIs and colon cancer, MGF ___ MIs, maternal uncle died at ___ from MI. Father had alcoholism with liver and kidney failure. Physical Exam: O: Laying flat on stretcher in hard collar in hallway of ED for examination. No acute distress. T: 97.3 BP: 124/70 HR:72 R:18 O2Sats:98% RA Gen: WD/WN, lacking dentition. NAD. HEENT: Head atraumatic, symmetrical. Pupils: ___ reactive bilaterally. EOMs and visual acuity intact. Squinting to focus on R visual field. Neck: Hard collar in place. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, month and year. Motor: D B T WE WF IP Q H AT ___ G Sensation: Intact to light touch. Intrinsics ___ bilaterally. Reflexes: B Br Pa Ac Right ___ non-reflexive Left ___ non-reflexive No clonus. ? ___ on right non-reproducible. Upon discharge: A&Ox3, ASPEN Collar in place B/L UE ___ B/L ___ ___ SILT Pertinent Results: ___ Cervical/Head CTA CT HEAD I -: No acute intracranial process. CTA HEAD AND NECK: The principal vessels of the neck are patent throughout their course, with no evidence of occlusion or dissection. Known C2 fractures through the bilateral transfers foramina are again noted better assessed on outside CT of the cervical spine. No intracranial malformation or aneurysm greater than 3 mm is detected. Severe biapical emphysema is present, along with upper mediastinal lymphadenopathy, possibly reactive. Medications on Admission: 1. Cimetidine 300 mg PO BID 2. ClonazePAM 2 mg PO BID 3. Fluticasone Propionate 110mcg 1 PUFF IH BID 4. Methadone 160 mg PO DAILY 5. QUEtiapine Fumarate 150 mg PO QHS 6. Sertraline 200 mg PO DAILY 7. Temazepam 30 mg PO QHS:PRN sleep 8. Albuterol Inhaler ___ PUFF IH Q4H:PRN Dyspnea / Wheeze / Cough 9. Aspirin 81 mg PO DAILY 10. Simvastatin 40 mg PO DAILY 11. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea/wheeze/cough 2. Aspirin EC 81 mg PO DAILY 3. Cimetidine 300 mg PO BID 4. ClonazePAM 2 mg PO BID 5. Fluticasone Propionate 110mcg 1 PUFF IH BID 6. Methadone 160 mg PO DAILY 7. QUEtiapine Fumarate 150 mg PO QHS 8. Sertraline 200 mg PO DAILY 9. Simvastatin 40 mg PO DAILY 10. Temazepam 15 mg PO QHS:PRN sleep 11. Tiotropium Bromide 1 CAP IH DAILY 12. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine craving 13. Gabapentin 300 mg PO TID 14. Rolling Walker Diagnosis: unsteady gait Prognosis: good Length of need: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: C2 lateral mass 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: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: History: ___ with known C2 fracture. // Evaluate for vascular injury TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 4) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP = 27.2 mGy-cm. 5) Spiral Acquisition 4.9 s, 38.3 cm; CTDIvol = 31.9 mGy (Head) DLP = 1,224.3 mGy-cm. Total DLP (Head) = 2,149 mGy-cm. COMPARISON: Reference CT head and cervical spine from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is a mucous retention cyst in the right maxillary sinus. The remaining visualized paranasal sinuses and mastoid air cells are clear. The visualized portion of the orbits are unremarkable. Again seen is a fractures involving bilateral transverse foramen at the level of C2 vertebrae as seen on image 5:176 -181. CTA HEAD: There is mild atherosclerosis involving bilateral cavernous carotid arteries. The vessels of the circle of ___ and their principal intracranial branches appear unremarkable without stenosis, occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There is a 3 vessel arch. Incidentally seen is hypoplastic left vertebral artery. There is calcified and noncalcified plaque involving bilateral carotid bifurcations without any stenosis by NASCET criteria. There is mild focal narrowing of the left vertebral artery at the C2 transverse process without evidence of intimal flap for filling defect, likely representing atherosclerotic disease and turn of the vessel. The carotid and vertebral arteries and their major branches appear otherwise unremarkable with no evidence of stenosis orocclusion. OTHER: There is extensive centrilobular emphysema involving the visualized upper lung zones. The prominent mediastinal lymph nodes, for example pretracheal lymph node on image 5:14 measuring 15 x 9 mm, a right paratracheal lymph node on image 5:48 measuring 8 x 8 mm. These are likely reactive in etiology. The thyroid gland appears unremarkable. No cervical lymphadenopathy is seen. There is atherosclerosis involving the aortic arch. IMPRESSION: 1. Atherosclerosis involving bilateral carotid bifurcations. Otherwise, essentially unremarkable CTA of the head and neck. 2. No acute intracranial abnormality. 3. Fractures involving bilateral C2 transverse foramen is again seen. 4. Severe centrilobular emphysema with mediastinal lymphadenopathy in the visualized upper lung zones. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: s/p Fall, C-spine fracture Diagnosed with Unsp disp fx of second cervical vertebra, init for clos fx, Fall on same level, unspecified, initial encounter temperature: 97.3 heartrate: 72.0 resprate: 18.0 o2sat: 98.0 sbp: 124.0 dbp: 70.0 level of pain: 5 level of acuity: 2.0

Discharge Instructions Cervical Fracture Activity • You must wear your hard cervical collar at all times. • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • No contact sports until cleared by your neurosurgeon. • Do NOT smoke. Smoking can affect your healing and fusion. Medications • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. • It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: • Fever greater than 101.5 degrees Fahrenheit • New weakness or changes in sensation in your arms or legs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: Altered mental status, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Obtained per chart, patient not reliable historian, son not available. Per son in ___ and chart: ___, h/o dementia, TIA, HTN alterntating with hypotension, afib on coumadin, ___, mild MS, mild pulm htn, lower extremity edema discharged from OSH about 2 weeks ago after being treated for PNA saw PCP today and referred to the ___ for confusion, weakness, ? hypotension. Per son she has had decreased PO intake and weakness x3 days, required more supervision taking medications. Also, she had a fall about 4 days ago and hit her head. Has had a cough, no fevers. Also with abdominal pain, no n/v, no diarrhea/constipation or bloody stool. In the ___ initial vitals: 0 97.3 82 100/52 20 100% . Labs notable for Cr 1.9 (baseline 1.47), K was hemolyzed and normal on repeat. UA with 8wbc's, <1 epi, neg nitrite. Lactate 2.1. BNP 1881, INR 2.3. Given 500cc NS, 1g Ceftriaxone. CT abdomen showed fecal loading. cxr, ct cspine and head unrevealing. Vitals on transfer : Today 21:26 0 97.7 72 112/60 18 100% RA Past Medical History: Permanent atrial fibrillation, CHADS2 score of 5, on Coumadin. Fluctuating blood pressures with periodic hypertension and hypotension. Diastolic CHF, ___ Heart Association Class 3. known ___ systolic ejection murmur loud P2 and a ___ diastolic murmur heard loudest at the base. Mild functional MS. ___ pulmonary hypertension. Lower extremity edema. Dementia. History of TIA ___ years ago. Right hip fracture in ___. Borderline diabetes. Fibromyalgia. GERD. Hearing loss. Sinusitis. Vertigo. Social History: ___ Family History: N/c Physical Exam: ADMISSION Vitals - T: 97.5, 162/76, 84, 18, 99%RA GENERAL: NAD, HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, dentures NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, ___ systolic murmur LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mildly tender in suprapubic region and superior to this, no rebound EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. Oriented to person, date of birth, ___ "snow outside". Could not guess year or date or her age. Able to do days of week backwards. Speech fluent and appropriate. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE Vitals: 98.4 98.1 134-157/59-67 ___ 96-98% RA General: asleep in bed, easily aroused, NAD HEENT: sclera anicteric, MMM Lungs: diffuse crackles, no incr WOB CV: irregularly irregular, nl rate, nl S1/S2, ___ systolic murmur best heard over RLSB, no rubs or gallops; no carotid bruit appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: MS: oriented x name only. More attentive and more linear thought process than yesterday. Pertinent Results: ADMISSION LABS: =============== ___ 04:10PM BLOOD WBC-4.6 RBC-4.74 Hgb-13.5 Hct-41.8 MCV-88 MCH-28.5 MCHC-32.4 RDW-15.2 Plt ___ ___ 04:10PM BLOOD Neuts-52.8 ___ Monos-12.2* Eos-2.2 Baso-0.4 ___ 04:10PM BLOOD ___ PTT-41.7* ___ ___ 04:10PM BLOOD Plt ___ ___ 04:10PM BLOOD Glucose-99 UreaN-52* Creat-1.9* Na-134 K-7.5* Cl-97 HCO3-26 AnGap-19 ___ 04:10PM BLOOD ALT-23 AST-81* CK(CPK)-135 AlkPhos-78 TotBili-0.3 ___ 04:10PM BLOOD Lipase-97* ___ 04:10PM BLOOD proBNP-1881* ___ 04:10PM BLOOD Albumin-3.5 Calcium-8.7 Phos-4.0 Mg-2.4 ___ 04:27PM BLOOD Lactate-2.1* Na-135 K-4.6 ___ 06:15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM ___ 06:15PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-<1 TransE-1 ___ 06:15PM URINE CastHy-32* ___ 06:15PM URINE Mucous-RARE PERTINENT LABS: =============== ___ 07:31AM BLOOD ___ PTT-47.9* ___ ___ 07:31AM BLOOD Lipase-60 ___ 05:59PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:59PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05:59PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1 ___ 05:59PM URINE CastHy-6* DISCHARGE LABS: =============== ___ 06:50AM BLOOD WBC-5.7 RBC-4.46 Hgb-12.5 Hct-38.9 MCV-87 MCH-27.9 MCHC-32.0 RDW-15.0 Plt ___ ___ 10:15AM BLOOD ___ ___ 06:50AM BLOOD Glucose-80 UreaN-21* Creat-1.1 Na-141 K-3.9 Cl-105 HCO3-28 AnGap-12 ___ 06:50AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.1 MICROBIOLOGY: ============= ___ BLOOD CULTURE Blood Culture, Routine (Pending): ___ URINE URINE CULTURE (Final ___: <10,000 organisms/ml IMAGING: ======== CXR ___: Hiatal hernia, small right pleural effusion. No overt edema or pneumonia. CT C-spine ___: No acute fracture, malalignment, or prevertebral soft tissue abnormality. CT Head ___: 1. No acute infarct, hemorrhage, or fracture. 2. Age-related involutional changes and sequela of chronic small vessel ischemic disease. CT A/P ___: 1. Large fecal loading of the colon, most severe in the rectum, with probable mild proctitis. 2. Large hiatal hernia. CT Head ___: No acute intracranial hemorrhage or mass effect. Other details as above. Correlate clinically the to decide on the need for further workup or followup. CXR ___: The heart is mildly enlarged, slightly increased in size since ___. There is increased central pulmonary vascular congestion, without overt edema. There is no pneumothorax, focal consolidation, or pleural effusion. Moderate degenerative changes throughout the thoracic spine appear stable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Klor-Con M20 (potassium chloride) 20 mEq oral daily 2. Lisinopril 5 mg PO DAILY 3. Warfarin 2.5 mg PO QMWF 4. Furosemide 40 mg PO BID 5. Warfarin 5 mg PO QTRSASU Discharge Medications: 1. Furosemide 40 mg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS 6. Polyethylene Glycol 17 g PO TID 7. Senna 8.6 mg PO BID 8. Klor-Con M20 (potassium chloride) 20 mEq oral daily Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Altered mental status of unclear etiology Constipation Acute kidney injury Secondary diagnoses: Atrial fibrillation Diastolic congestive heart failure Dementia 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: CHEST (AP AND LAT) INDICATION: ___ with afib s/p fall on ___ on warfarin, son concern for decrease mental status and decrease po intkae // ct head rule out intracranial hemorrhage c-spine rule out fratureCXR eval for worsening pna COMPARISON: Chest CT from ___. FINDINGS: AP upright and lateral views of the chest provided. Retrocardiac opacity with an air-fluid level is compatible with known hiatal hernia. There is a small right pleural effusion. The lungs appear clear without convincing sign of pneumonia or overt edema. Cardiomediastinal silhouette appears within normal limits. No acute osseous abnormality. IMPRESSION: Hiatal hernia, small right pleural effusion. No overt edema or pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: Status post fall 5 days prior with decreased mental status and PO intake, in a patient with atrial fibrillation on anticoagulation. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 52.9 mGy-cm CTDI: 891.9 mGy COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. Prominent ventricles and sulci are suggestive of age-related involutional change. Periventricular white matter hypodensities are consistent with severe chronic small vessel ischemic disease. No osseous abnormalities seen. There is mild mucosal thickening in the right maxillary sinus. The other visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute infarct, hemorrhage, or fracture. 2. Age-related involutional changes and sequela of chronic small vessel ischemic disease. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: Status post fall 5 days prior with decreased mental status and PO intake, in a patient with atrial fibrillation on anticoagulation. TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 36.7 mGy DLP: 710.3 mGy-cm COMPARISON: None FINDINGS: Alignment is normal. No fractures are identified. There is no evidence of spinal canal or neural foraminal narrowing. There is no evidence of infection or neoplasm. IMPRESSION: No acute fracture, malalignment, or prevertebral soft tissue abnormality. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ women with hypotension, generalize weakness and lethargy, question acute intra-abdominal process. TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed without contrast. Multiplanar reformations were provided. IV contrast withheld due to compromised renal function. DOSE: DOSE: 486 mGy-cm COMPARISON: Abdominal MRI from ___, PET-CT from ___. FINDINGS: Lung Bases: There is a large hiatal hernia again seen. Tiny right pleural effusion noted. Imaged portion of the heart unremarkable. The imaged lung bases are clear. Abdomen: The unenhanced appearance of the liver is normal. The gallbladder is unremarkable. The pancreas is atrophic. Known pancreatic IPMN not visualized on this non contrast exam. The spleen appears normal. Dense aortic atherosclerotic calcification is noted without aneurysmal dilation. There is no retroperitoneal lymphadenopathy or hematoma. Adrenal glands are normal bilaterally. The kidneys appear unremarkable. Pelvis: Loops of small and large bowel demonstrate no signs of ileus or obstruction. A candidate appendix is seen on series 2, image 55 appearing normal. Large fecal loading in the colon noted most severe in the rectum. There is mild perirectal fat stranding of the possibility of mild proctitis is raised. Foley catheter seen within the decompressed bladder. No free pelvic fluid. No free air. Bones: No worrisome lytic or blastic osseous lesion is seen. Diffuse bony demineralization is noted. 3 pins stabilize the right femoral neck. There is a grade 1 anterolisthesis of L4 on L5 which appears unchanged compared to ___ radiograph. IMPRESSION: 1. Large fecal loading of the colon, most severe in the rectum, with probable mild proctitis. 2. Large hiatal hernia. Radiology Report INDICATION: New infection. COMPARISON: Chest radiograph from ___. TECHNIQUE: Frontal and lateral chest radiographs. IMPRESSION: The heart is mildly enlarged, slightly increased in size since ___. There is increased central pulmonary vascular congestion, without overt edema. There is no pneumothorax, focal consolidation, or pleural effusion. Moderate degenerative changes throughout the thoracic spine appear stable. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with dementia, AF on coumadin, and multiple other medical problems who was admitted for AMS following OSH treatment for PNA. Of note, fall w/ headstrike 4 days PTA, no hemorrhage visualized on CT in ED on day of admission. Now with AMS and INR 4.1. // Evaluate for acute or subacute hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 785 mGy-cm CTDI: 55 mGy COMPARISON: Prior head CT from ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass effect. Prominence of ventricles and sulci is consistent with age related involutional changes. Periventricular white matter hypodensities are likely the sequela of severe chronic small vessel ischemic disease. No osseous abnormalities seen. There is mild mucosal thickening of the anterior ethmoidal air cells and right maxillary sinus. The remaining visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. Dense atherosclerotic calcifications noted a the carotid siphons bilaterally. IMPRESSION: No acute intracranial hemorrhage or mass effect. Other details as above. Correlate clinically the to decide on the need for further workup or followup. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness, EPISODIC HYPOTENTION Diagnosed with URIN TRACT INFECTION NOS temperature: 97.3 heartrate: 82.0 resprate: 20.0 o2sat: 100.0 sbp: 100.0 dbp: 52.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ on ___ for concerns about confusion, weakness, decreased food intake, and abdominal pain. We ruled out infection, including pneumonia or urinary tract infection, electrolyte imbalances, medication-related changes, or possible bleeding in your head after your fall a few days prior. Your abdominal discomfort was likely due to constipation, which resolved. Your kidney function was decreased when you arrived but has since returned to normal. You have remained confused since your admission, but we have ruled out important reversible or life-threatening causes of your mental status changes. It is possible that given the reported onset of these changes since your admission for pneumonia at ___, it will take significant time to return to baseline. We had to hold your warfarin during the admission, and we will restart it at rehab. Thank you for allowing us to take part in your care. ___ MDs

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall, weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of HTN, ___ disease on Sinemet four times a day, chronic low back pain presents for worsening lower extremity weakness. She was recently discharged from rehab and in her usual state of health until approximately ___ days prior to admission when she started having difficulty standing and using her walker due to unsteadiness and weakness in her legs. She fell off the commode a week ago but denies head strike or LOC. She states that she just sat back down whenever she experienced the unsteadiness and that she did not experience any other falls. She has not experienced any lightheadedness or palpations when standing up. She denies any headache, chest pain, SOB, N&V, abdominal pain, worsening of her back pain, urinary retention, bladder/bowel incontinence, saddle anesthesia, or other complaints. No dysuria, urgency, or frequency. No blood in urine or stool. No f/c. No recent weight loss. She lives at home with her daughter and uses a walker at baseline. Her daughter is assisting her with her medications. She states that she would be open to going to a rehab facility, but that she would want to go back home after. In the ED, initial vitals: T 97.9 HR 67 BP 114/51 RR 18 O2 sat 99% RA General - thin, no acute distress HEENT - head NC/AT, bilateral cataracts Cardiovascular - RRR, 2+ DP pulses bilaterally Respiratory - CTA bilaterally, no wheezing GI - abdomen soft, nontender, no rebound or guarding Neuro - bilateral grip strength ___, bilateral UE strength ___, bilateral ___ strength ___, sensation intact, down-going Babinski Musculoskeletal - no spinal midline tenderness, mild left lumbosacral paraspinal tenderness Skin - warm and dry Labs notable for normal CBC, chemistry, negative troponin, negative serum and utox, and UA with 14 WBC and small leuks. CXR showed no acute cardiopulmonary abnormality, and CT head showed no acute process. CT T and L spine showed no acute fracture or malalignment with chronic L1 compression fracture. Neurology was consulted, and felt that the patient's neuro exam was at baseline, and that MRI L spine would be of little utility given low suspicion for cord compression and that patient would not surgery. Medicine admission was pursued for case management input for placement, as well as treatment of possible UTI. On arrival to the floor, the patient denies any new symptoms. Of note, per her neurologist's note from ___, on ___ she was brought to ___ for difficulty standing up and feeling very weak. UA was negative for UTI. Also had some chronic low back pain. CT L spine was done showing a severe L1 compression fracture of unknown chronicity. She was discharged to rehab, where she has done very well with physical therapy. During the clinic visit on ___, it was noted that since her admission to ___ she had noticed that she has had a lot of urinary incontinence. She could not feel the need to urinate, happened every ___ hours but was reportedly slowly getting better. In the setting of back pain, ___ weakness, and urinary incontinence, the risk of cord compression was discussed during this clinic visit. Given that the solution would have been spinal surgery should severe compression be found on MRI, the patient and her family both said that she would not want any surgery. Because of this, MRI was deferred. Per her PCP's note from ___, the patient was recently hospitalized for another fall: The pt was ambulating around her house with a walker, let go off the walker, and fell into a radiator and hit her left knee upon the radiator causing second-degree burn and then also hit her right knee on the floor. Patient was admitted to ___ for a period of two days and then was discharged to rehab, and she was discharged from rehab to home on ___. She currently lives at home with her daughter, ___, who does her pills and manages her medication. She was discharged from rehab to home with ___ services, Occupational and Physical Therapy at home. Past Medical History: BREAST DUCTAL CARCINOMA IN SITU COLONIC POLYPS DEPRESSION ENDOMETRIAL POLYP FIBROID UTERUS GOUT LOW BACK PAIN OBESITY OBSTRUCTIVE SLEEP APNEA REFLUX ESOPHAGITIS VENOUS STASIS ULCERS ___ DISEASE Social History: ___ Family History: mother and sister - DM Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.4 PO 177 / 48 68 20 100 Ra General: laying in bed, cachectic, frail, chronically ill-appearing, but not toxic HEENT: NCAT, no lacerations, sclera anicteric, PERRL, EOMI, OP clear, MMM Neck: supple, JVP 7-8 cm, no LAD Resp: normal effort, clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops GI: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Extr: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: two healing abrasions to the left patella with no signs of surrounding erythema or warmth concerning for infection Neuro: AAOx3, answering all questions promptly and appropriately, CNs2-12 intact, UE and ___ motor strength ___, sensation to light touch intact throughout, hand tremor present (R>L) DISCHARGE PHYSICAL EXAM: Vitals: Temp: 98.2 (Tm 98.5), BP: 142/62 (99-149/57-69), HR: 65 (60-119), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: Ra, Wt: 139.7 lb/63.37 kg General: sitting in chair for breakfast, chronically ill-appearing, no acute distress HEENT: NCAT, no lacerations, sclera anicteric, PERRL, EOMI, OP clear, MMM Resp: normal effort, clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops GI: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Extr: warm, well perfused Skin: two healing abrasions to the left patella with no signs of surrounding erythema or warmth concerning for infection Neuro: AAOx3, answering all questions promptly and appropriately, moving all extremities with purpose, pill-rolling hand tremor present (R>L) Pertinent Results: ADMISSION LABS -------------- ___ 08:10PM BLOOD WBC-4.7 RBC-4.06 Hgb-12.0 Hct-36.8 MCV-91 MCH-29.6 MCHC-32.6 RDW-14.7 RDWSD-49.2* Plt ___ ___ 08:10PM BLOOD Neuts-55.9 ___ Monos-12.9 Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.60 AbsLymp-1.44 AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00* ___ 08:10PM BLOOD Glucose-72 UreaN-8 Creat-0.5 Na-142 K-4.1 Cl-101 HCO3-27 AnGap-14 ___ 08:10PM BLOOD ALT-16 AST-17 AlkPhos-86 TotBili-0.2 ___ 08:10PM BLOOD cTropnT-0.01 ___ 09:15PM BLOOD CK-MB-2 cTropnT-0.01 ___ 07:15AM BLOOD CK-MB-1 cTropnT-0.02* ___ 08:10PM BLOOD Albumin-3.6 ___ 09:15PM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7 ___ 08:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS -------------- ___ 07:15AM BLOOD WBC-6.0 RBC-4.20 Hgb-12.5 Hct-37.8 MCV-90 MCH-29.8 MCHC-33.1 RDW-14.6 RDWSD-48.3* Plt ___ ___ 07:15AM BLOOD ___ PTT-33.5 ___ ___ 07:15AM BLOOD Glucose-88 UreaN-13 Creat-0.6 Na-137 K-4.2 Cl-99 HCO3-28 AnGap-10 ___ 07:15AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2 URINE STUDIES ------------- ___ 07:00PM URINE RBC-2 WBC-14* Bacteri-FEW* Yeast-NONE Epi-0 TransE-<1 RenalEp-<1 ___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM* ___ 07:00PM URINE Color-Straw Appear-Clear Sp ___ MICROBIOLOGY ------------ ___ 1:53 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ------- ___ CXR IMPRESSION: No pneumonia. Chronic borderline cardiac enlargement and mild vascular congestion; no evidence of acute cardiac decompensation. ___ MR HEAD W/O CONTRAST IMPRESSION: 1. No evidence of hemorrhage or infarction. 2. Global parenchymal volume loss and evidence of chronic small vessel ischemic disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Carbidopa-Levodopa (___) 1 TAB PO QID 3. Citalopram 40 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild 7. Aspirin 81 mg PO DAILY 8. Vitamin D ___ UNIT PO DAILY 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY:PRN lower extremity swelling 2. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Carbidopa-Levodopa (___) 1 TAB PO QID 6. Citalopram 40 mg PO DAILY 7. Lisinopril 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ----------------- # Falls # Weakness SECONDARY DIAGNOSES ------------------- # Possible UTI # ___ disease # Deconditioning # Hypertension # Depression 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: MR HEAD W/O CONTRAST T9113 MR HEAD INDICATION: ___ year old woman with ___ disease and possible left facial droop// eval for CVA 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 ___, CTA head and neck ___. FINDINGS: There is no evidence of infarction, hemorrhage, mass, mass effect, edema or midline shift. The ventricles and sulci are prominent. Periventricular and subcortical white matter FLAIR hyperintensities are noted, a nonspecific finding that most likely represents the sequelae of chronic small vessel ischemic disease. There is gross preservation of the principal intracranial vascular flow voids. Mild mucosal thickening is seen in scattered ethmoid air cells. The remainder of the visualized paranasal sinuses, middle ear cavities, and mastoid air cells are well aerated and clear. The patient is status post bilateral lens replacement. IMPRESSION: 1. No evidence of hemorrhage or infarction. 2. Global parenchymal volume loss and evidence of chronic small vessel ischemic disease. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: s/p Fall, Weakness Diagnosed with Urinary tract infection, site not specified temperature: 97.9 heartrate: 67.0 resprate: 18.0 o2sat: 99.0 sbp: 114.0 dbp: 51.0 level of pain: 6 level of acuity: 3.0

Dear Ms ___, It was a pleasure taking care of you at ___! Why was I admitted to the hospital? - you were weak and had difficulty walking - physical therapy saw you and recommended discharge to rehab - you were found to have a possible infection in your urine and were given antibiotics to treat the infection What should I do after discharge? - please take all of your medications as prescribed - please go to all follow up appointments as detailed below All the best! Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Vicodin Attending: ___. Chief Complaint: Perforation of colon and peritonitis Major Surgical or Invasive Procedure: Sigmoidoscopy with dilation of anastamotic stricture and subsequent perforation - ___ Laparoscopy converted to laparotomy, washout, drainage of pelvis, and diverting loop ileostomy (for perforated colon with peritonitis) - ___ Reopening of recent laparotomy, abdominal washout, mobilization and division of the transverse and descending colon, colon decompression, and open abdomen - ___ Abdominal exploration and washout - ___ Abdominal washout, partial closure colonic mucous fistula, placement of a drain - ___ Fascial closure of abdominal wall - ___ History of Present Illness: ___ with h/o perforated diverticulitis s/p robotic sigmoid colectomy (___) now s/p sigmoidoscopy with dilation for anastomotic stricture with finding of colonic perforation on CT scan. He has a known 2 - 2.5cm anastomotic stricture at 20cm treated with CRE balloon dilations under fluoroscopy on ___, ___, and ___, and presented for repeat sigmoidoscopy with dilation earlier today due to recurrent symptoms. Per GI report, sigmoidoscopy was performed under fluoroscopy with gradual progressive dilation of the anastamotic stricture from 12mm to 16.5mm. Post procedure, he developed lower abdominal pain and chest pain around 12:15pm, described as located at the sternum and radiating to both collar bones. The "discomfort" lasted approximately 15 minutes, then subsided. He denies shortness of breath, nausea / vomiting, and/or diaphoresis. EKG demonstrated <___hanges in leads I and II, and he was subsequently referred to the Emergency Room for further evaluation. CXR obtained in the ER found free air under the diaphragam, for which colorectal surgery was consulted. Past Medical History: PMHx: perforated diverticulitis, anastomotic stricture, HTN, obesity, anxiety, strabismus PSHx: robotic sigmoid colectomy (___), s/p sigmoidoscopy w/dilation x4 for anastomotic stricture, s/p strabismus correction as child, removal skin lesion on leg (___) Social History: ___ Family History: uncle with colon cancer and negative for inflammatory bowel disease or other cancers Physical Exam: Physical exam on admission: T 97.8 HR 90 BP 131/80 RR 16 O2sat 97%RA Gen: NAD although extremely anxious CV: mild tachycardia Pulm: CTA bilaterally Abd: well healed incisions, soft, obese, tender lower abdomen, no voluntary guarding or rebound tenderness Ext: warm, well-perfused Physical exam on discharge: 98.7, 113, 122/78, 18, 96% RA Gen: NAD, slightly anxious CV: tachycardic rate, regular rhythm, no murmurs, rubs, or gallops Pulm: CTA Abd: midline vertical wound has VAC dressing; ileostomy on R - stoma pink (bridge removed prior to discharge); small scab above stoma; old mucous fistula site on L covered; old JP site covered with dry gauze Back: grade 2 sacral ulcer Ext: warm, well-perfused, no extremity swelling Pertinent Results: ___ 05:50AM BLOOD WBC-13.0* RBC-3.77* Hgb-9.9* Hct-30.0* MCV-80* MCH-26.4* MCHC-33.1 RDW-14.7 Plt ___ ___ 04:40PM BLOOD Glucose-101* UreaN-17 Creat-0.5 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 ___ 04:40PM BLOOD Calcium-8.1* Phos-3.0 Mg-2.4 Medications on Admission: HCTZ 25mg daily Lisinopril 20mg daily Colace Discharge Medications: 1. Acetaminophen 650 mg PO Q4H 2. Lorazepam 0.5 mg PO Q4H:PRN Anxiety RX *lorazepam 0.5 mg 1 tablet by mouth every our hours as needed for anxiety Disp #*60 Tablet Refills:*0 3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*7 Tablet Refills:*0 4. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth every day (same time each day) Disp #*3 Tablet Refills:*0 5. Lisinopril 20 mg PO DAILY ___ were taking this medication at home but should stop taking it and discuss with your primary care physician when to ___ 6. LOPERamide 2 mg PO TID RX *loperamide 2 mg 1 capsule by mouth three times a day Disp #*100 Capsule Refills:*0 7. Hydrochlorothiazide 25 mg PO DAILY ___ were taking this medication at home but should stop taking it and discuss with your primary care physician when to ___ 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ capsule(s) by mouth every four hours as needed for pain Disp #*50 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Perforated colon with peritonitis 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: Chest pain, question mediastinal pathology, free air. COMPARISON: None. TECHNIQUE: Frontal and lateral views of the chest. FINDINGS: Evidence of free air is seen beneath the diaphragms, right greater than left. There are relatively low lung volumes and minimal bibasilar atelectasis. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: Evidence of pneumoperitoneum raising concern for bowel perforation. Dr. ___, was paged at 3:40 p.m. at the time of discovery. Through ED dashboard, the ED team is aware of free air under the diaphragms. Dr. ___ this at 3:45pm. Radiology Report HISTORY: Abdominal pain and free air under chest radiograph in a patient status post sigmoidoscopy. TECHNIQUE: MDCT acquired axial images were obtained from the lung bases to the pubic symphysis after administration of 130 cc Omnipaque intravenous contrast material as well as 400 cc of Optiray water soluble contrast per rectum. Coronal and sagittal reformats reviewed. COMPARISON: CT from ___. FINDINGS: The lower chest is unremarkable. The liver enhances homogeneously, without focal lesion. Gallbladder and biliary tree are normal. The spleen, adrenal glands, pancreas are normal. The kidneys enhance normally and excrete contrast symmetrically. There is a duplicated left collecting system. There are multiple small simple cysts in the bilateral kidneys. One complex cyst in the lower pole of the right kidney (2:52) appears unchanged with two possible inferior foci of enhancement, measuring 14-mm. The abdominal aorta is normal caliber with patent main branches. The portal, splenic, mesenteric veins are patent. The stomach and small bowel appear normal. The patient is status post sigmoidectomy. The colon is distended with gas. The descending colon again demonstrates wall thickening to the level of the anastamosis with surrounding stranding and adenopathy. The proximal extent of colonic wall thickening has progressed to the transverse colon compared to the prior study. The distal colon demonstrates circumferential wall thickening and extensive surrounding fat stranding. There is active extravasation of rectal contrast and air in the distal colon, just proximal to the anastomosis, best seen on series 2, image 70. There is fluid and fat stranding but no organized collection. There is large volume pneumoperitoneum as seen on the chest radiograph. The bladder, prostate, and seminal vesicles appear normal. There are no lytic or sclerotic osseous lesions concerning for malignancy. IMPRESSION: 1. Distal colonic perforation just proximal to the site of the anastomosis with leakage of air and rectal contrast into the peritoneum. There is no organized fluid collection. 2. Worsening descending colonic thickening and inflammatory changes, when compared to the prior study, compatible with colitis, possibly ischemic, infectious or inflammatory in etiology, 3. 14-mm complex right renal cyst could be further characterized by ultrasound. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with perforated colon during sigmoidoscopy with stricture dilatation. AP radiograph of the chest was reviewed, focusing on the lower chest, upper abdomen. The NG tube tip is in the proximal stomach and should be advanced. The stomach remains distended. There is interval decrease in intraperitoneal air. The lung bases are essentially clear. Due to different projection of the radiograph, it's difficult to assess the cardiomediastinal silhouette that appears to be artificially enlarged. Radiology Report REASON FOR EXAMINATION: Perforated diverticulitis after sigmoidectomy with anastomosis and now with tachycardia, assessment of the central venous line. AP radiograph of the chest was compared to ___. The right subclavian line has a somewhat tortuous course with the tip terminating in the mid SVC at the level of the carina. Correlation with the output of the line is recommended since it is unlikely to follow the usual course and potentially can be in one of the chest wall veins. Also, there is slight interval increase of amount of pleural fluid on the right that should be also further assessed to exclude the possibility of intrapleural position of the central venous line. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with bowel perforation, intubated. AP radiograph of the chest was reviewed in comparison to ___. The ET tube tip is 4.7 cm above the carina. NG tube tip is in the stomach. The central venous line tip is at the level of mid SVC. There is interval additional increase in pleural effusion and currently interval development of left lower lobe atelectasis. Patient is in interstitial pulmonary edema. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with bowel perforation, intubated, followup. AP radiograph of the chest was compared to prior study obtained the same day earlier. The ET tube tip is 6 cm above the carina. Right subclavian line tip is in the mid SVC. NG tube tip is in the stomach. Bilateral pleural effusions and bibasilar areas of atelectasis are demonstrated, but there is improvement of the left lower lobe atelectasis on the current study. No evidence of pneumothorax. Radiology Report CHEST RADIOGRAPH INDICATION: Perforated bowel, evaluation for endotracheal tube position. COMPARISON: ___, 11:14 a.m. FINDINGS: As compared to the previous radiograph, the position of the endotracheal tube is not substantially changed. The tube projects 5 cm above the carina. Also unchanged is the course of the nasogastric tube, the position of the right subclavian vein catheter. The patient continues to display bilateral pleural effusions and areas of bilateral basal atelectasis. Mild pulmonary edema might also be present. However, there is no evidence for a newly occurred parenchymal opacity suggesting pneumonia. No pneumothorax. Radiology Report INDICATION: History of perforated bowel status post repair. Patient requiring fluid resuscitation. Please evaluate for fluid status. COMPARISONS: Chest radiographs dating back to ___. TECHNIQUE: Single AP portable exam of the chest. FINDINGS: The ET tube terminates approximately 5.3 cm above the carina. There is a right-sided subclavian catheter which terminates in the mid SVC. The lung volumes are low resulting in crowding of the bronchovascular structures; however, there appears to be mild pulmonary vascular congestion. The patient continues to display small bilateral pleural effusions and mild areas of bilateral basilar atelectasis. There may be mild pulmonary edema, overall unchanged compared to the prior exam. There is no evidence of a pneumothorax. The heart size is normal. The hilar and mediastinal contours are normal. IMPRESSION: Stable mild bibasilar atelectasis. Mild pulmonary vascular congestion with mild bilateral pulmonary edema. Radiology Report HISTORY: Possible ARDS. FINDINGS: In comparison with the study of ___, the endotracheal tube is somewhat further above the clavicles, though only about 6 cm above the carina. Other monitoring and support devices are unchanged. Continued pulmonary vascular congestion with hazy opacification at the bases, silhouetting the hemidiaphragms, consistent with layering pleural effusions and compressive atelectasis at the bases. Radiology Report HISTORY: ___ man status post ex-lap and washout, ileostomy, mucus fistula, with ? ARDS. Evaluate for interval change. TECHNIQUE: Portable AP semi-erect chest radiograph was obtained. COMPARISON: Chest radiograph from ___. FINDINGS: Continued mild pulmonary edema is seen, and opacification at bilateral bases is seen, consistent with pleural effusions and associated compressive atelectasis. The heart size is normal. The right central venous line ends at the mid-lower SVC, and the gastric tube curls in the stomach. ET tube is positioned high in the trachea, above the level of the clavicles. IMPRESSION: Continued pulmonary edema and bibasilar pleural effusions and compressive atelectasis. Recommend advancement of ET tube. Initial findings were conveyed to ___ of the surgical team on ___ at 10:15 immediately following review by Dr. ___. Radiology Report HISTORY: Abdominal closure. COMPARISON: None. FINDINGS: Supine views of the chest and abdomen were provided. Enteric tube is seen with tip in the gastric fundus. 2 surgical drains project over the pelvis as well as skin staples. There is no radiopaque foreign body identified. Nonspecific nonobstructive bowel gas pattern is seen. Extremely low lung volumes identified. IMPRESSION: No radiopaque foreign body besides drains and tubes as above. Findings were discussed with Dr. ___ the phone at time of interpretation at 21:40 on ___. Radiology Report HISTORY: ___ man status post bowel perforation repair, section. Evaluate volume status. TECHNIQUE: Portable AP semi-erect chest radiograph was obtained. COMPARISON: Chest radiograph from ___. FINDINGS: Bilateral basilar opacification is seen with no focal consolidation or pneumothorax. The cardiac silhouette is mildly enlarged with mild vascular congestion. ET tube is in appropriate position, and the gastric tube coils in the stomach. Right subclavian line ends in the lower SVC in appropriate position. IMPRESSION: Unchanged bilateral pleural effusions and bibasilar atelectasis. Mild cardiomegaly with mild vascular congestion. Radiology Report AP CHEST, 10:55 A.M., ___ HISTORY: ___ male with abdominal sepsis and desaturation. IMPRESSION: AP chest compared to ___ at 5:07 a.m.: Moderate bilateral pleural effusions and mild pulmonary edema have both improved since earlier in the day. Tip of the endotracheal tube at the upper margin of the clavicles, is no less than 5 cm from the carina. Heart size normal. No pneumothorax. Upper enteric drainage tube is curled in the gastric fundus. Right subclavian line ends in the mid-to-low SVC. No pneumothorax. Radiology Report AP CHEST, 3:54 A.M., ___ HISTORY: A ___ man with an anastomotic leak. IMPRESSION: AP chest compared to ___: Previous mild pulmonary edema continues to clear since ___. Substantial right pleural effusion and bibasilar atelectasis remain. The heart size is normal. Azygous distention suggests elevated central venous pressure. The tip of the endotracheal tube just below the upper margin of the clavicles with the chin down, is 4.5 cm above the carina, 2 cm above optimal placement for the chin in neutral position. The right subclavian line ends low in the SVC. No pneumothorax. Radiology Report AP CHEST, 12:39 P.M., ___ HISTORY: ___ man with bowel perforation and new left subclavian line placed. Evaluate possible pneumothorax. IMPRESSION: AP chest compared to ___, 3:54 a.m.: The tip of the new left subclavian line lies alongside the right line in the mid-to-low SVC. There is no pneumothorax or mediastinal widening. Moderate right pleural effusion has been present for several days, as has bibasilar atelectasis. Heart size normal. No pneumothorax. The tip of the endotracheal tube above the upper margin of the clavicles, nearly 6 cm from the carina is 2 cm above standard positioning, as before. Radiology Report CLINICAL HISTORY: Fluid overload. Evaluate for pulmonary edema or effusions. CHEST AP: ___. The position of the various lines and tubes is unchanged since the prior chest x-ray. The left lung shows some atelectasis, but is otherwise clear. A right effusion is present, decreased in size since the prior chest x-ray. IMPRESSION: Right effusion is somewhat smaller. Radiology Report CLINICAL HISTORY: Nasogastric tube repositioned, check position. CHEST: On the prior ultrasound the nasogastric tube is curled up within the fundus of the stomach. It has been withdrawn and the tip now lies within the stomach and is no longer curled. Elsewhere, the lung changes are unaltered. Radiology Report PORTABLE CHEST X-RAY, ___ COMPARISON: Chest x-ray one day earlier. FINDINGS: Indwelling support and monitoring devices are in standard position, and cardiomediastinal contours are stable in appearance. Slight improvement in small right pleural effusion with adjacent right lower lobe opacity which probably reflects atelectasis. Left lung is grossly clear except for minimal linear atelectasis at the left base. Radiology Report INDICATION: Bowel perforation after dilation of an anastomotic stricture from prior sigmoid colectomy. Now septic following diverting ileostomy, multiple washouts, with interstitial pulmonary edema. The last washout was on ___, followed by closure on ___. TECHNIQUE: MDCT-acquired axial images of the chest, abdomen, and pelvis were obtained following the uneventful administration of 130 cc of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 5 mm slice thickness. CT OF THE CHEST WITH IV CONTRAST: Included views of the thyroid are within normal limits. A left subclavian central venous catheter terminates at the lower SVC (2:23). The heart size is normal. There is a small pericardial effusion (2:38). An endotracheal tube terminates at the lower trachea (2:7). Small amount of mucous secretion lies just above the carina (2:12). The airways are otherwise patent to the subsegmental levels. There are small bilateral pleural effusions, larger on the right, with adjacent moderate compressive atelectasis of the bilateral lower lobes (2:31, 35). There are no pulmonary nodules or masses. There is no mediastinal or hilar lymphadenopathy. The great vessels are patent and normal in caliber. No large pulmonary embolus is detected to the segmental levels. CT OF THE ABDOMEN WITH IV CONTRAST: There is a left lower quadrant colostomy and right lower quadrant ileostomy (2:94, 73). Intra-abdominal loops of small and large bowel are normal in caliber. A nasogastric tube terminates in the stomach lumen (2:54). Mild ascites is within post-surgical limits. Tiny pockets of fluid track along both paracolic gutters (2:64, 78) and along the anterior abdomen (2:83), accompanied by mild neighboring peritoneal wall and fascial enhancement. Trace pneumoperitoneum is within post-surgical limits (2:52). The liver, pancreas, spleen, adrenal glands, and kidneys appear normal. Subcentimeter hypodense lesions throughout both kidneys (2:67, 85, 68) are unchanged in comparison to the reference CT examination from ___, and are statistically likely benign cysts. There is no mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: A left lower approach surgical drain loops across the central pelvis (2:104). A small amount of intrapelvic ascites is seen. No discrete intrapelvic collection is present. A sigmoid anastomosis appears intact (2:106). The prostate and bladder are normal. A Foley catheter resides within the bladder, which contains a moderate amount of gas (2:115). There is no intrapelvic lymphadenopathy. OSSEOUS STRUCTURES: There is no acute fracture. There are no bony lesions concerning for malignancy or infection. IMPRESSION: 1. Mild intra-abdominal and intrapelvic ascites within post-surgical limits. Tiny pockets of fluid along the anterior abdomen and paracolic gutters are accompanied by mild peritoneal and fascial enhancement, reflecting inflammatory changes but indistingushable from infection. This is accessible to US or CT guided aspiration, if warranted. 3. Non-obstructed ileostomy and colostomy. 4. Subcentimeter hypodense renal lesions are statistically likely cysts, but are too small for further characterization on this single phase study. 5. Small pericardial effusion. Radiology Report HISTORY: Postoperative respiratory difficulties. FINDINGS: In comparison with the study of ___, there are lower lung volumes. Poor definition of the hemidiaphragms, especially on the right, suggests atelectatic change with possible effusions. There is an area of increased opacification just above the minor fissure, which could reflect either fluid in the fissure or possible developing consolidation in the upper lobe. The monitoring and support devices have all been removed. This information has been conveyed to Dr. ___, who is covering for Dr. ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with CHEST PAIN NOS, DIVERTICULITIS OF COLON temperature: 97.8 heartrate: 78.0 resprate: 18.0 o2sat: 100.0 sbp: 156.0 dbp: 111.0 level of pain: 4 level of acuity: 2.0

___ were admitted to the hospital after a perforated colon, for which ___ underwent numerous operations, including the creation of a diverting loop ileostomy and abdomen with a VAC. ___ have recovered from these operations and hospital course well and ___ are now ready to return home. ___ have tolerated a regular diet, passing gas/stool in your ostomy and your pain is controlled with pain medications by mouth. ___ may return home to finish your recovery. ___ will get ___ and physical therapy at home (set up by the hospital). ___ have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If ___ find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. If ___ have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. In addition, continue eating small, frequent meals throughout the day to maintain your nutritional status. Your goal caloric intake is approximately 2800 calories/day, but do not eat so much that ___ feel nauseated or vomit. ___ have a long vertical incision on your abdomen. The skin is left open. ___ had a VAC on it while in the hospital. When ___ go home, ___ will go home with wet to dry dressings and the visiting nurses ___ replace the VAC. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if ___ develop a fever. Please call the office if ___ develop these symptoms or go to the emergency room if the symptoms are severe. ___ may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. ___ may gradually increase your activity as tolerated but clear heavy exercise with Dr. ___. ___ will be prescribed a small amount of the pain medication oxycodone. Please take this medication exactly as prescribed. ___ may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. ___ will also be prescribed Ativan for your anxiety. Please continue to take it as needed, but be sure to follow up with your primary care doctor for further long-term management. In addition, as discussed, your baseline heart rate since ___ left the ICU was 110-120 beats per minute. We are not concerned about this and feel that it is your current baseline, but ___ should also follow up with your primary care physician about this. ___ were taking lisinopril and hydrochlorothiazide (HCTZ) before ___ came to the hospital. Please do not ___ these, but ask your primary care physician when it would be appropriate to ___ them. Thank ___ for allowing us to participate in your care! Our hope is that ___ will have a quick return to your life and usual activities. Good luck!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with hypothyroidism, obesity, T2DM, recent diagnosis of tracheomalacia, presenting with worsening shortness of breath. She reports having shortness of breath with exertion and at rest for at least the past year. About one year ago she could walk about one block before having to stop and catch her breath. Her shortness of breath has since progressed. She was hospitalized several months ago at ___ for these symptoms and was treated with steroids. At that time a chest CT was performed and demonstrated evidence of tracheobronchialmalacia with evidence of dynamic collapse at distal trachea and bilateral mainstem. In addition to prednisone, she has had trials of several different inhaled medications, without significant improvement. Currently she uses albuterol nebulizers with partial relief (up to q4hr when she is symptomatic, several times per week). She becomes SOB after walking only several feet. She has also had a chronic nonproductive cough. Describing her shortness of breath, at times she feels like she cannot get air in or out and also hears squeaks when she breaths. There are no apparent associated exacerbating or alleviating factors. She has had negative allergy testing, although does have rhinorrhea. She has had additional diagnostic studies for evaluation of shortness of breath including cardiac cath and multiple CT scans. Cath reportedly showed one area of 50% stenosis but no other abnormalities. Additionally, she has had intermittent swelling in her lower legs for at least the past several months, especially involving the right leg. This swelling is generally worse at the end of the day. She has had negative ___ ultrasounds during prior hospitalizations for shortness of breath in the past and has never had leg pain. Several days prior to the current presentation she had a severe episode of right ankle/foot swelling for which she kept her leg elevated with gradual improvement in this symptom. Ms. ___ was recently hospitalized at ___ with this SOB and right leg swelling as described above; she was discharged ___ for outpatient management. She was hoping to be evaluated by a thoracic surgeon, could not get an appointment until ___, and therefore presented to the ED for evaluation. On ROS, it is unclear if she has had PND, although she sleeps with 2 pillows. She has not had hemoptysis, fever, chills, night sweats, chest pain, or palpitations. She has not recent illnesses or travel. She does not smoke. Past Medical History: - Hypothyroidism - DM2 (on metformin in the past) - OSA - no established CPAP use as of yet - Hyperlipidemia - Hypertension - CAD (reported 50% stenosis on catheterization) Past Surgical History: - Thyroidectomy for benign nodules Social History: ___ Family History: Family history of relatives with DM2, ___ disease Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 97.8 PO 129 / 67 76 18 95 Ra ___: Alert, oriented, no acute distress, obese, sitting on side of bed HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP could not be assessed, no LAD CV: Regular rate, S1 + S2, no murmurs, rubs, gallops audible Lungs: Symmetric chest rise, clear to auscultation bilaterally, no wheezes or crackles audible Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: Warm, well perfused, 1+ pulses b/l, trace LLE edema, 2+ RLE edema, no erythema or tenderness Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM: Vital Signs: 97.7 117 / 74 67 18 97 Ra ___: Alert, oriented, no acute distress, obese, sitting on side of bed HEENT: Sclerae anicteric, MMM, oropharynx clear, no apparent cobble stoning, EOMI, PERRL Neck: Neck supple, JVP could not be assessed, no LAD CV: Regular rate, S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally; no stridor, wheezes, or crackles Abdomen: Soft, non-tender, bowel sounds present GU: No foley Ext: Warm, well perfused, 1+ pulses b/l, trace LLE edema, 2+ RLE edema, no erythema or tenderness Neuro: moving all four extremities, A&Ox3 Pertinent Results: ADMISSION LABORATORY STUDIES ================================== ___ 07:58AM BLOOD WBC-15.6* RBC-4.29 Hgb-12.5 Hct-37.9 MCV-88 MCH-29.1 MCHC-33.0 RDW-16.3* RDWSD-52.1* Plt ___ ___ 07:58AM BLOOD ___ PTT-21.8* ___ ___ 07:58AM BLOOD Glucose-244* UreaN-27* Creat-0.6 Na-138 K-4.0 Cl-98 HCO3-22 AnGap-22* DISCHARGE LABORATORY STUDIES ================================== ___ 07:45AM BLOOD WBC-8.7 RBC-4.45 Hgb-13.0 Hct-40.2 MCV-90 MCH-29.2 MCHC-32.3 RDW-16.6* RDWSD-54.2* Plt ___ ___ 07:45AM BLOOD Glucose-108* UreaN-20 Creat-0.6 Na-140 K-4.4 Cl-100 HCO3-27 AnGap-17 ___ 07:45AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.2 ___ 07:45AM BLOOD TSH-1.3 ___ 07:45AM BLOOD Free T4-1.9* IMAGING/REPORTS ================================== CT TRACHEA W/O CONTRAST: IMPRESSION: No or stricture or other fixed structural abnormality of the trachea. There is a decrease in tracheal diameter 41-42% upon expiration. Generalized severe decrease in lobar bronchial diameter upon expiration is more than physiologic expectations and may contribute to mild air trapping. RIGHT LOWER EXTREMITY DUPLEX ULTRASOUND No evidence of deep venous thrombosis in the right lower extremity veins. PFTS: pending on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 200 mcg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. PredniSONE 60 mg PO DAILY 4. Losartan Potassium 25 mg PO DAILY 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 6. Atorvastatin 40 mg PO QPM 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Metoprolol Succinate XL 25 mg PO DAILY 10. mometasone-formoterol 200-5 mcg/actuation inhalation 2 puffs BID 11. Montelukast 10 mg PO DAILY 12. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. PredniSONE 50 mg PO DAILY decrease by 10mg every 3 days (i.e. 50 mg for 3 days, then 40mg for 3 days, etc.) Tapered dose - DOWN 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB INH Q6H:PRN Disp #*30 Ampule Refills:*0 3. Atorvastatin 40 mg PO QPM 4. Clopidogrel 75 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Levothyroxine Sodium 200 mcg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Metoprolol Succinate XL 25 mg PO DAILY 10. mometasone-formoterol 200-5 mcg/actuation inhalation 2 puffs BID 11. Montelukast 10 mg PO DAILY 12. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home Discharge Diagnosis: Tracheobronchomalacia 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 tracheomalacia.// change in CXR? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___, CT chest ___ FINDINGS: Cardiac silhouette size remains moderately enlarged. The mediastinal and hilar contours are unchanged. Pulmonary vasculature is not engorged. No focal consolidation, pleural effusion or pneumothorax is seen. Mild degenerative changes are noted in the thoracic spine. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CT TRACHEA W/O CONTRAST INDICATION: ___ year old woman with cough. TECHNIQUE: Multi detector helical scanning of the chest was performed at end inspiration, reconstructed as contiguous 5.0 and 1.25 mm thick axial and 2.5 mm thick coronal images of the full chest. Multi detector helical scanning of the chest was repeated during forced expiration, and reconstructed as contiguous 5.0 and 1.25 mm thick axial images. Endoscopic navigation and localization images were reconstructed from both end inspiration and dynamic expiration scanning, and 3D volume renderings were reconstructed from the expiration scans. Intravenous contrast agent was not employed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 41.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 849.9 mGy-cm. 2) Spiral Acquisition 2.7 s, 42.2 cm; CTDIvol = 4.1 mGy (Body) DLP = 172.1 mGy-cm. Total DLP (Body) = 1,022 mGy-cm. COMPARISON: ___ outside hospital chest CT FINDINGS: DYNAMIC TRACHEAL IMAGING REPORT NOW = current study; MRP = most recent prior CT Dynamic Trachea I. INSPIRATORY TRACHEA LENGTH from vocal cords/arytenoids to carina: Approximately 13cm SHAPE: Horseshoe RoundX lenticular Sabre-sheath Crescent Other:_________ Wall thickening: NX y: unifocal multifocal max thickness: mm Abn calcification: NX y: unifocal multifocal max thickness: mm Abn peritrachea: NX y: unifocal multifocal FOCAL NARROWING (STRICTURE) 1. N X y II. DYNAMIC TRACHEA 1. At sternal notch NOW Cor x Sag INSP: 307.0mm2 EXP: 177.4mm2 I-E/I = 42% decrease SHAPE during EXP Horseshoe Round Lenticular Sabre-sheath CrescentX Other:_________ 2. Upper margin of azygos (series 302, image 94; series 303, image 85) NOW Cor x Sag INSP: 256.3mm2 EXP: 152.0mm2 I-E/I = 41% decrease SHAPE during EXP Horseshoe Round Lenticular Sabre-sheath CrescentX Other:_________ III. DYNAMIC BRONCHI R Main - smallest true diameter NOW INSP 8mm EXP 3mm L Main - smallest true diameter NOW INSP 9mm EXP 3mm BrI - smallest true diameter NOW INSP 9mm EXP 4mm Bronchi: Exp diameter < 3mm RUL N YX RBT N YX LUL NX y LBT N YX ?Air trapping? Mild x moderate severe CHEST CT: Heart size is normal. No pericardial effusion. Coronary artery calcifications are minimal. Aortic arch calcifications are minimal. The thoracic aorta is normal in caliber. The main pulmonary artery is mildly enlarged with a diameter of 3.4 centimeters, though the right main pulmonary artery is normal in caliber. Supraclavicular, axillary, mediastinal and hilar lymph nodes are not enlarged. No evidence of pulmonary parenchymal abnormality. No pulmonary nodules. No pleural effusion or pneumothorax. Airways are patent to the subsegmental level. The visualized portion of the base of the neck is unremarkable. The visualized portion of the abdomen is unremarkable. No lytic or blastic osseous lesion suspicious for malignancy is identified. A T3 vertebral body hemangioma is noted. IMPRESSION: No or stricture or other fixed structural abnormality of the trachea. There is a decrease in tracheal diameter 41-42% upon expiration. Generalized severe decrease in lobar bronchial diameter upon expiration is more than physiologic expectations and may contribute to mild air trapping. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old woman with several months of progressive dyspnea and intermittent leg swellig// Swelling R>L, evaluate for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation 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. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dizziness, Dyspnea Diagnosed with Other specified diseases of upper respiratory tract, Dyspnea, unspecified temperature: 97.3 heartrate: 103.0 resprate: 28.0 o2sat: 97.0 sbp: 153.0 dbp: 83.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you during your hospital stay at ___. You were hospitalized for shortness of breath. You were treated for shortness of breath related to tracheobronchomalacia with breathing treatments. On discharge, it is important for you to complete the recommended diagnostic testing and attend your scheduled outpatient appointments for further treatment and follow up. Please continue to follow up with your primary care physician, and specialists upon discharge from the hospital. Please continue to take your home medications as prescribed. Please decrease your prednisone (decrease by 10mg every 3 days, meaning you should take 50mg for three days, then 40mg for three days, then 30mg for three days, etc.). Take Care, Your ___ Team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol / gabapentin Attending: ___. Chief Complaint: fever, dysuria Major Surgical or Invasive Procedure: none History of Present Illness: PCP: ___ . CC: fever, dysuria . HPI/EVENTS: ___ yo M h/o HTN, TIA s/p L CEA ___, BPH admitted with 2 days of fever, dysuria, frequency and urgency. At baseline, Mr ___ is very functional, able to ambulate, independent and lives alone. He was in USOH until 1 wk ago when he noted bil flank pain radiating to shoulders. Subsequently noted dysuria, incomplete urination, nausea, and fever. Denies blood in urine. Presented to the ED where he was found to be febrile to 101.2. BP stable. WBC 14. No CVA appreciate. Prostate was enlarged but not tender. He was given 400mg iv of ciprofloxacin, IVF, ibuprofen, zofran, ketorolac. Feeling well upon transfer to the floor. Denies N/V, abd/flank pain, chills. ROS: per HPI, denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, hematuria. A 10 pt review of sxs was otherwise negative. Past Medical History: # HTN/hyperchol - Stress MIBI ___: mod ___ 5.5 mins (~ ___ METS), 63%. Normal myocardial perfusion scan. # L carotid stenosis s/p CEA ___ # TIA ___ - MRI/MRA old thalamic lacune, e/o chronic small vessel ischemia and <30% stenosis ___ basilar artery # chronic venous insufficiency, symptomatic R leg varicose veins s/p leg GSV RFA ___ # OSA # BPH # GERD Social History: ___ Family History: NC Physical Exam: Vital Signs: 98.5 ___ 14 98% on RA glucose: . GEN: NAD, well-appearing, lying in bed, interactive EYES: PERRL, EOMI, conjunctiva clear, anicteric ENT: moist mucous membranes, no exudates NECK: supple CV: RRR s1s2 nl, no m/r/g PULM: CTA, no r/r/w GI: normal BS, NT/ND, no HSM, no flank pain EXT: warm, no c/c/e SKIN: no rashes NEURO: alert, oriented x 3, answers ? appropriately, follows commands, non focal PSYCH: appropriate ACCESS: PIV FOLEY: absent Pertinent Results: # (___) WBC 14.1, BUN/Cr ___, TBili 2.3 U/A large ___, nit+, WBC >183 Blood cx Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Doxazosin 8 mg PO HS 2. Fluticasone Propionate NASAL ___ SPRY NU DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Metoprolol Tartrate 25 mg PO BID 5. Omeprazole 20 mg PO BID 6. Sildenafil 50 mg PO PRN prior to sex activity 7. Simvastatin 40 mg PO DAILY 8. Aspirin 325 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Doxazosin 8 mg PO HS 3. Fluticasone Propionate NASAL ___ SPRY NU DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Metoprolol Tartrate 25 mg PO BID 6. Omeprazole 20 mg PO BID 7. Simvastatin 40 mg PO DAILY 8. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*10 Tablet Refills:*0 9. Ibuprofen 600 mg PO Q8H:PRN pain 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 17 gm powder(s) by mouth Daily Disp #*20 Packet Refills:*0 11. Sildenafil 50 mg PO PRN prior to sex activity Discharge Disposition: Home Discharge Diagnosis: Urinary tract infection Benign prostate hypertrophy 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 man with fever. // Please evaluate for cause of fever TECHNIQUE: CHEST (PA AND LAT) COMPARISON: ___ and ___ IMPRESSION: Heart size is top-normal. , unchanged. Tortuous aorta E is unchanged. Lungs are essentially clear. No appreciable pleural effusion or pneumothorax demonstrated. Opacity projecting over the heart on the lateral view is unchanged and most likely reflects extensive fat pad. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old man with fevers, elevated bilirubin, ? pyelonephritis, with ongoing fevers despite abx // eval for cbd dimension/dilation, any other pathology, also, please eval for perinephric abscess TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound from ___. FINDINGS: LIVER: The echogenicity of the liver is homogeneous. The contour of the liver is smooth. There is no focal liver mass. Main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. No ___ sign was elicited. PANCREAS: Head, body and tail of the pancreas are within normal limits, without masses or pancreatic ductal dilatation. SPLEEN: Normal echogenicity, measuring 10.4 cm. KIDNEYS: The right kidney measures 10.0 cm. The left kidney measures 10.1 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones or hydronephrosis in the kidneys. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: Normal abdominal ultrasound. Specifically, no US evidence for pyelonephritis or perinephric fluid collection detected. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: Fever, Nausea Diagnosed with URIN TRACT INFECTION NOS, PYELONEPHRITIS NOS temperature: 101.2 heartrate: 111.0 resprate: 18.0 o2sat: 100.0 sbp: 135.0 dbp: 96.0 level of pain: 2 level of acuity: 3.0

As you know, you were admitted with urinary tract infection and fever. You were treated with oral antibiotics and intravenous fluids with good response. You did well on this and had no subsequent fever. Please continue to take the antibiotics for the next 5 days. Please see Dr. ___ in the next ___ weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: hydrochlorothiazide / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: left hip fracture Major Surgical or Invasive Procedure: Surgical fixation of left hip fracture History of Present Illness: ___ female history of PMR on prednisone who presents with the above fracture s/p mechanical fall. Patient was on the train his morning when she tripped and fell, striking her left hip and the back of her head. No loss of consciousness. Patient was seen and evaluated at ___ ED but requested transfer here since she is a patient of Dr. ___. She endorses left hip pain and possible initial numbness at time of injury but no current numbness or tingling. According to chart review she has been taking ___ mg of prednisone daily for PMR taper. Past Medical History: ECZEMATOUS DERMATITIS HYPERTENSION MENOPAUSE ACTINIC KERATOSIS KERATOACANTHOMA CLAVUS/CALLUS/CORN ACTINIC KERATOSIS DERMATITIS, ATOPIC INGUINAL HERNIA MILIA/MILIUM OSTEOPENIA POLYMYALGIA RHEUMATICA SCOLIOSIS AORTIC SCLEROSIS FEMORAL HERNIA Social History: ___ Family History: NC Physical Exam: Left lower extremity exam -dressing c/d/I -fires ___ -silt s/s/sp/dp/t nerve distributions -foot WWP Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. PredniSONE 2 mg PO DAILY 2. Chlorthalidone 12.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 30 mg SC QHS RX *enoxaparin 30 mg/0.3 mL ___t bedtime Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain don't drink/drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*30 Tablet Refills:*0 5. Senna 8.6 mg PO BID 6. PredniSONE 2 mg PO ONCE Duration: 1 Dose 7. PredniSONE 0.5 mg PO QAM 8. PredniSONE 1.5 mg PO QPM 9. Chlorthalidone 25 mg PO DAILY 10. PredniSONE 2 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left intertrochanteric hip 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 INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC// ___ yo F s/p mechanical fall on left side, +HS,-LOC TECHNIQUE: AP view of the pelvis and two views of the left femur COMPARISON: ___ pelvis and left hip radiographs.. FINDINGS: Left intertrochanteric femoral neck fracture is demonstrated with mild lateral displacement and varus angulation of the distal fracture fragment. Osseous structures are diffusely demineralized. No dislocation. Mild degenerative changes of both hips with joint space narrowing and subchondral sclerosis. Diffuse vascular calcifications are present. No diastases of the pubic symphysis or sacroiliac joints. Mild degenerative changes are noted in the lower lumbar spine. Visualized aspect of the left knee demonstrates no gross acute abnormality. Spiral tacks from prior hernia repair project over the right pelvis. IMPRESSION: Mildly displaced left intertrochanteric femoral neck fracture with mild varus angulation. Radiology Report INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC// ___ yo F s/p mechanical fall on left side, +HS,-LOC TECHNIQUE: Supine AP view of the chest COMPARISON: Chest radiograph ___ and chest CT ___ FINDINGS: Mild cardiac enlargement is re-demonstrated. Mediastinal and hilar contours are within normal limits. Pulmonary vasculature is normal. No focal consolidation, pleural effusion, or pneumothorax. No displaced fractures are evident. Mild scoliosis of the visualized thoracolumbar spine is unchanged. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC. Evaluation for intracranial hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 17.2 cm; CTDIvol = 46.7 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: No relevant prior imaging for comparison. FINDINGS: There is no evidence of intracranial hemorrhage, acute large territorial infarction, edema,or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical hypodensities are nonspecific, though likely sequela of chronic small vessel ischemic disease. There is no evidence of fracture. There is layering fluid and locules of air within the left maxillary sinus, which may represent sinusitis. Minimal 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. IMPRESSION: 1. No evidence of acute intracranial abnormality. 2. Layering fluid and locules of air within the left maxillary sinus, findings which may represent acute sinusitis and clinical correlation is suggested. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ yo F s/p mechanical fall on left side, +HS,-LOC. Evaluation for fracture. TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.1 s, 20.0 cm; CTDIvol = 22.6 mGy (Body) DLP = 452.4 mGy-cm. 2) Sequenced Acquisition 1.0 s, 4.1 cm; CTDIvol = 14.7 mGy (Body) DLP = 60.0 mGy-cm. Total DLP (Body) = 512 mGy-cm. COMPARISON: No relevant prior imaging for comparison. FINDINGS: Mild anterolisthesis of C2 on C3, C3 on C4, and C5 on C6, likely chronic and secondary to degenerative change.No acute fractures are identified. Extensive multilevel degenerative change is noted, including multilevel disc space narrowing most severe at C3-C4 and C4-C5 and fusion of the facet joints at these levels. Moderate multilevel anterior and posterior osteophytosis is demonstrated. Extensive pannus formation with calcification at the atlanto-axial region. A cyst is seen within the dens which is likely degenerative in etiology. Mild multilevel canal narrowing secondary to posterior disc/osteophyte complexes, most notably at C3-C4 and C5-C6. Mild right-sided neural foraminal narrowing at C3-C4, severe bilateral neural foraminal narrowing at C4-C5, severe bilateral neural foraminal narrowing at C5-C6, and moderate bilateral neural foraminal narrowing at C6-C7, secondary to uncovertebral osteophytes. There is no prevertebral soft tissue swelling. The thyroid gland is unremarkable. Partially visualized lung apices are notable for a 3 mm pulmonary nodule at the right upper lobe. IMPRESSION: 1. No evidence of acute fracture or traumatic malalignment. 2. Extensive multilevel degenerative change, most notably at C4-C5 and C5-C6. Multilevel subluxations likely degenerative in etiology. 3. Solitary 3 mm pulmonary nodule at the right upper lobe. As per the ___ society guidelines included below, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Radiology Report INDICATION: Fracture TECHNIQUE: 3 fluoroscopic spot images of the left hip COMPARISON: ___ FINDINGS: 3 fluoroscopic spot images of the left hip demonstrate a gamma nail construct transfixing a intertrochanteric femur fracture. There is good overall alignment. The total fluoroscopic time is 80.0 seconds. For further details please see the intraoperative note. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Hip fracture, s/p Fall Diagnosed with Displaced intertrochanteric fracture of left femur, init, Occ of rail trn/veh injured by fall in rail trn/veh, init temperature: 98.0 heartrate: 76.0 resprate: 18.0 o2sat: 100.0 sbp: 180.0 dbp: 72.0 level of pain: 3 level of acuity: 3.0

Started discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -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: 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. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: wbat lle

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right foot pain/ischemia Major Surgical or Invasive Procedure: 1. Realtime ultrasound-guided access to the left common femoral artery and placement of a ___ sheath. 2. Selective catheterization of the right peroneal artery, a third-order vessel. 3. Percutaneous transluminal angioplasty and stenting of the left common iliac artery using an 8 x 38 iCAST stent. 4. Abdominal aortogram. 5. Right lower extremity angiogram. 6. Percutaneous transluminal angioplasty and stenting of the left common iliac artery using an 8 x 38 iCAST stent. 7. Percutaneous transluminal angioplasty and stenting of the right external iliac artery using a 7 x ___ Innova stent. 8. Percutaneous transluminal angioplasty and stenting of the right peroneal artery and tibioperoneal trunk using a 3 mm x 38 mm Premier Rx coronary stent. 9. Closure of the left common femoral puncture site using an ___ Angio-Seal device. History of Present Illness: Mr. ___ is a ___ with history of ESRD on HD, DM, Hep C, PVD s/p right fem-BKpop bypass and left fem-AKpop bypass ___ ___ for a right ___ toe nonhealing ulcer and bilateral lower extremity rest pain, now presenting with acute worsening right foot pain. He was in his usual state until ___ days ago when he started noticing right greater than left calf pain. This morning he developed severe right foot pain and parasthesias with discoloration of his right ___ toes. He also noticed decreased foot and leg sensation up to the level of his midshin. He therefore presented to ___ for further evaluation. CTA was obtained at that time which showed occlusion of the right fem-BK pop bypass graft. Given these findings, he was started on heparin and transferred to ___ for furthervascular care. ROS: (+) per HPI (-) Denies fevers, chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: PMH: diabetes, ESRD on HD, Hep C, HTN, HLD PSH: - failed left radialcephalic and brachialcephalic fistulas, functioning right brachialcephalic fistula - right ___ toe ray amputation - simultaneous left fem-AK pop bypass and right fem-BKpop bypass Social History: ___ Family History: Mother - CAD Father - diabetes Physical Exam: Physical Exam at Discharge: VS: 98.0, 150/61, 82, 18, 100% RA HEENT: normocephalic atraumatic CV: RRR PULM: breathing comfortably on room air ABD: Soft, non-tender, no rebound or guarding Ext: right toes ___ cyanontic/insensate/cold, open ulcer on the dorsum of the foot with frank bloody ooze, calf tenderness, but soft Access: RUE AVF with bruit and thrills. Pulses: R: p/d/-/- L: p/d/-/d Pertinent Results: ___ 05:30AM BLOOD WBC-12.3* RBC-2.47* Hgb-7.8* Hct-24.0* MCV-97 MCH-31.6 MCHC-32.5 RDW-13.6 RDWSD-48.3* Plt ___ ___ 05:32PM BLOOD WBC-13.5* RBC-3.34* Hgb-10.6* Hct-31.7* MCV-95 MCH-31.7 MCHC-33.4 RDW-14.9 RDWSD-51.4* Plt ___ ___ 05:30AM BLOOD Glucose-139* UreaN-31* Creat-6.7*# Na-135 K-4.7 Cl-90* HCO3-27 AnGap-18 ___ 05:32PM BLOOD Glucose-156* UreaN-33* Creat-6.3* Na-133* K-7.2* Cl-87* HCO3-29 AnGap-17 ___ 05:30AM BLOOD Calcium-9.4 Phos-5.8* Mg-2.4 ___ ABI: Impression significant bilateral multi segmental, primarily tibial arteryvocclusive disease with severe flow deficit. ___ Veinous Duplex/Vein Mapping Findings duplex evaluations for both greater saphenous vein. The right isvpatent with suitable diameters. The left is patent but diminutive. Impression patent bilateral greater saphenous veins, diminutive on the left. Evaluate scanned worksheet Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 200 mg PO QHS 2. Albuterol Inhaler ___ PUFF IH Frequency is Unknown 3. Pantoprazole 20 mg PO Q24H 4. Nortriptyline 25 mg PO TID 5. Metoclopramide 5 mg PO QID 6. Lisinopril 5 mg PO DAILY 7. Januvia (SITagliptin) 100 mg oral DAILY 8. Carvedilol 25 mg PO DAILY 9. BusPIRone 10 mg PO BID 10. amLODIPine 10 mg PO DAILY 11. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain/headache Do not drink alcohol on this medication. RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours as needed Disp #*30 Tablet Refills:*1 2. Amoxicillin-Clavulanic Acid ___ mg PO Q24H RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth every 24 hours Disp #*14 Tablet Refills:*0 3. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*12 4. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth two times a day as needed Disp #*60 Capsule Refills:*0 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain Please do not drink alcohol or drive while on this medication. RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours as needed Disp #*30 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily as needed Refills:*0 8. Senna 8.6 mg PO BID:PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 1 tablet by mouth two times a day as needed Disp #*60 Tablet Refills:*0 9. sevelamer CARBONATE 1600 mg PO TID W/MEALS RX *sevelamer carbonate 800 mg 2 tablet(s) by mouth three times a day with meals Disp #*180 Tablet Refills:*3 10. Albuterol Inhaler ___ PUFF IH Q6H:PRN short of breath 11. amLODIPine 10 mg PO DAILY 12. Atorvastatin 40 mg PO QPM 13. BusPIRone 10 mg PO BID 14. Carvedilol 25 mg PO DAILY 15. Gabapentin 200 mg PO QHS 16. Januvia (SITagliptin) 100 mg oral DAILY 17. Lisinopril 5 mg PO DAILY 18. Metoclopramide 5 mg PO QID 19. Nortriptyline 25 mg PO TID 20. Pantoprazole 20 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: critical right lower limb ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - partially weight bearing Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with limb ischemia, to OR// eval for infiltrate COMPARISON: None FINDINGS: PA and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Aortic calcification noted. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Radiology Report Study venous duplex extremity. Reason bypass Findings duplex evaluations for both greater saphenous vein. The right is patent with suitable diameters. The left is patent but diminutive. Impression patent bilateral greater saphenous veins, diminutive on the left. Evaluate scanned worksheet Radiology Report Study arterial extremity rest. Reason gangrene. Findings Doppler evaluation was performed of both lower extremities. On the right Doppler waveforms are biphasic femoral levels only. There monophasic below. Pulse volume recordings show significant drop-off in the ankle and are flat line at the metatarsal. The left waveforms are biphasic at the femoral and popliteal. There monophasic below. Pulse volume recordings show significant drop-off. The toe pressure is 24. Impression significant bilateral multi segmental, primarily tibial artery occlusive disease with severe flow deficit. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: R Foot pain, Transfer Diagnosed with Pain in right ankle and joints of right foot, Other disorder of circulatory system temperature: 98.4 heartrate: 90.0 resprate: 16.0 o2sat: 100.0 sbp: 180.0 dbp: 82.0 level of pain: 4 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ with worsening lower extremity pain and critical limb ischemia due to a clot in your prior graft site. You underwent thrombectomy or removal of clot in your prior graft and peroneal angioplasty or ballooning of one of your arteries. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: MEDICATION: • Take Aspirin 325mg (enteric coated) once daily • If instructed, take Plavix (Clopidogrel) 75mg once daily • Continue all other medications you were taking before surgery, unless otherwise directed • You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: • Elevate your leg above the level of your heart with pillows every ___ hours throughout the day and night • Avoid prolonged periods of standing or sitting without your legs elevated • It is normal to feel tired and have a decreased appetite, your appetite will return with time • Drink plenty of fluids and eat small frequent meals • It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing • To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: • When you go home, you may walk and use stairs • You may shower (let the soapy water run over groin incision, rinse and pat dry) • Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area • No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) • After 1 week, you may resume sexual activity • After 1 week, gradually increase your activities and distance walked as you can tolerate • No driving until you are no longer taking pain medications CALL THE OFFICE FOR: ___ • Numbness, coldness or pain in lower extremities • Temperature greater than 101.5F for 24 hours • New or increased drainage from incision or white, yellow or green drainage from incisions • Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) • Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office ___. If bleeding does not stop, call ___ for transfer to closest Emergency Room. You are being discharged home with visiting nursing and home physical therapy. If at any point this is too difficult, you have been accepted at the following facility ___ Please call ___ admission to see if there is still a bed: ___. If one is available they have accepted your admission.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left ankle pain Major Surgical or Invasive Procedure: Left tibia IMN History of Present Illness: ___ w/ hx of L ACL rupture s/p repair ___ w/ Dr. ___ L ankle pain after motorcycle accident. He was taking a turn when he hit a patch of sand and fell onto his L side with his bike landing on top of him. He has immediate pain in L ankle and was unable to bear weight. Denies weakness or numbness. No LOC or headstrike. Denies pain in other locations. Past Medical History: - L ACL rupture s/p repair ___ w/ Dr. ___ ___ History: ___ Family History: NC Physical Exam: In general the patient is an average aged male in NAD Calm and comfortable AVSS Left lower extremity: Skin intact + Edema and ecchymosis Tenderness to palpation over medial and lateral malleoli Ankle ROM limited ___ pain Full, painless AROM/PROM of hip and knee ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Pertinent Results: ___ 04:54PM ___ PTT-26.8 ___ ___ 04:20PM GLUCOSE-98 UREA N-18 CREAT-1.0 SODIUM-133 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-28 ANION GAP-11 ___ 04:20PM estGFR-Using this ___ 04:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:20PM WBC-10.2 RBC-4.87 HGB-15.2 HCT-44.6 MCV-92 MCH-31.3 MCHC-34.1 RDW-12.6 ___ 04:20PM NEUTS-84.8* LYMPHS-9.9* MONOS-4.6 EOS-0.3 BASOS-0.4 ___ 04:20PM PLT COUNT-228 Medications on Admission: See OMR. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe SC QPM Disp #*14 Syringe Refills:*0 Discharge Disposition: Home Discharge Diagnosis: left distal third tibia fracture & ___ fibula fracture Discharge Condition: Pt was A&Ox3 and able to ambulate with crutches. His vital signs were stable, pain controlled without nausea and tolerating PO's Followup Instructions: ___ Radiology Report LEFT TIBIA, FIBULA AND ANKLE FILMS: ___. HISTORY: ___ male with left ankle pain status post MVC. FINDINGS: Frontal and lateral views of the left knee. Frontal and lateral views of the proximal and distal left tibia and fibula. Postoperative changes of prior ACL repair are seen. There are acute fractures identified through the tibia and fibula. There is a comminuted proximal left tibial fracture with mild anterior angulation of the main fracture fragment with respect to the proximal fibula. Acute obliquely oriented distal left tibial diaphyseal fracture is seen with approximately 1.4 cm of lateral displacement of the distal fracture fragment. Degenerative changes are partially visualized at the left knee. IMPRESSION: Acute fractures through the proximal left fibula and distal left tibia as above. Radiology Report PORTABLE CHEST: ___. HISTORY: ___ male pre-op chest x-ray. COMPARISON: None. FINDINGS: Single AP view of the chest. The lungs are clear. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormality is identified. IMPRESSION: No acute cardiopulmonary process. Radiology Report LEFT TIBIA AND FIBULA FILMS: ___ HISTORY: ___ male with left tib-fib fracture, status post reduction. COMPARISON: Films from earlier the same day. FINDINGS: Frontal and lateral views of the proximal and distal left tibia and fibula demonstrate comminuted fractures of the proximal left fibula and oblique fractures through the distal left tibia. There has been no significant interval change in the degree of lateral displacement of the largest distal tibial fracture fragment. Overlying cast obscures fine bony detail. Post-operative changes of prior ACL repair are again noted. Radiology Report STUDY: Left tib-fib, ___. CLINICAL HISTORY: Patient with tibial fracture, status post fixation. FINDINGS: Comparison is made to previous study from ___. There has been placement of an intramedullary rod and proximal and distal interlocking screws fixating an oblique fracture through the left distal tibial shaft. There is also a fracture involving the proximal fibular shaft with butterfly fragment. There is improvement in anatomic alignment and no signs of hardware-related complications. The total intraservice fluoroscopic time was 270 seconds. Please refer to the operative note for additional details. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: L Ankle injury, MOTORCYCLE ACCIDENT Diagnosed with FX ANKLE NOS-CLOSED, FX UPPER END FIBULA-CLOS, MV TRAFF ACC NEC-MOCYCL temperature: 98.6 heartrate: 72.0 resprate: 18.0 o2sat: 100.0 sbp: 132.0 dbp: 78.0 level of pain: 3 level of acuity: 2.0

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks ACTIVITY AND WEIGHT BEARING: - WBAT LLE Physical Therapy: - WBAT LLE Treatments Frequency: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get Air Cast Boot wet

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: minoxidil Attending: ___. Chief Complaint: subtherapeutic INR Major Surgical or Invasive Procedure: None. History of Present Illness: ___ h/o HTN, DMII, ESRD on HD MWF via RUE AV fistula, asthma, PVD, with recent dx of RUE axillary DVT who presents for subtherapeutic INR. Of note patient was recently admitted for RUE swelling and was found to have axillary vein DVT. Despite history of GI bleed he was started on warfarin. He also had a Fistulogram on ___ with high grade stenosis of outflow tract which was fixed with balloon angioplasty. The patient presents today for low INR. He had INR of 1.38 and was sent for admission from rehab for heparin bridge. He was referred in when ___ was trialing lovenox for bridge despie ESRD. The patient denies any new chest pain no cough no lightheadedness new hemoptysis or any progression of the symptoms from his baseline. INR recently: ___: 1.38 ___: 1.47 ___: 1.4 ___: 2.3 ___: 2.6 In the ED, initial vitals were: 96.6 88 149/97 24 100% nasal - Labs notable for: Trop 0.07, K 5.4 but hemolysed Troponin 0.07 - Patient was given: IV heparin ggt, duoneb - Vitals prior to transfer: 97.4 87 144/104 22 100% Nasal Cannula Unfortunately patient arrived on floor at 6 am and was unable to obtain ___ interpreter. PAtient however appeared to be in no distress. With phone interpreter he did appear to be AAO to person and place; he reported having baseline body aches he gets before HD. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: 1. Benign Hypertension 2. Type 2 Diabetes 3. Stage V chronic kidney disease from diabetic nephropathy 4. Hx of strokes ___ and ___ -> R arm and leg weakness with slurred speech intermittently 5. Asthma 6. Hypercholesterolemia. 7. PVD 8. Seizures - complex partial 9. Hx of DVT/PE in ___ 10. Schizophrenia 11. s/p L CEA 12. Left-to-right femoral-to-femoral bypass with PTFE, Right femoral endarterectomy with profundoplasty ___ 13. left arm AV fistula placement on ___ -> occluded left brachial artery -> emergent thrombectomy of the left brachial artery on ___ 14. Ischemic colitis which occurred due to hypotension during dialysis 15. Diverticulosis 16. Fistulogram s/p angioplasty (___) 17. Right axillary DVT ___ Social History: ___ Family History: Mother died at age ___ and father died at a young age of unknown cause, sister died during childbirth in ___. Physical Exam: ADMISSION PHYSICAL EXAM ======================= PHYSICAL EXAM: Vital Signs: HR 100 BP 179/91 T 97.3 R 20 100 % ion 3 L NC General: Alert, oriented, moving around, in mild distress, slightly SOB HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: irregular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally over anterior chest, bibasilar crackles posterior chest Abdomen: Soft, non-tender, slightly 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: moving all extremeities DISCHARGE PHYSICAL EXAM ======================= Vital Signs: 97.8 106/62 (106-169/62-76) 77 (75-82) ___ on RA General: Alert, oriented, at HD, lying comfortably in bed HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: irregular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally over anterior chest, diminished lung sounds at R lung base with egophony, dullness to percussion, and slight rhonchi- overall improvement w/fewer rhonchi today. Abdomen: Soft, non-tender, slightly distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Significant swelling of right upper extremity. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Trace edema in bilateral lower extremities. Pertinent Results: ADMISSION LABS: =============== ___ 07:32PM PTT-83.9* ___ 10:16AM ___ PTT-44.4* ___ ___ 02:47AM GLUCOSE-161* UREA N-40* CREAT-5.0*# SODIUM-133 POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-22 ANION GAP-22* ___ 02:47AM estGFR-Using this ___ 02:47AM CK(CPK)-124 ___ 02:47AM CK-MB-3 cTropnT-0.07* ___ 02:47AM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-1.9 ___ 02:47AM WBC-7.3 RBC-3.52* HGB-11.0* HCT-33.3* MCV-95 MCH-31.3 MCHC-33.0 RDW-14.6 RDWSD-50.1* ___ 02:47AM NEUTS-69.5 LYMPHS-13.3* MONOS-13.5* EOS-3.0 BASOS-0.4 IM ___ AbsNeut-5.09 AbsLymp-0.97* AbsMono-0.99* AbsEos-0.22 AbsBaso-0.03 ___ 02:47AM PLT COUNT-199 MICROBIOLOGY: ============= Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. ___ 1:43 pm SPUTUM Source: Expectorated. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. MRSA SCREEN (Final ___: No MRSA isolated. Streptococcus pneumoniae Antigen Detection (___): Pending IMAGING: ======== Chest PA&LAT (___): FINDINGS: Again seen is a right subclavian stent with collapse of the medial aspect of the stent. There are diffusely prominent reticular markings, compatible with mild interstitial edema, unchanged compared to radiographs from ___. There is a small, layering right pleural effusion, decreased from prior. There is no left pleural effusion. The cardiomediastinal silhouette and bilateral hilar contours remain unchanged. There is no pneumothorax. There is a healed fracture of the left midclavicle. IMPRESSION: Mild interstitial edema, unchanged compared to radiographs of the chest from ___. Small, layering right pleural effusion, decreased from prior. Chest portable (___): FINDINGS: Cardiac silhouette is moderately enlarged. Moderate pulmonary edema persists. Small pleural effusions are suspected. Right subclavian vascular stents with kinking is unchanged. No acute osseous abnormalities. IMPRESSION: Cardiomegaly with pulmonary edema and small bilateral effusions. Chest portable (___): FINDINGS: The cardiac silhouette is enlarged however to a lesser degree than prior. There is decreased pulmonary edema, now mild to moderate in extent. There are small bilateral pleural effusions. Opacities in the right lower lung are more conspicuous than on the prior examination. The appearance of a right subclavian stent is unchanged. IMPRESSION: Persisting pulmonary edema, and slightly decreased in extent since prior. Increased right basilar opacities may reflect atelectasis and/or consolidation. DISCHARGE AND PERTINENT LABS: ============================= ___ 07:15AM BLOOD WBC-11.6* RBC-3.48* Hgb-10.8* Hct-32.3* MCV-93 MCH-31.0 MCHC-33.4 RDW-14.3 RDWSD-48.2* Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-203* UreaN-81* Creat-7.1*# Na-135 K-4.2 Cl-94* HCO3-19* AnGap-26* ___ 07:15AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.8 Radiology Report EXAMINATION: Chest radiographs from ___ INDICATION: ___ year old man with ESRD and RUE DVT now with hypoxia and new O2 requirement// pneumonia vs. pulm edema TECHNIQUE: AP radiograph of the chest was performed COMPARISON: Chest radiographs from ___ FINDINGS: Again seen is a right subclavian stent with collapse of the medial aspect of the stent. There are diffusely prominent reticular markings, compatible with mild interstitial edema, unchanged compared to radiographs from ___. There is a small, layering right pleural effusion, decreased from prior. There is no left pleural effusion. The cardiomediastinal silhouette and bilateral hilar contours remain unchanged. There is no pneumothorax. There is a healed fracture of the left midclavicle. IMPRESSION: Mild interstitial edema, unchanged compared to radiographs of the chest from ___. Small, layering right pleural effusion, decreased from prior. Radiology Report INDICATION: ___ year old man with HTN, DMII, ESRD on HD, asthma, RUE AV fistula and RUE DVT here w/ SOB, crackles and wheezes// fluid overload? TECHNIQUE: Single portable view of the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Cardiac silhouette is moderately enlarged. Moderate pulmonary edema persists. Small pleural effusions are suspected. Right subclavian vascular stents with kinking is unchanged. No acute osseous abnormalities. IMPRESSION: Cardiomegaly with pulmonary edema and small bilateral effusions. Radiology Report INDICATION: ___ year old man with hypoxia, w/volume overload and c/f viral bronchitis.// evaluate for consolidation, volume overload TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The cardiac silhouette is enlarged however to a lesser degree than prior. There is decreased pulmonary edema, now mild to moderate in extent. There are small bilateral pleural effusions. Opacities in the right lower lung are more conspicuous than on the prior examination. The appearance of a right subclavian stent is unchanged. IMPRESSION: Persisting pulmonary edema, and slightly decreased in extent since prior. Increased right basilar opacities may reflect atelectasis and/or consolidation. Gender: M Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Subtherapeutic INR Diagnosed with Acute embolism and thrombosis of deep veins of r up extrem temperature: 96.6 heartrate: 88.0 resprate: 24.0 o2sat: 100.0 sbp: 149.0 dbp: 97.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you! Why you were admitted: -You were admitted because blood work showed that you were not receiving sufficient anticoagulation with the dose of warfarin you were taking. What we did for you: - We changed the dose of your warfarin so that you are being anticoagulated sufficiently. - You also became short of breath during your hospitalization, and we determined that this was likely because you had fluid in your lungs, a pneumonia, and exacerbation of your asthma. We removed the fluid with hemodialysis, treated your pneumonia with antibiotics, and treated you with steroids for your asthma. You improved after receiving these treatments. What to do when you leave: - You will need to complete a course of antibiotics (levofloxacin) for your pneumonia, which is scheduled to end on ___. - Please take all of your other medications as directed. - Please also make sure to set up a follow-up appointment with your primary care physican after your discharge from your rehabilitation facility.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left-sided abdominal pain, low-grade fevers Major Surgical or Invasive Procedure: NA History of Present Illness: ___ with a history of hemoglobin SC, hypertension who presents with 2 days of left upper quadrant abdominal pain. She was seen in ___ on three days prior to presentation for vaso-occlusive crisis of the left arm and was given IV narcotics with improvement in her pain and was discharged with oxycodone. The next day she developed acute onset of left upper quadrant abdominal pain. She has had this pain in the past that was related to her spleen. Her pain is worse now and associated with nausea and an episode of non-bilious non-bloody vomiting. She had a temperature to 100. She reports that breathing or moving worsens the pain. She denies any cough, urinary symptoms, hip pain. She does endorse lower back pain over the last few weeks. She is followed by Dr. ___ in the hematology department for her sickle cell anemia. In the ED, initial VS were: T 97.8, HR 76, BP 143/79, RR 18, 100% RA Exam notable for: Physical exam shows left upper quadrant tenderness with no rebound or guarding. Labs showed: - CBC: WBC 18.2 (86.6%n), Hgb 7.9, Plt 164 - Lytes: 139 / 99 / 14 ------------- 105 3.5 \ 25 \ 1.3 - Ret-Aut: 4.9, Abs-Ret: 0.13 - AST 98, ALT 65, AP 85, Tbili 1.5, Alb 4.2, Lip 15 - Lactate:1.0 - Flu swab negative Imaging showed: - CT a/p w/ contrast with: 1. Bilateral lower lobe basal segment mixed ground-glass and consolidative opacities, possibly atelectasis, developing infection, or sequela of acute chest syndrome. 2. Enlarged, heterogeneously enhancing spleen. Difficult to exclude areas of developing infarction. 3. Cholelithiasis. 4. Bilateral femoral head avascular necrosis without evidence of collapse. Patient received: ___ 12:22 IV Ondansetron 4 mg ___ 12:22 IVF NS 1000 mL ___ 12:22 IV HYDROmorphone (Dilaudid) ___ 12:52 IV HYDROmorphone (Dilaudid) .5 mg ___ 13:50 IV Piperacillin-Tazobactam 4.5 g ___ 14:57 IV Vancomycin 1000 mg ___ 16:16 IV Azithromycin 500mg ___ 16:16 IV HYDROmorphone (Dilaudid) .5 mg ___ 16:16 IV Ondansetron 4 mg ___ 17:36 IV Ondansetron 4 mg ___ 19:00 PO Hydroxyurea 500 mg ___ 20:12 IV HYDROmorphone (Dilaudid) .5 mg Transfer VS were: On arrival to the floor, patient reports improvement in her pain that is mostly located in her lower back Past Medical History: -- Hemoglobin SC disease -- Hypertension -- Low-grade cervical dysplasia with high-risk HPV -- Bilateral knee pain -- Gonococcal cervicitis (teenager) -- Lymphedema -- Depression SURGICAL HISTORY: -- Tonsillectomy -- Right neck excisional lymph node biopsy (benign) -- Postpartum tubal ligation -- Prior colposcopies and cryosurgery Social History: ___ Family History: Per past notes: - Father with prostate cancer, sickle trait. - No known history of diabetes or heart disease. Physical Exam: ADMISSION EXAM: =============== VS: 99.6 PO 130 / 78 L Lying 93 18 93 Ra GENERAL: NAD HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple 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 EXAM: =============== 24 HR Data (last updated ___ @ 1150) Temp: 97.9 (Tm 98.9), BP: 145/80 (mannual) (145-171/80 (mannual)-97), HR: 76 (65-78), RR: 19 (___), O2 sat: 96% (93-97) GENERAL: sitting up in bed, appears comfortable and bright HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: mild basilar crackles, breathing comfortably on room air ABDOMEN: normoactive bowel sounds, TTP in LUQ with no rebound or guarding, moving in bed with no discomfort EXTREMITIES: BLE warm with no edema Pertinent Results: ADMISSION LABS: =============== ___ 12:00PM BLOOD WBC-18.2* RBC-2.68* Hgb-7.9* Hct-21.7* MCV-81* MCH-29.5 MCHC-36.4 RDW-14.3 RDWSD-41.3 Plt ___ ___ 12:00PM BLOOD Neuts-86.6* Lymphs-3.9* Monos-8.7 Eos-0.2* Baso-0.2 NRBC-0.9* Im ___ AbsNeut-15.77* AbsLymp-0.72* AbsMono-1.58* AbsEos-0.04 AbsBaso-0.04 ___ 12:00PM BLOOD Plt ___ ___ 12:00PM BLOOD Ret Aut-4.9* Abs Ret-0.13* ___ 12:00PM BLOOD Glucose-105* UreaN-14 Creat-1.3* Na-139 K-3.5 Cl-99 HCO3-25 AnGap-15 ___ 12:00PM BLOOD ALT-65* AST-98* AlkPhos-85 TotBili-1.5 ___ 12:00PM BLOOD Lipase-15 ___ 12:00PM BLOOD Albumin-4.2 ___ 12:12PM BLOOD Lactate-1.0 INTERIM LABS: =============== ___ 06:20AM BLOOD ALT-63* AST-83* LD(LDH)-1209* AlkPhos-92 TotBili-1.2 ___ 06:54AM BLOOD ALT-90* AST-107* AlkPhos-121* ___ 06:50AM BLOOD ZINC (SPIN NVY/EDTA)-Test 67 (60-130 mcg/dL) DISCHARGE LABS: =============== ___ 06:55AM BLOOD WBC-10.6* RBC-3.06* Hgb-9.4* Hct-26.3* MCV-86 MCH-30.7 MCHC-35.7 RDW-17.1* RDWSD-53.0* Plt ___ ___ 06:55AM BLOOD Glucose-87 UreaN-8 Creat-0.8 Na-142 K-4.5 Cl-100 HCO3-30 AnGap-12 ___ 06:55AM BLOOD ALT-76* AST-55* LD(LDH)-1007* AlkPhos-156* TotBili-0.9 MICROBIO: ========= Blood culture and urine cultures no growth ___ IMAGING: ======== CT abdomen and pelvis with contrast ___: 1. Bilateral lower lobe basal segment mixed ground-glass and consolidative opacities, possibly atelectasis, developing infection, or sequela of acute chest syndrome. 2. Enlarged, heterogeneously enhancing spleen. Difficult to exclude areas of developing infarction. 3. Cholelithiasis. 4. Bilateral femoral head avascular necrosis without evidence of collapse. CXR PA&LAT ___: Left lower lobe consolidative opacity concerning for pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. PENDING ======== Parvovirus antibodies and PCR Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydroxyurea 500 mg PO BID 2. OxyCODONE (Immediate Release) 5 mg PO TID 3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 4. Naproxen 250 mg PO Q12H:PRN Pain - Mild 5. FLUoxetine 20 mg PO DAILY 6. FoLIC Acid 5 mg PO DAILY 7. LORazepam 1 mg PO QHS:PRN insomnia 8. Vitamin D 1000 UNIT PO DAILY 9. maca (bulk) miscellaneous DAILY 10. turmeric root extract ___ mg oral DAILY 11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Polyethylene Glycol 17 g PO BID constipation RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth twice a day Refills:*0 2. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*10 Tablet Refills:*0 3. Acetaminophen 1000 mg PO Q8H 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe Do not take with Ativan. RX *oxycodone 5 mg 1 tablet(s) by mouth q4h PRN pain Disp #*20 Tablet Refills:*0 5. FLUoxetine 20 mg PO DAILY 6. FoLIC Acid 5 mg PO DAILY 7. Hydroxyurea 500 mg PO BID 8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 9. LORazepam 1 mg PO QHS:PRN insomnia Do not take with oxycodone. 10. maca (bulk) miscellaneous DAILY 11. turmeric root extract ___ mg oral DAILY 12. Vitamin D 1000 UNIT PO DAILY 13.Outpatient Lab Work ICD 9 282.62 Labs to be drawn: CBC, LFTs/Tbili, LDH, Chem-7. Fax results to: ___ ___ Discharge Disposition: Home Discharge Diagnosis: Sickle cell crisis Splenic infarct Pneumonia vs. Acute chest syndrome Bilateral avascular necrosis of the femoral head Transaminitis Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with chest pain// evaluate for intra-thoracic process TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. New consolidative opacity in the left lower lobe is concerning for pneumonia. The right lung is clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Left lower lobe consolidative opacity concerning for pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. Radiology Report EXAMINATION: CT abdomen/pelvis INDICATION: ___ with LUQ pain, sickle cell disease. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 22.7 mGy (Body) DLP = 1,203.2 mGy-cm. Total DLP (Body) = 1,210 mGy-cm. COMPARISON: ___ chest CTA FINDINGS: LOWER CHEST: Mixed ground-glass and consolidative opacities in the lower lobe basal segments. Heart size appears mildly enlarged. There may be a tiny left pleural effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. No evidence of focal lesions. The portal veins are patent. 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. No peripancreatic stranding. SPLEEN: Spleen remains enlarged measuring up to 16.1 cm in craniocaudal dimension, but heterogeneously. No discrete focal lesion is identified. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Left kidney is compressed by the adjacent enlarged spleen. The kidneys are otherwise of symmetric size with normal nephrogram. No evidence of concerning renal lesions or hydronephrosis. GASTROINTESTINAL: Stomach is unremarkable. Small bowel loops are unremarkable. No bowel obstruction. Diverticulosis of the colon is noted, without evidence of wall thickening and fat stranding. The appendix is normal. PELVIS: The urinary bladder is unremarkable. No free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is anteverted. There is a small calcification in the right adnexa, possibly a small dermoid. LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. VASCULAR: No abdominal aortic aneurysm. No significant atherosclerotic disease. BONES/SOFT TISSUES: There is no aggressive osseous lesion or acute fracture. Incidental note is made of bilateral avascular necrosis of the femoral heads without evidence of collapse. Small, fat containing umbilical hernia. IMPRESSION: 1. Bilateral lower lobe basal segment mixed ground-glass and consolidative opacities, possibly atelectasis, developing infection, or sequela of acute chest syndrome. 2. Enlarged, heterogeneously enhancing spleen. Difficult to exclude areas of developing infarction. 3. Cholelithiasis. 4. Bilateral femoral head avascular necrosis without evidence of collapse. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Pneumonia, unspecified organism temperature: 97.8 heartrate: 76.0 resprate: 18.0 o2sat: 100.0 sbp: 143.0 dbp: 79.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a pleasure to take care of you at ___ ___. WHY YOU WERE HERE: - You came into the hospital because you had left-sided abdominal pain and some shortness of breath, likely representing a sickle cell event. WHAT WE DID FOR YOU: - We did imaging of your abdomen and found that you had an enlarged spleen with impaired blood flow likely from sickling of blood cells. This was most likely causing your abdominal pain. There was no need for surgery for this. - You were also seen by the hematology (blood) team. - We gave you blood transfusions, IV fluid, oxygen and worked on controlled your pain. - You were also found on imaging to have imparied blood flow to your hip joints (called "avascular necrosis of the femoral head"): we contacted orthopedic surgery, and they decided that there was no intervention at this point because you had no symptoms. You have an appointment with them scheduled below. - Of note, we also found you have gallstones. This can happen in sickle cell disease. Please talk to your primary care doctor about this. There is nothing to do for it right now. WHAT TO DO WHEN YOU LEAVE THE HOSPITAL: - Please follow up with your doctors as ___ below. - Please be sure to take the hydroxyurea, as this can help prevent sickle cell events. - Please have your labs re-checked next ___ before you see your primary care doctor, we have given you a lab slip. - Please make sure you take senna and miralax while you are taking pain medication, this will prevent constipation! - We noticed your blood pressures are high. Please have your primary care doctor check this and discuss if you need further evaluation or treatment. - Please do not take oxycodone and drive, and do not take oxycodone and drink alcohol. Please do not take it with lorazepam (also called Ativan) as this can cause dangerous sedation and respiratory depression. PLEASE CALL OR VISIT YOUR DOCTOR IF YOU DEVELOP: - Worsening abdominal pain. - Worsening shortness of breath. - Fevers, chills, lightheadedness. - Any symptoms that concern you. We wish you all the best! Sincerely, Your Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Procainamide / Amiodarone / lisinopril / All procaine drug / Sulfa (Sulfonamide Antibiotics) / Codeine Attending: ___. Chief Complaint: Constipation Rectal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with a history of atrial fibrillation on warfarin, cataracts c/b bilateral vision loss, significant anxiety, polyneuropathy, HTN, HLD, OA, HFpEF, with recent admission for rectal pain and severe constipation (discharged on ___, now representing after numerous telephone calls to outpatient providers with ongoing concerns for severe rectal pain/constipation. Of note, patient was seen in the ED on ___nd was found to have a positive udip and CT positive for hydronephrosis for which she was prescribed nitrofurantoin and tramadol for pain. She was also found to have a large stool burden and manual disimpaction was offered but refused. She later returned to the ED on ___ with complaints of rectal pain and request for disimpaction, which she later refused. She was subsequently admitted to HMED on ___. While on the floor, patient had a spontaneous large BM with persistent stool ball in rectum seen on repeat KUB. She refused oral medications, excepting magnesium citrate but later allowed Colace, lactulose and PRN magnesium citrate which led to improvement in her symptoms. She was also found to have urinary retention with an associated painful, distended bladder which, when scanned, demonstrated >1L of urine. Multiple catheter placements were attempted but these failed and catheterization was not reattempted after goals of care discussion when this was deemed to be outside goals of care. For patients UTI found during her initial ED presentation on ___, she was treated with ciprofloxacin x 3 days. She was discharged home after improvement in constipation/rectal pain and after goals of care conversation with patient status of DNR/DNI confirmed. Since discharge, patient has contacted PCP office for rectal pain, constipation and dysuria. Patient has attempted five doses of lactulose, without additional medications, without relief of pain or bowel movement since ___. In the ED today (___), patient was afebrile, mildly hypertensive to 150's/90's, otherwise HDS and satting well on RA. She refused all bowel medications and IVF. GI was consulted who recommended inpatient management for titration of bowel regimen medications and r/o of other contributers to abdominal pain/concern for infectious process. CT scan was performed which demonstrated large pancolonic stool burden, without obstruction, and mild bilateral hydronephrosis c/w prior imaging studies. On the floor, patient states she has fluctuating "burning, squeezing pain" that is in her abdomen. She notes this pain "moves around" but when asked to specify she states the pain is all over. Of note, patient's daughter, ___, is present, who is quite distressed regarding her mother's constipation and pain and feels it has not been treated adequately, with prescribed pain medications likely contributing. She is happy that her mother has been admitted and that she is now working with the GI specialists. She brought record of her mother's intake since her ___ discharge and she did receive 30mL lactulose per day, was eating well but did not drink more than 16 oz a day. She is quite concerned that her mother's temperature is ~99 degrees as she says her mother always runs ~97 degrees. Past Medical History: Atrial fibrillation (on warfarin) Cataracts ___ c/b bilateral vision loss and suspected ___ syndrome Polyneuropathy HTN HLD OA ?BPPV HFpEF Asthma IBS Social History: ___ Family History: Unable to obtain as patient declines. Physical Exam: ADMISSION EXAM: ================= VITALS: Reviewed in ___ GENERAL: Alert and intermittently moaning on exam EYES: Anicteric ENT: Moist mucous membranes CV: irregularly irregular rhythm; no M/R/G RESP: Breathing is non-labored GI: Soft, mildly distended, hyperactive bowel sounds, no guarding/rebound, no pain to palpation; patient refused rectal exam GU: Pain to palpation of suprapubic area with notable bladder distension MSK: Moves all extremities SKIN: No rashes or ulcerations noted PSYCH: Frustrated DISCHARGE EXAM: ================= Temp: 98.4 PO BP: 111/66 HR: 89 RR: 18 O2 sat: 96% O2 delivery: RA GENERAL: Elderly cachectic women, appears to be in NAD this AM CV: pt refused exam RESP: breathing comfortably with no accessory muscle use GI: pt refused exam; abdomen appears nondistended rectal: pt refused exam SKIN: pt refused exam MSK: pt refused exam Neuro: pt refused exam Pertinent Results: ___ 07:04AM BLOOD WBC-4.5 RBC-3.72* Hgb-11.0* Hct-35.2 MCV-95 MCH-29.6 MCHC-31.3* RDW-14.6 RDWSD-51.3* Plt ___ ___ 07:11AM BLOOD Neuts-71.7* Lymphs-14.3* Monos-11.0 Eos-2.2 Baso-0.2 Im ___ AbsNeut-3.31 AbsLymp-0.66* AbsMono-0.51 AbsEos-0.10 AbsBaso-0.01 ___ 07:04AM BLOOD ___ ___ 07:04AM BLOOD Glucose-93 UreaN-21* Creat-0.5 Na-140 K-3.8 Cl-99 HCO3-31 AnGap-10 ___ 07:04AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1 Discharge Labs: ================ ___ 05:50AM BLOOD WBC-3.8* RBC-3.07* Hgb-9.2* Hct-29.6* MCV-96 MCH-30.0 MCHC-31.1* RDW-14.7 RDWSD-52.1* Plt ___ ___ 05:50AM BLOOD ___ PTT-33.7 ___ ___ 05:50AM BLOOD Glucose-105* UreaN-22* Creat-0.5 Na-142 K-4.6 Cl-106 HCO3-28 AnGap-8* ___ 07:11AM BLOOD ALT-9 AST-15 AlkPhos-60 TotBili-0.5 ___ 05:50AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem 30 mg PO TID:PRN palpitations 2. Warfarin 1 mg PO DAILY16 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Docusate Sodium 200 mg PO DAILY 5. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Rectal pain 6. Lactulose 30 mL PO DAILY 7. LORazepam 0.5 mg PO Q4H:PRN anxiety 8. Magnesium Citrate 300 mL PO DAILY:PRN third line constipation 9. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q6H:PRN Pain - Severe 10. Albuterol Inhaler 1 PUFF IH Q4H:PRN shortness of breath 11. nystatin 100,000 unit/gram topical Q12H 12. TraMADol 50 mg PO Q8H:PRN Pain - Moderate 13. NIFEdipine (Extended Release) 30 mg PO ONCE SBP >180 Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Polyethylene Glycol 17 g PO BID titrate intake as needed for regular bowel movements 4. Thiamine 100 mg PO DAILY 5. Warfarin 2 mg PO DAILY16 FOLLOW UP WITH PCP ___ ___ ON ___ for dosage adjustments. RX *warfarin 2 mg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Albuterol Inhaler 1 PUFF IH Q4H:PRN shortness of breath 8. Docusate Sodium 200 mg PO DAILY 9. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Rectal pain 10. Lactulose 30 mL PO DAILY 11. LORazepam 0.5 mg PO Q4H:PRN anxiety 12. Magnesium Citrate 300 mL PO DAILY:PRN third line constipation 13. nystatin 100,000 unit/gram topical Q12H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Constipation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis without contrast. INDICATION: ___ woman with severe constipation, tympanitic abdomen. NO_PO contrast. Eval for stool burden or evidence of large bowel obstruction. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.9 s, 54.1 cm; CTDIvol = 11.1 mGy (Body) DLP = 600.3 mGy-cm. Total DLP (Body) = 600 mGy-cm. COMPARISON: CT torso from ___ and abdominopelvic CT from outside hospital dated ___. FINDINGS: LOWER CHEST: There heart is slightly enlarged and aortic calcifications are again demonstrated, similar to the previous study. Small bilateral pleural effusions are noted, associated with dependent atelectasis similar to prior. No focal consolidation is present. ABDOMEN: HEPATOBILIARY: A 1.2 cm circumscribed hypodensity in segment 5 has not significantly changed, probably represents a hepatic cyst (02:15). Otherwise, the liver demonstrates homogeneous attenuation throughout. There is no evidence of new focal lesions within the limitations of an unenhanced scan. Central intrahepatic biliary ductal dilatation is unchanged and may be related to post cholecystectomy state. The gallbladder is not visualized. PANCREAS: Pancreatic atrophy with diffuse fatty replacement is again demonstrated. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: A left parapelvic cyst is largely unchanged. Otherwise, the kidneys are of normal and symmetric size. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is mild bilateral hydronephrosis, unchanged. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. A large pancolonic stool burden, including the rectum, is present. The appendix is not visualized. PELVIS: The urinary bladder is distended and an air locule is present within lumen. High-density material is seen in the dependent portion of the urinary bladder, similar to the previous study, could represent small stones. The distal ureters are unremarkable. There is no free fluid in the pelvis. 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. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: Multilevel degenerative changes without worrisome osseous lesions or acute fracture. SOFT TISSUES: Diffuse anasarca is unchanged. Otherwise, the abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No sequela of trauma based on unenhanced scan. 2. Large pancolonic stool burden, including large stool ball in the rectum, without evidence of obstruction. 3. Mild bilateral hydronephrosis with high-density material seen in the dependent portion of the urinary bladder, similar to previous study, could represent small stones. Small air locule within the urinary bladder may be iatrogenic. 4. Small bilateral pleural effusions, unchanged. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Constipation Diagnosed with Unspecified abdominal pain, Other specified diseases of anus and rectum, Constipation, unspecified, Dehydration, Unspecified atrial fibrillation temperature: 99.5 heartrate: 78.0 resprate: 18.0 o2sat: 97.0 sbp: 158.0 dbp: 90.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, ___ was a pleasure taking care of you at ___ ___! Why was I in the hospital? - You were admitted to the hospital for severe constipation and rectal pain. What was done for me in the hospital? - We gave you pain medications to help with your rectal pain. - We gave you medications for your constipation to help you have bowel movements. - The palliative care physicians worked with you and your daughter. What should I do when I leave the hospital? - Please take all of your medications as prescribed. - Please keep all of your doctors ___. We wish you the best in your recovery! 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: Anemia Major Surgical or Invasive Procedure: ___: Diagnostic Paracentesis. ___: EGD History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ with a PMH notable for HCV cirrhosis, varices s/p banding, HCC s/p TACE in ___ presents with 3 days of progressive shortness of breath and abdominal distension. The patient additionally reports intermittant fevers for several months which are typically worse at night. He had one episode of vomiting yesterday morning which was nonbloody. He denies any hemoptysis or hematochezia, abdominal pain, chest pain. He states that he has never had abdominal distension like this before. In the ED, initial vitals: 99.6 93 136/67 18 100% ra The patient underwent a RUQ ultrasound as well as a CXR which were unremarkable. He was found to have an initial Hct of 18, down from a baseline of 37 two months ago. Repeat Hct was 16.4. Guiac positive but no frank melena or BRBPR. Paracentesis was performed and the fluid was sent for the usual tests revealing no signs of significant blood or infection in the ascitic fluid. Hepatology was consulted and they agreed to perform EGD in the morning. The patient was given 2 units of PRBCs and transferred to the MICU for further evaluation. On transfer, vitals were: 98.4 84 126/76 18 100% RA Past Medical History: -Cirrhosis due to hepatitis B (non-compliant with treatment of entacavir) as well as a longstanding alcohol use, c/b portal hypertension, esophageal varices for which he has undergone serial band ligation given prior GI bleeding, on nadolol for secondary prophylaxis of bleeding. -HTN -Sleep apnea with CPAP at night -Atrial Fibrillation (paroxysmal) -Atypical chest pain -Mild aortic dilatation -Reflux esophagitis -Chronic iron-deficiency anemia -Chronic neck and back pain -Depression/anxiety -s/p L cataract repair -Large hiatal hernia - Social History: ___ Family History: One of 8 siblings (one brother who died of MI in his ___, 2 brothers with DM). ___ are deceased (father from suicide, mother with ?liver disease). 5 healthy children. No family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: BP: 129/61 P: 79 R: 14 O2: 100 RA GENERAL: Alert, oriented, no acute distress HEENT: NCAT, EOMI, PERRLA, edentulous 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: significantly distended with +fluid wave, soft, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Some nonpitting edema of the feet. SKIN: Warm, no rash, non-jaundiced. NEURO: CN II-XII grossly intact, speech fluent, moving all extremities DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.1-98.3, 105-109/51-55, 63-79, 20, 98-99% on RA. GENERAL: Sitting up in bed, in NAD, resting comfortably. HEENT: NCAT, EOMI, PERRLA, edentulous NECK: supple, JVP not elevated, no LAD LUNGS: Decreased breath sound at left base. CV: RRR S1 and S2 present, no murmurs, rubs or gallops. ABD: distended abdomen, but non-tender no rebound or guarding. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Non-pitting edema of the feet. SKIN: Warm, no rash, non-jaundiced. NEURO: CN II-XII grossly intact, speech fluent, moving all extremities Pertinent Results: ADMISSION LABS ============== ___ 10:45PM BLOOD WBC-3.0* RBC-2.27*# Hgb-5.0*# Hct-18.0*# MCV-79*# MCH-22.2*# MCHC-28.0*# RDW-15.8* Plt Ct-84* ___ 10:45PM BLOOD Neuts-46.2* ___ Monos-9.8 Eos-4.4* Baso-0.3 ___ 10:45PM BLOOD ___ PTT-34.9 ___ ___ 10:45PM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-138 K-4.0 Cl-107 HCO3-23 AnGap-12 ___ 10:45PM BLOOD ALT-19 AST-25 AlkPhos-86 TotBili-0.5 ___ 10:45PM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.1 Mg-1.8 DISCHARGE LABS ============== ___ 05:02AM BLOOD WBC-3.9* RBC-2.97* Hgb-7.1* Hct-23.2* MCV-78* MCH-23.8* MCHC-30.4* RDW-17.8* Plt Ct-84* ___ 05:02AM BLOOD ___ PTT-40.4* ___ ___ 05:02AM BLOOD Glucose-112* UreaN-14 Creat-0.9 Na-135 K-3.9 Cl-106 HCO3-23 AnGap-10 ___ 05:02AM BLOOD ALT-16 AST-27 AlkPhos-83 TotBili-0.5 ___ 05:02AM BLOOD Albumin-2.2* Calcium-7.8* Phos-2.7 Mg-1.8 ANEMIA EVALUATION ================= ___ 05:42AM BLOOD Ret Man-2.2* ___ 05:42AM BLOOD Hapto-76 LIVER STUDIES ============= ___ 07:00AM BLOOD AFP-3.3 ASCITIC FLUID STUDIES ===================== ___ 11:00PM ASCITES WBC-242* RBC-132* Polys-15* Lymphs-21* Monos-43* Mesothe-3* Macroph-18* ___ 11:00PM ASCITES TotPro-0.7 Glucose-124 Albumin-LESS THAN MICROBIOLOGY ============ ___ 11:00 pm PERITONEAL FLUID **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___: BLOOD CULTURE: NO GROWTH (FINAL) ___: BLOOD CULTURE: NO GROWTH (FINAL) ___: MRSA SCREEN; NASAL SWAB: NO MRSA ISOLATED. ___ 5:42 am SEROLOGY/BLOOD ___ ADDED TO ___. **FINAL REPORT ___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA. (REFERENCE RANGE: NEGATIVE). ___: HELICOBACTER PYLORI STOOL ANTIGEN: NOT DETECTED. IMAGING ======= ___: CHEST X-RAY (PA AND LATERAL) FINDINGS: PA and lateral views of the chest provided. There is a small left pleural effusion, new from prior. Mildly elevated right hemidiaphragm is unchanged. No focal consolidation concerning for pneumonia. There is a retrocardiac opacity which is compatible with known moderate hiatal hernia. No signs of pneumonia. No pneumothorax. Cardiomediastinal silhouette is stable. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: Small left pleural effusion, moderate hiatal hernia. ___: RIGHT UPPER QUADRANT ULTRASOUND WITH DOPPLER IMPRESSION: 1. Cirrhosis with sequela of portal hypertension, including splenomegaly and moderate ascites. 2. Patent main portal vein. 3. Mild gallbladder wall thickening, without evidence of stones. This is likely is secondary to third spacing in the setting of ascites. ___: CTA ABDOMEN AND PELVIS IMPRESSION: 1. Somewhat limited assessment for lower GI bleeding due to residual oral contrast in the ascending and proximal transverse colon. However no definite evidence for active extravasation. 2. Cirrhosis with portal hypertension including splenomegaly and moderate hemorrhagic ascites 3. Status post chemo embolization of the liver. The known mass in the dome of the liver is difficult to visualize 4. Large hiatal hernia 5. Small left pleural effusion and adjacent atelectasis 6. No evidence for retroperitoneal hematoma 7. Hyperdense cyst with calcification in the right kidney ___: MRI LIVER WITH AND WITHOUT CONTRAST FINDINGS: The lung bases are grossly clear. There is no pleural or pericardial effusion. Large hiatal hernia is present. The liver is cirrhotic with nodular border and progressive reticular enhancement. There is no evidence of steatosis. Multiple T1 hyperintense regenerative nodules are seen throughout the liver. No of arterially hyperenhancing or washing not lesions are identified. Conventional arterial hepatic anatomy is present. The portal and hepatic veins are patent. The spleen is enlarged, measuring 13.5 cm in craniocaudal dimension. Multiple varices are demonstrated. The pancreas is normal in size and signal, without focal masses or ductal dilatation. Cortical renal cysts are seen bilaterally. The adrenals are normal. There is a moderate amount of ascites. No concerning retroperitoneal or mesenteric lymphadenopathy seen. The bone marrow signal is normal. IMPRESSION: 1. Cirrhosis with portal hypertension, splenomegaly and varices. No evidence of malignancy. Patent portal and hepatic vasculature. Moderate amount of ascites. 2. Large hiatal hernia. 3. Small bilateral pleural effusions. ENDOSCOPIC PROCEDURES ===================== ___: EGD Findings: Esophagus: 2 cords of grade I varices were seen in the lower third of the esophagus. The varices were not bleeding. A single clean based ulcer was found near gastroesophageal junction. There was no evidence of active bleeding. Stomach: A few clean based, non-bleeding ulcers were found in the antrum of the stomach. Duodenum: Multiple small clean based ulcers were found in the duodenal bulb with no evidence of active bleeding. Impression: Multiple ulcers were found in the esophagus, stomach and duodenum that could contribute anemia via slow, chronic GI losses. None had high risk stigmata that required intervention. Ulcer in the gastroesophageal junction Varices at the lower third of the esophagus Ulcers in the duodenal bulb Ulcers in the stomach Otherwise normal EGD to third part of the duodenum Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Entecavir 0.5 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Voltaren (diclofenac sodium) 1 % topical bid pain 4. Acetaminophen 1000 mg PO Q8H:PRN pain 5. Aspirin 81 mg PO DAILY 6. Bumetanide 0.5 mg PO DAILY 7. Clotrimazole Cream 1 Appl TP BID 8. Enalapril Maleate 10 mg PO BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Hydrochlorothiazide 25 mg PO DAILY 11. ketotifen fumarate 0.025 % ophthalmic QD 12. Lorazepam 1 mg PO QHS:PRN insomnia 13. Multivitamins 1 TAB PO DAILY 14. Nadolol 40 mg PO DAILY 15. Omeprazole 20 mg PO DAILY 16. Prochlorperazine 10 mg PO Q8H:PRN nausea 17. Sucralfate 1 gm PO QID 18. Thiamine 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Bumetanide 0.5 mg PO DAILY 3. Clotrimazole Cream 1 Appl TP BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. Enalapril Maleate 10 mg PO BID 6. Entecavir 0.5 mg PO DAILY 7. Lorazepam 1 mg PO QHS:PRN insomnia 8. Nadolol 40 mg PO DAILY 9. Prochlorperazine 10 mg PO Q8H:PRN nausea 10. Sucralfate 1 gm PO QID 11. Thiamine 100 mg PO DAILY 12. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 13. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 14. Aspirin 81 mg PO DAILY 15. Ferrous Sulfate 325 mg PO DAILY 16. ketotifen fumarate 0.025 % ophthalmic QD 17. Multivitamins 1 TAB PO DAILY 18. Voltaren (diclofenac sodium) 1 % topical bid pain Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================= Cirrhosis Secondary to Hepatitis B c/b portal hypertension, esophageal varices, ascites. Peptic Ulcer Disease Chronic Iron Deficiency Anemia Secondary Diagnosis =================== -Hypertension -Sleep Apnea on CPAP -Paroxysmal Atrial Fibrillation -Mild Aortic Dilatation -Reflux Esophagitis -Depression/Anxiety Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with anemia liver // access for PVT TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT of the abdomen dated ___, and MRI of the abdomen 8 dated ___. FINDINGS: LIVER: The liver is coarsened and nodular. Multiple hypoechoic regenerative nodules are seen in the liver. The main portal vein is patent with hepatopetal flow. There is moderate ascites. A left pleural effusion is also noted. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm. GALLBLADDER: No evidence of gallstones. Mild gallbladder wall thickening is likely secondary to third spacing the setting of ascites. PANCREAS: The pancreas is obscured by overlying bowel gas, and is not well seen. SPLEEN: Splenomegaly, measuring 15 cm. KIDNEYS: Limited views of the right kidney demonstrates a 6 mm nonobstructing stone in the midpole. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhosis with sequela of portal hypertension, including splenomegaly and moderate ascites. 2. Patent main portal vein. 3. Mild gallbladder wall thickening, without evidence of stones. This is likely is secondary to third spacing in the setting of ascites. Radiology Report INDICATION: ___ year old man with hct of 16, actively dropping. // Please eval for RP bleed or other source of intraabdominal blood loss TECHNIQUE: MDCT images were obtained from the lung bases to the lesser trochanters after administration of oral and intravenous contrast. Coronal and sagittal reformations were prepared. DLP: 2593 MGY PER CM COMPARISON: CT examination of ___, MRI examination of ___. FINDINGS: CT ABDOMEN: There is a small left sided pleural effusion and atelectasis in the left lower lobe of the lung. There is a large axial hiatal hernia. The visualized portions of the heart pericardium are normal. The liver contains lipiodol consistent with status post chemo embolization. The amount of lipiodol has decreased from prior examination. There are no definite areas of arterial hyper enhancement or there is subtle washout in the dome of the liver on series 4B, ___ 190 measuring approximately 2.7 cm. This corresponds to the abnormality biopsied on ultrasound. . The liver is small and has a nodular contour consistent with cirrhosis. The portal vein and hepatic veins are patent. The hepatic and portal veins are patent. The gallbladder, pancreas, and adrenals are normal. There is splenomegaly of 13.6 cm. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis. There is a sub cm are slightly hyperdense lesion in the right kidney at midpole most consistent with a hyperdense cyst. There are 2 cysts in the left kidney at midpole 1 measuring 13 ___ and a second measuring 29 ___ however the latter measured 23 ___ on the recent noncontrast enhanced scan and therefore also represents a hyperdense cyst. There are 2 small adjacent calcifications. The stomach and small bowel are unremarkable. There is no portacaval, mesenteric and retroperitoneal lymphadenopathy. There is a moderate amount of ascites throughout the abdomen and pelvis. CT PELVIS: The appendix is not identified. The colon, rectum, urinary bladder and are normal. There is no pelvic lymphadenopathy or free fluid. OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for malignancy. CT angiography subtle hyperdense foci seen on series 4a, image 44 in the colon at the splenic flexure, image 93 in the small bowel and image 153 at the anorectal junction 2 not persist on the portal venous phase and are therefore artifactual. IMPRESSION: 1. Somewhat limited assessment for lower GI bleeding due to residual oral contrast in the ascending and proximal transverse colon. However no definite evidence for active extravasation. 2. Cirrhosis with portal hypertension including splenomegaly and moderate hemorrhagic ascites 3. Status post chemo embolization of the liver. The known mass in the dome of the liver is difficult to visualize 4. Large hiatal hernia 5. Small left pleural effusion and adjacent atelectasis 6. No evidence for retroperitoneal hematoma 7. Hyperdense cyst with calcification in the right kidney Revised findings regarding impression 1. were discussed with Dr. ___ at 10:24 on ___ by Dr. ___ by telephone Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with new intubation // ET tube ET tube COMPARISON: Prior chest radiographs since ___ most recently ___. IMPRESSION: Tip of the endotracheal tube is less than a cm from the carina and oriented toward the rib right main bronchus. This may explain new left lower lobe collapse responsible for leftward mediastinal shift. Large hiatus hernia is visible. Right lung is clear. RECOMMENDATION(S): Withdrawn ET tube 20- 25 mm. NOTIFICATION: Dr. ___ reported the findings to ___, the get remain get Y item is way that degree a may is already at ___ year wall ___ by telephone on ___ at 11:44 AM, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: MRI abdomen with and without contrast. INDICATION: ___ year old man with ___ s/p TACE in ___ with increased hemorrhagic ascites. // Please assess for HCC. TECHNIQUE: Multiplanar T1 and T2 weighted sequences were obtained in a 1.5 Tesla magnet including dynamic 3D imaging performed prior to, during, and after the uneventful administration 8cc of ___. COMPARISON: CT from ___, MRI from ___. FINDINGS: The lung bases are grossly clear. There is no pleural or pericardial effusion. Large hiatal hernia is present. The liver is cirrhotic with nodular border and progressive reticular enhancement. There is no evidence of steatosis. Multiple T1 hyperintense regenerative nodules are seen throughout the liver. No of arterially hyperenhancing or washing not lesions are identified. Conventional arterial hepatic anatomy is present. The portal and hepatic veins are patent. The spleen is enlarged, measuring 13.5 cm in craniocaudal dimension. Multiple varices are demonstrated. The pancreas is normal in size and signal, without focal masses or ductal dilatation. Cortical renal cysts are seen bilaterally. The adrenals are normal. There is a moderate amount of ascites. No concerning retroperitoneal or mesenteric lymphadenopathy seen. The bone marrow signal is normal. IMPRESSION: 1. Cirrhosis with portal hypertension, splenomegaly and varices. No evidence of malignancy. Patent portal and hepatic vasculature. Moderate amount of ascites. 2. Large hiatal hernia. 3. Small bilateral pleural effusions. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dyspnea, Abdominal distention Diagnosed with ANEMIA NOS temperature: 99.6 heartrate: 93.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 67.0 level of pain: 6 level of acuity: 3.0

Dear Mr. ___, You were admitted to ___ after developing fatigue and weakness. You were found to have low blood counts requiring blood transfusions. In order to determine the cause of the bleding, you underwent a procedure to look at the stomach and small intestine. This did not reveal any acute source of bleeding. This procedure did reveal ulcers in the esophagus, stomach, and small intestine. Your blood counts stabilized after receiving the blood transfusions. Due to these ulcers, you were started on a medication called pantoprazole. Please continue to take pantoprazole 40 mg by mouth EVERY 12 HOURS. As you were noted to have fluid within your abdomen (ascites), please continue to take ciprofloxacin 500 milligrams by mouth EVERY DAY with end date ___. Please assess your stools and look for any dark or tarry stools. Please avoid alcohol and non-steroidal anti-inflammatories such as ibuprofen or naproxen. Since you had an MRI of your liver obtained during this hospitalization, you do not need the repeat MRI that was previously scheduled for ___. It was a pleasure taking care of you during your hospitalization. We wish you all the best! Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right ankle pain Major Surgical or Invasive Procedure: ORIF Right distal tibia fx ___ ___ History of Present Illness: ___ s/p fall down 10 stairs with a R distal tib/fib fx (above existing ankle ORIF hardware). Past Medical History: CHF prior Right ankle fracture s/p ORIF Social History: ___ Family History: Non-contributory Physical Exam: General: alert, oriented, no acute distress; pain controlled Resp/Chest: non-labored breathing, no respiratory distress Abdomen: grossly non-distended RLE: splint in place, intact (removed and incisional dressings noted to be satisfactory; short leg cast placed); SILT at toes; fires FHL/FDL, ___ foot pink, perfused Pertinent Results: ___ 05:05AM BLOOD WBC-9.9 RBC-3.78* Hgb-11.6* Hct-34.9* MCV-92 MCH-30.7 MCHC-33.2 RDW-14.7 RDWSD-49.8* Plt ___ ___ 06:40AM BLOOD WBC-10.6* RBC-3.34* Hgb-10.5* Hct-31.4* MCV-94 MCH-31.4 MCHC-33.4 RDW-14.6 RDWSD-50.2* Plt Ct-92* ___ 05:05AM BLOOD Glucose-113* UreaN-22* Creat-1.0 Na-140 K-4.4 Cl-103 HCO3-23 AnGap-14 ___ 06:40AM BLOOD Glucose-83 UreaN-12 Creat-0.8 Na-138 K-4.0 Cl-101 ___ AnG___ Medications on Admission: Lisinopril 2.5 once daily Potassium chloride 10 mEq once daily Furosemide 20 mg once daily Discharge Medications: 1. Acetaminophen 650 mg PO Q4H Use for baseline pain control. Discontinue when no longer needed. RX *acetaminophen 325 mg 2 capsule(s) by mouth 5 times daily while awake Disp #*120 Capsule Refills:*1 2. Docusate Sodium 100 mg PO BID Use to prevent post-operative constipation. Hold for diarrhea/loose stools. RX *docusate sodium 100 mg 2 capsule(s) by mouth daily Disp #*20 Capsule Refills:*0 3. Enoxaparin Sodium 40 mg SC QPM Use for 4 weeks post-operatively to prevent blood clots. RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously every evening Disp #*24 Syringe Refills:*0 4. Gabapentin 300 mg PO BID Don't take before driving, operating machinery, or with alcohol/sedatives/hypnotics. RX *gabapentin 300 mg 1 capsule(s) by mouth twice daily Disp #*28 Capsule Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain Discontinue when not needed. Do not take before driving/operating machinery/with sedatives. RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*15 Tablet Refills:*0 6. Senna 8.6 mg PO DAILY Use to prevent post-operative constipation. Hold for diarrhea/loose stools. RX *sennosides 8.6 mg 2 tablets by mouth nightly Disp #*20 Tablet Refills:*0 7. Furosemide 20 mg PO DAILY 8. Lisinopril 2.5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right distal tibia fracture (above existing ankle ORIF hardware) Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Followup Instructions: ___ Radiology Report EXAMINATION: ORIF right ankle INDICATION: ORIF right ankle TECHNIQUE: Fluoroscopic guidance for ORIF right ankle COMPARISON: ___ FINDINGS: 11 intraoperative images were acquired without a radiologist present. Images show shows evidence of internal fixation of the right ankle. IMPRESSION: Intraoperative images were obtained during ORIF right ankle. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with fall// pre op TECHNIQUE: Semi-erect frontal view of the chest COMPARISON: No relevant comparison identified. FINDINGS: Lungs are clear. The cardiac silhouette is top-normal in size. Mediastinal and hilar contours are within normal limits. There is mild calcification of the aortic knob. Pleural spaces are normal. IMPRESSION: 1. Clear lungs. 2. Mild calcification of the aortic knob. Heart is top normal in size. Radiology Report EXAMINATION: DX TIB/FIB AND ANKLE INDICATION: ___ with fracture s/p reduction// reduction? TECHNIQUE: AP oblique and cross-table lateral views of the right tibia and fibula COMPARISON: Outside images of the right tibia and fibula from ___ at 20:36 and at 23:37 FINDINGS: Fine bony detail is partially obscured by overlying plaster cast. Again seen are obliquely oriented distal tibial and fibular fractures, just above and below previously seen hardware, respectively. Alignment is overall improved with residual anterolateral displacement of the distal tibial fracture and residual lateral and anterior displacement of the distal fibular fracture. No additional fracture is appreciated. IMPRESSION: Distal tibial and fibular fractures status post reduction with overall slightly improved alignment with some residual displacement of each fracture, as described above. Radiology Report EXAMINATION: CT lower extremity with runoff INDICATION: ___ year old man with ankle injury, diminished pulse// please characterize ankle for pre-op. also w/ thready pulse, ?vascular injury. please imaged from mid-tibia distally TECHNIQUE: Noncontrast images were obtained from the distal right femur through the toes. Following this, content is enhanced, arterial phase imaging was obtained of the right lower extremity beginning in the distal femur through the toes after uneventful administration of 100 cc of Omnipaque 350. Delayed images were then obtained. MIPS, sagittal, and coronal reformats were then obtained. DOSE: Acquisition sequence: 1) Spiral Acquisition 8.3 s, 65.1 cm; CTDIvol = 2.4 mGy (Body) DLP = 155.1 mGy-cm. 2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 21.3 mGy (Body) DLP = 10.6 mGy-cm. 3) Spiral Acquisition 7.9 s, 62.4 cm; CTDIvol = 6.3 mGy (Body) DLP = 390.0 mGy-cm. 4) Spiral Acquisition 7.9 s, 62.4 cm; CTDIvol = 5.3 mGy (Body) DLP = 333.0 mGy-cm. Total DLP (Body) = 889 mGy-cm. COMPARISON: Tibia/fibula radiograph from ___ at 06:45 FINDINGS: Just inferior to the lateral buttress plate of the distal fibula, there is an obliquely oriented, minimally displaced impacted fracture with approximately 6 mm of lateral displacement of the distal fragment and approximately 10 mm of anterior displacement of the distal fragment. There is also an obliquely oriented, distal tibial fracture, just superior to the previously placed inter fragmentary screws, with approximately 9 mm of lateral displacement of the distal fragment and approximately 13 mm of anterior displacement of the distal fragment. Assessment of distal vasculature is partially obscured due to streak artifact from overlying hardware. Within these limitations, normal triple vessel runoff is appreciated from the popliteal fossa through the foot. There are no filling defects, evidence of thrombus, or contrast extravasation. No pseudoaneurysm formation identified. There is nonocclusive atherosclerotic calcification within the right anterior tibial artery. Nonocclusive calcified plaques are also noted within the peroneal artery. The dorsalis pedis artery and the dorsal arch vessel branches are patent. No entrapment of arteries seen at the fracture site. IMPRESSION: 1. Distal tibial and fibular fractures of the right lower extremity, as described above. Addendum with details of fracture description from an MSK dedicated radiologist to follow. 2. Normal three-vessel runoff of the right lower extremity without evidence of filling defects, thrombus, or contrast extravasation. No pseudoaneurysm formation or entrapment of arteries noted at the fracture site. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R Leg injury, s/p Fall Diagnosed with Unsp fracture of shaft of right tibia, init for clos fx, Fall (on) (from) unspecified stairs and steps, init encntr temperature: 99.7 heartrate: 87.0 resprate: 16.0 o2sat: 95.0 sbp: 100.0 dbp: 63.0 level of pain: 5 level of acuity: 3.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Nonweightbearing of 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 daily for 4 weeks post-operatively to prevent blood clots. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Cast must be left on until follow up appointment unless otherwise instructed - Do NOT get cast wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Per discussion with Dr. ___ may ___ with the following surgeon in ___: Dr. ___ Address: ___ Phone: ___ You should ___ in 1 week after discharge. Physical Therapy: Patient to remain non-weightbearing to the RLE in short leg cast. He should use walker provided for BUE assist. Patient instructed to ___ with Dr. ___) in 1 week following discharge from ___. Should remain ___ until otherwise directed by Dr. ___. Treatments Frequency: Patient in short leg cast. No need for dressing changes.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending: ___. Chief Complaint: incidental aneurysm Major Surgical or Invasive Procedure: ___ diagnostic cerebral angiogram History of Present Illness: ___ yo F hx HTN and ocular migraines who has had 3 episodes of visual disturbances since ___ and was found to have 2 aneurysms on MRI during outpatient work up. MRI results were communicated to the patient today and in the setting of intermittent right arm numbness she presented to the ED. Pt describes the previous visual disturbances as being "unable to see straight." She felt that her eyes were moving in different directions. All 3 episodes happened when she felt otherwise exhausted. Has hx migraine HAs when she was younger, none recently. Occasional HA, no change in frequency or severity. Deniescurrent HA, nausea, vomiting, current vision changes, numbness, weakness or tingling. Past Medical History: Hypertension Tobacco dependence Ankle fracture Herpes Infection, Other Colonic adenoma Alopecia areata Uterine prolaps Overweight(278.02) bh Osteoporosis Vitamin D insufficiency Cerebral aneurysm Parotid mass Social History: ___ Family History: Mother sudden death age ___, unclear cause FH of breast cancer and ovarian cancer Physical Exam: On Discharge: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation intact to light touch Groin: c/d/i, no hematoma, dressing in place Pertinent Results: please see OMR for pertinent results Medications on Admission: - Betamethasone, Augmented 0.05 % Ointment Apply twice daily for two weeks and then twice weekly if needed. - cholecalciferol, vitamin D3, 2,000 units daily - hydrochlorothiazide 25 mg tablet Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: anterior communicating artery aneurysm left ICA aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Diagnostic cerebral angiogram for evaluation of multiple aneurysms identified on MRA. During the procedure the following vessels were selectively catheterized angiograms were performed: Left internal carotid artery Right internal carotid artery Left vertebral artery Right common femoral artery Three-dimensional rotational angiography of the left internal carotid artery circulation requiring post processing on an independent workstation and concurrent attending physician interpretation and review Three-dimensional rotational angiography of the right internal carotid artery circulation requiring post processing on an independent workstation and concurrent attending physician interpretation and review Ultrasound-guided access to the right common femoral artery INDICATION: This is a ___ female who had multiple episodes of difficulty with vision. Workup with MRI was concerning for an aneurysm in the Acom and the left ICA. The patient was admitted through the emergency room angiogram was performed to further delineate the anatomy. ANESTHESIA: Moderate sedation was provided by administering divided doses of Versed and fentanyl throughout the total intra service time of 50 minutes during which the patient's hemodynamic parameters were continuously monitored by a trained, independent observer. Patient received a total of 100 mcg of fentanyl and 2 mg of Versed. TECHNIQUE: Diagnostic cerebral angiogram COMPARISON: MRA PROCEDURE: The patient was identified and brought to the neuro radiology suite. She was transferred to the fluoroscopic table supine. Moderate sedation was administered. Bilateral groins were prepped and draped in standard sterile fashion. A time-out was performed. The right common femoral artery was identified using anatomic and radiographic landmarks. The right common femoral artery was accessed using standard micropuncture technique after infiltration of local anesthetic. Using ultrasound guidance a short 5 ___ sheath was introduced, connected to continuous heparinized saline flush, and secured. Next a Berenstein catheter was introduced. It was connected to continuous heparinized saline flush as well as power injector. Is advanced over 038 glidewire through the aorta into the aortic arch. The catheter was positioned in the left internal carotid artery over the wire.. The wire was removed. Vessel patency was confirmed via hand injection.. Standard AP and lateral as well as high magnification oblique three-dimensional rotational image was obtained of the intracranial circulation. The catheter was withdrawn and a road map was obtained of the carotid bifurcation. The catheter was withdrawn the aortic arch and the wire was introduced. The right internal carotid artery was selected with a catheter over the wire. The wire was removed. Vessel patency was confirmed via hand injection. Standard AP and lateral as well as three-dimensional rotational images were obtained. The catheter was once again withdrawn the aortic arch. The wire was introduced and a catheter is positioned in the left subclavian artery over the wire. The wire was removed. The catheter was withdrawn as contrast was injected in order to identify the region of the left vertebral artery origin. A roadmap was performed. The left vertebral artery was selected with a catheter over the wire using roadmap guidance. The wire was removed. Vessel patency was confirmed via hand injection. Standard AP and lateral intracranial views were obtained. Next the diagnostic catheter was removed. Right common femoral angiogram was performed via hand injection through the sheath. The sheath was removed and the arteriotomy was closed using a 6 ___ Angio-Seal. The patient was removed from the fluoroscopy table remained at her neurologic baseline without any evidence of thromboembolic complications. OPERATORS: Dr. ___ Dr. ___ physician performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. FINDINGS: Ultrasound the right common femoral artery: There is a single noncompressible, arterial, pulsatile lumen. There is evidence of access of the wire into the lumen Left internal carotid artery: Vessel caliber smooth and regular. There is opacification the anterior middle cerebral arteries no distal territories. There is a fetal configuration to the posterior communicating artery. There is evidence of a 15 x 15 mm aneurysm of the left ICA bifurcation. The venous phase is unremarkable. The three-dimensional images confirm the aneurysm in orientation. There is no evidence of additional aneurysm or AVM. There is no evidence of carotid stenosis in the left cervical carotid based on roadmap images and NASCET criteria. Right internal carotid artery. The vessel caliber smooth and regular. There is opacification the anterior middle cerebral arteries no distal territories. There is filling of a 15 x 9 cm anterior communicating artery aneurysm that is inferiorly projecting. The three-dimensional rotational images confirm this. There is no evidence of additional aneurysm. The venous phase is unremarkable. Left vertebral artery: Vessel caliber smooth and regular. There is opacification the basilar artery as well as the right posterior cerebral artery and the bilateral superior cerebellar arteries. There is diminutive flow in the left PCA but there is a fetal configuration on that side. There is no evidence of aneurysm or AVM. The venous phase is unremarkable. Right common femoral artery: Arteriotomy is above the bifurcation. There is good distal runoff. There is no evidence of dissection. Vessel caliber appropriate for closure device. IMPRESSION: 1. 15 x 15 mm left ICA bifurcation aneurysm. 2. 15 x 9 mm anterior communicating artery aneurysm that fills from the right. RECOMMENDATION(S): Will discuss at vascular conference plans for treatment Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abnormal MRI, R Arm numbness Diagnosed with Anesthesia of skin temperature: 97.8 heartrate: 69.0 resprate: 18.0 o2sat: 97.0 sbp: 179.0 dbp: 102.0 level of pain: 0 level of acuity: 1.0

Discharge Instructions Dr. ___ ___ Angiogram Activity · You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. · Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. · You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. · Do not go swimming or submerge yourself in water for five (5) days after your procedure. · You make take a shower. Medications · Resume your normal medications and begin new medications as directed. · It is very important to take the medication your doctor ___ prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Care of the Puncture Site · You will have a small bandage over the site. · Remove the bandage in 24 hours by soaking it with water and gently peeling it off. · Keep the site clean with soap and water and dry it carefully. · You may use a band-aid if you wish. What You ___ Experience: · Mild tenderness and bruising at the puncture site (groin). · Soreness in your arms from the intravenous lines. · The medication may make you bleed or bruise easily. · Fatigue is very normal. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the puncture site. · Fever greater than 101.5 degrees Fahrenheit · Constipation · Blood in your stool or urine · Nausea and/or vomiting Call ___ and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Penicillins / niacin / Crestor / Humira Attending: ___. Chief Complaint: diplopia Major Surgical or Invasive Procedure: None History of Present Illness: ___ RHM gentleman, past medical history of CAD status post MI, peripheral vascular disease status post stents, hyperlipidemia, OSA not on CPAP, CKD, diabetes, HTN, HLD, and lupus anticoagulant on anticoagulation, presents with a sudden onset of lightheadedness, blurry vision, and triplicate to quadruplicate vision. He was in his usual state of health today when he was at the ___ surgeon's office, where he presented for planned outpatient removal of squamous cell skin cancer of the left forearm. While he was sitting in the office, he had a sudden onset of dizziness (described as lightheadedness), and he began to see ___ of every object. His vision was also blurry at this time. He endorses nausea but no vomiting. This episode lasted for ___ minutes. He has had no prior episodes like this before. He recalled that the physician did the ___ test and that he kept missing on the right side. Per atria's records he had a sudden onset of double vision lasting ___ minutes with blurry vision. On their documented exam they noted that the right eye was deviated medially with right lid ptosis. He cannot complete right finger nose on the right upper extremity rapid alternating movements were intact and Romberg was normal. On their exam there are no other notable deficits. Fingerstick was 209. His blood pressure was 128/64 at that time. Of note after his vision had resolved he stated that that Dr. ___ ___ him go to the bathroom and while he was walking he noticed he was veering towards the right side. He felt lightheaded when walking. He denies any vertigo. He notes that he has had vertigo in the past. He was sent to ___ ED for further workup. Of note, he stopped his Coumadin on ___ in preparation for this outpatient operation. He took Lovenox ___ through ___. He did not take any Lovenox this morning. The initial plan was to take 6.25 of Coumadin and 100 mg of Lovenox this evening postoperatively. Past Medical History: - CAD s/p inferior MI complicated by ventricular fibrillation, cardiac arrest in ___. - ___ - recent EF 60-65% - obesity - type 2 diabetes - hyperlipidemia - hypertension - hx of colorectal polyps and diverticulosis - hx of DVT and PE in ___, + lupus antibodies - asthma/COPD - sleep apnea (not using CPAP) - GERD - PVD - stents in R. leg and bypass in left leg - psoriasis - Autoimmune Hemolytic Anemia - s/p chemotherapy Social History: ___ Family History: Mom, dad, and grandparents with heart disease. Brother in ___ with MI. Father with stroke and lung cancer. Brother with colon cancer. Physical Exam: General: obese man in NAD, sitting up in bed, HEENT: NC/AT Pulmonary: mildly diminished air movement bilaterally Cardiac: RRR, nl s1-s2 Abdomen: soft, NT/ND Extremities: wwp. trace non-pitting edema bilateral legs up to mid shin, with chronic venous stasis Skin: there are scaly, slivery lesions on erythematous base in the extensor surfaces over arms and legs Neurologic: -MS: alert, oriented. language is fluent. follows commands. no dysarthria. mild asterixis bilaterally. -CN: no ptosis. eyes conjugate at rest. 3 beats of end gaze nystagmus bilaterally. slight anisocoria with R>L, both briskly reactive. no diplopia or skew seen. face is symmetric. palateelevates symmetrically. tongue midline. -Motor [Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas] L 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 4* 5 5 -Sensory: no deficits to light touch throughout -Reflexes: toes downgoing bilaterally -Coordination: no dysmetria on FNF -Gait: deferred Pertinent Results: ===ADMISSION LABS=== ___ 12:20PM BLOOD WBC-8.1 RBC-3.61*# Hgb-11.3*# Hct-34.7*# MCV-96 MCH-31.3 MCHC-32.6 RDW-18.0* RDWSD-63.3* Plt ___ ___ 12:20PM BLOOD ___ PTT-28.0 ___ ___ 12:20PM BLOOD Glucose-154* UreaN-65* Creat-2.7* Na-139 K-3.9 Cl-93* HCO3-28 AnGap-22* ___ 12:20PM BLOOD ALT-33 AST-36 AlkPhos-57 TotBili-0.6 ___ 12:20PM BLOOD proBNP-141 ___ 12:20PM BLOOD Albumin-4.8 Calcium-10.7* Phos-3.8 Mg-2.4 ___ 06:50PM BLOOD Triglyc-628* HDL-23* CHOL/HD-7.6 LDLmeas-58 ___ 06:50PM BLOOD %HbA1c-6.0 eAG-126 ___ 06:50PM BLOOD TSH-1.4 ___ 12:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:56PM BLOOD Lactate-1.9 ===RELEVANT RESULTS=== CTA HEAD AND NECK ___ 1. Severe atherosclerotic calcification causing severe stenosis at the proximal left subclavian artery, with unremarkable distal run-off. 2. Heavy atherosclerotic calcification of the origin of the left vertebral artery from the left subclavian artery V2 segment of the left vertebral artery demonstrates lack of opacification/heavily diminished opacification with reconstitution at the level of V3, likely due to retrograde collateral flow from the patent right vertebral artery. 3. Given the stenosis at the origin of the left subclavian artery with differential upper extremity blood pressures, it is possible that the lack of opacification of the left vertebral artery is secondary to steal syndrome. Although, occlusion of the left vertebral artery is more likely due to atherosclerotic disease, and the left vertebral artery itself would be expected to be opacified in the setting of subclavian steal. This can be further evaluated with ultrasound of the left vertebral artery. 4. The circle of ___ and its principal intracranial branches are patent. MRI ___ 1. No acute intracranial abnormality on noncontrast MRI head. Specifically no acute infarct. 2. There is lack of flow related signal of the left vertebral artery beginning at the distal V1 segment to the V4 segment. Contrast opacification seen in the V3 segment on earlier CTA is likely secondary to retrograde flow. There is no evidence of intramural thrombus or luminal thrombus on T1 fat saturated sequences with apparent preserved flow voids the left vertebral artery. Overall, in conjunction with evidence of high-grade stenosis of the proximal left subclavian artery with preserved flow related signal distally, the constellation of findings would suggest subclavian steal. Retrograde flow in the left vertebral artery can be definitively evaluated with ultrasound. 3. Allowing for mild atherosclerotic disease, unremarkable MRI brain. TTE ___ The left atrium and right atrium are normal in cavity size. With maneuvers, there is early appearance of agitated saline/microbubbles in the left atrium/left ventricle most consistent with a patent foramen ovale. The estimated right atrial pressure is ___ mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = 66 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size is normal with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. Increased velocity consistent with a significant gradient/coarctation (peak 36 mmHg) at the distal aortic arch. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, jet of mild to moderate (___) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Likely patent foramen ovale. Likely aortic coarctation. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild-moderate mitral regurgitation. Likely aortic coarctation. Increased PCWP. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. ___ CAROTID SERIES Pending final read Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insuline Glargine (Toujeo Solostar) 60 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Atenolol 25 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H:PRN hearburn 5. Vitamin D ___ UNIT PO DAILY 6. Torsemide 100 mg PO DAILY 7. Calcipotriene 0.005% Cream 1 Appl TP BID 8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 9. Clobetasol Propionate 0.05% Soln 1 Appl TP BID 10. Desonide 0.05% Cream 1 Appl TP BID 11. Voltaren (diclofenac sodium) 1 % topical TID W/MEALS 12. Pravastatin 40 mg PO QPM 13. fenofibrate micronized 200 mg oral DAILY 14. Benzonatate 100 mg PO TID:PRN cough 15. Enoxaparin Sodium 100 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 16. Tamsulosin 0.4 mg PO QHS 17. Allopurinol ___ mg PO DAILY 18. Metolazone 2.5 mg PO 1X/WEEK (MO) 19. ___ MD to order daily dose PO DAILY16 20. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 21. Docusate Sodium 100 mg PO BID 22. Halobetasol Propionate 0.05 % topical BID 23. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing Discharge Medications: 1. Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insuline Glargine (___ Solostar) 60 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. Warfarin 4 mg PO DAILY16 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing 5. Allopurinol ___ mg PO DAILY 6. Atenolol 25 mg PO DAILY 7. Benzonatate 100 mg PO TID:PRN cough 8. Calcipotriene 0.005% Cream 1 Appl TP BID 9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 10. Desonide 0.05% Cream 1 Appl TP BID 11. Docusate Sodium 100 mg PO BID 12. fenofibrate micronized 200 mg oral DAILY 13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 14. Halobetasol Propionate 0.05 % topical BID 15. Metolazone 2.5 mg PO 1X/WEEK (MO) 16. Pantoprazole 40 mg PO Q12H:PRN hearburn 17. Pravastatin 40 mg PO QPM 18. Tamsulosin 0.4 mg PO QHS 19. Torsemide 100 mg PO DAILY 20. Vitamin D ___ UNIT PO DAILY 21. Voltaren (diclofenac sodium) 1 % topical TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: TIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro: nonfocal Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ with dizziness diplopita and differential BPS in arms (30 point difference), weval for evidence of cva, arterial occlusion, or dissection. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of Omnipaque350 intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP = 24.5 mGy-cm. 3) Spiral Acquisition 5.5 s, 43.2 cm; CTDIvol = 31.1 mGy (Head) DLP = 1,344.0 mGy-cm. Total DLP (Head) = 2,171 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are prominent, compatible with involutional change. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. Incidental note is made of a fetal type origin of the right posterior cerebral artery. A millimetric infundibulum arises from the supraclinoid portion of the left carotid artery (3:79). CTA NECK: There is severe atherosclerotic calcification causing stenosis at the proximal left subclavian artery (3:79), with distal opacification. The left vertebral artery origin is also heavily calcified (3:111), and the V2 segment of the left vertebral artery is demonstrate lack of contrast opacification or severely diminished opacification, and reconstitutes at the level of V3, likely due to retrograde collateral flow from the patent right vertebral artery. Atherosclerotic calcification of the bilateral carotid bifurcations does not result in stenosis of the cervical internal carotid arteries by NASCET criteria. Arteries unremarkable. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Severe atherosclerotic calcification causing severe stenosis at the proximal left subclavian artery, with unremarkable distal run-off. 2. Heavy atherosclerotic calcification of the origin of the left vertebral artery from the left subclavian artery V2 segment of the left vertebral artery demonstrates lack of opacification/heavily diminished opacification with reconstitution at the level of V3, likely due to retrograde collateral flow from the patent right vertebral artery. 3. Given the stenosis at the origin of the left subclavian artery with differential upper extremity blood pressures, it is possible that the lack of opacification of the left vertebral artery is secondary to steal syndrome. Although, occlusion of the left vertebral artery is more likely due to atherosclerotic disease, and the left vertebral artery itself would be expected to be opacified in the setting of subclavian steal. This can be further evaluated with ultrasound of the left vertebral artery. 4. The circle of ___ and its principal intracranial branches are patent. RECOMMENDATION(S): Further evaluation of impression 2 and 3 with ultrasound is recommended. NOTIFICATION: The above findings and recommendation were communicated via telephone by Dr. ___ to Dr. ___ at 13:50 on ___, 5 minutes after discovery. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ INDICATION: ___ year old man with triplicate vision x 10 mins// stroke TECHNIQUE: Three dimensional time of flight MR arteriography was performed through the brain with maximum intensity projection reconstructions. 2D time of flight MR angiography of the neck was performed. Axial T1 fat saturated sequences through the neck performed. 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: CTA head and neck of ___ FINDINGS: MRI Brain: There is no intra or extra-axial mass, acute hemorrhage or infarct. The sulci, ventricles and cisterns are within expected limits for the patient's age. The major intracranial flow voids are preserved. There is mild mucosal thickening of the ethmoid air cells. Trace fluid signal is seen in the bilateral mastoid tips. The orbits are unremarkable. MRA brain: Mild numeral irregularity of the bilateral internal carotid arteries is compatible with mild atherosclerotic calcification. The intracranial vertebral and internal carotid arteries and their major branches otherwise appear normal without evidence of high-grade stenosis, occlusion, or aneurysm formation. MRA neck: Within confines of 2 dimensional time-of-flight MRA technique and motion artifact at the neck base, re-identified is lack of flow related signal of the left vertebral artery beginning at the distal V1 segment to the V4 segment. Contrast opacification seen in the V3 segment on earlier CTA is likely secondary to retrograde flow. There is no stenosis of the cervical internal carotid arteries by NASCET criteria. Within confines of technique, the visualize common carotid and right vertebral arteries are unremarkable. Re-identified is severe stenosis of the left subclavian artery near its origin. There is no evidence of T1 hyperintense signal within the lumen of the left vertebral artery or crescentic T1 hyperintense signal along the vessel wall to suggest thrombus or dissection. Of note, there appears to be uninterrupted flow voids through the left vertebral artery on the T1 fat saturated sequences. IMPRESSION: 1. No acute intracranial abnormality on noncontrast MRI head. Specifically no acute infarct. 2. There is lack of flow related signal of the left vertebral artery beginning at the distal V1 segment to the V4 segment. Contrast opacification seen in the V3 segment on earlier CTA is likely secondary to retrograde flow. There is no evidence of intramural thrombus or luminal thrombus on T1 fat saturated sequences with apparent preserved flow voids the left vertebral artery. Overall, in conjunction with evidence of high-grade stenosis of the proximal left subclavian artery with preserved flow related signal distally, the constellation of findings would suggest subclavian steal. Retrograde flow in the left vertebral artery can be definitively evaluated with ultrasound. 3. Allowing for mild atherosclerotic disease, unremarkable MRI brain. RECOMMENDATION(S): Further evaluation of impression 2 with ultrasound. Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old man with ?left subclavian steal syndrome// specifically, interested in flow direction on left vertebral artery TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: MRA head and neck ___ FINDINGS: RIGHT: The right carotid vasculature has moderate degree of calcified atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 59 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 71, 75, and 114 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 30 cm/sec. The ICA/CCA ratio is 1.9. The external carotid artery has peak systolic velocity of 87 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild degree of heterogeneous atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 73 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 44, 82, and 70 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 23 cm/sec. The ICA/CCA ratio is 1.1. The external carotid artery has peak systolic velocity of 103 cm/sec. The vertebral artery is patent with retrograde flow suggestive of subclavian steal. IMPRESSION: 1. Moderate calcified atherosclerotic plaque yielding a 40-59% degree stenosis 2. Mild calcified atherosclerotic plaques yielding a less than 40 degree percent stenosis. 3. Retrograde flow in the left vertebral artery suggestive of subclavian steal RECOMMENDATION(S): The ultrasound findings confirm the diagnosis from the prior CTA of the head that the patient has subclavian steal syndrome related to an occluded left subclavian artery ostium. The left vertebral artery is patent but has retrograde flow. An interventional radiology consult is recommended for subclavian artery stenting. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CVA Diagnosed with Diplopia temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Dear Mr. ___, You were admitted for sudden onset lightheadedness, blurry vision, and triplicate vision that was concerning for a stroke in the setting of having a subtherapeutic INR. You had an MRI of your brain done, and thankfully, it did not show a stroke. Nevertheless, you likely had a TIA (transient ischemic attack) given your symptoms and your risk factors. A TIA is a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot transiently. 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: Lupus anticoagulant positive High cholesterol Sleep apnea Diabetes Hypertension We are changing your medications as follows: Coumadin 4mg Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Percocet / Bactrim / Linzess Attending: ___. Chief Complaint: Fever, leg pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of urosepsis and obstructing kidney stones, aortic stenosis, afib on Xarelto, BPV, CHF with diastolic dysfunction, Barretts esophagus with dysphagia, hypothyroid, chronic lymphedema, HTN and ischemic colitis who is presenting with lower back pain for the past month and chills that started last night. She has a history of getting very sick quickly and ending up in septic shock with infections in the past. Her granddaughter's wedding is tomorrow at 3 ___ and she is upset to possibly miss this. She denies urinary symptoms, but does not usually have these with her UTI. She endorses severe shaking chills that started last night and then recurred today. She used Tylenol last night and today and an elevated temperature of ___. She also has increased incontinence over the last 2 weeks which is another indication of UTI per patient. She also endorses increasing redness and drainage from her left lower extremity for the past few days. She denies fall or trauma. She denies bowel incontinence. She denies numbness, weakness or tingling of her lower extremities. She denies nausea, vomiting, diarrhea, chest pain, shortness of breath, change in her chronic abdominal pain. Her chronic back pain is also unchanged from baseline. In the ED, initial VS were: 100.9 56 185/59 16 98% RA Exam notable for: Left anterior ___ with redness and weeping and warmth compared to right ___ of equal size. Bilateral 4+ edema of the ___. Midline spinal tenderness of L2-L4, no paraspinous muscle tenderness. Mild Right CVAT. NTND abd. RRR. Mild crackles bilaterally. Labs showed: - WBC: 10.4 (PMN 95%), Hgb 11.3 (baseline) - INR 1.3 - Na 140, K 4.7 (hemolyzed), Cr 0.8 (baseline) - Lactate 1.2 - U/A 1.023, ___, +Nit, 47 WBC, mod Bact, 1 Epi Imaging showed: - CXR: no acute process - CTU (NC): no acute abnormality, hydronephrosis or perinephric abnormality, or fracture. Nonobstructive nephrolithiasis and diverticulosis without diverticulitis. Patient received: Acetaminophen 1000 mg IV Ceftriaxone 1 gm Amiodarone 200 mg Rosuvastatin Calcium 5 mg Lisinopril 20 mg Allopurinol ___ mg Tramadol 50 mg Rivaroxaban 20 mg Lidocaine 5% Patch Transfer VS were: 98.1 64 131/67 16 99% RA On arrival to the floor, patient reports that she has not had any more chills. She c/o her chronic back pain and says her left leg is more painful than her right. She did not notice the erythema on the left leg. She denies acutely worsening edema, dyspnea or exercise tolerance. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: Atrial fibrillation CAD HFpEF Aortic stenosis HTN HLD Urosepsis Recurrent UTIs Urinary incontinence Thyroid cancer s/p partial thyroidectomy Hyperparathyroidism Hypothyroidism ___ ___'s Nephrolithiasis, obstructive Stasis dermatitis / Lymphedema Gout GERD ___ esophagus Ischemic colitis BPPV Chronic back pain OA knees Morbid obesity OSA Hearing loss Social History: ___ Family History: Father who had a renal calculus once, DM, mother with congestive heart failure, and a brother with ESRD on HD, DM Physical Exam: ===================== ADMISSION ===================== VS: 135/55 55 20 96% RA Weight; 115.67 kg GENERAL: WDWN woman in NAD HEENT: EOMI, PERRL, anicteric sclera, hearing aid in place, MOM, OP clear NECK: supple, no LAD, JVD to below chin at 30 degrees HEART: RRR, normal S1/S2, III/VI SEM RUSB LUNGS: NLB on RA, CTAB ABDOMEN: soft, nondistended, mildly tender in LLQ, no rebound/guarding, +BS EXTREMITIES: no cyanosis, severe lymphedema BLE to hips equally with B/L distal stasis growths. LLE with erythema extending to mid thigh, ill defined border with associated warmth and tenderness with purulent cellulitis distal LLE GU: trace left sided back pain at CVAT PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, face symmetric, moving all 4 extremities with purpose SKIN: warm and well perfused ===================== DISCHARGE ===================== VS: 97.9, 151/76, 53 18 97 Ra GENERAL: AOx3, lying in bed, NAD NEURO: AOx3, no focal deficits. EYES: Anicteric sclera ENT: MMM NECK: Supple CV: RRR, III/VI systolic murmur at RUSB RESP: CTAB GI: soft, NT/ND, Bowel sounds present MSK: Lymphedema B/L extending to her hips. B/L distal stasis growths, Her LLE demonstrates erythema extending to the mid-shin with poorly demarcated borders. There is associated mild TTP and warmth. No evidence of purulence. EXT: warm and well perfused; no clubbing or cyanosis. Pertinent Results: ==================== ADMISSION LABS ==================== ___ 07:45PM BLOOD WBC-10.4*# RBC-3.74* Hgb-11.3 Hct-35.7 MCV-96 MCH-30.2 MCHC-31.7* RDW-14.0 RDWSD-49.0* Plt ___ ___ 07:45PM BLOOD Neuts-95.1* Lymphs-2.1* Monos-2.3* Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.91*# AbsLymp-0.22* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01 ___ 07:45PM BLOOD ___ PTT-34.2 ___ ___ 07:45PM BLOOD Glucose-95 UreaN-22* Creat-0.8 Na-140 K-4.7 Cl-102 HCO3-24 AnGap-14 ___ 07:45PM BLOOD Calcium-9.6 Phos-2.9 Mg-2.1 ___ 07:55PM BLOOD Lactate-1.2 ==================== PERTINENT RESULTS ==================== MICROBIOLOGY ==================== __________________________________________________________ ___ 6:42 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 7:10 am SWAB Source: LLE drainage material. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S 2 S LEVOFLOXACIN---------- 0.25 S MEROPENEM------------- 0.5 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S __________________________________________________________ ___ 8:05 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 8:05 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S __________________________________________________________ ___ 7:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): ==================== IMAGING ==================== CXR (___): No acute intrathoracic process. Specifically, no signs of pneumonia. === CTU Abdomen/Pelvis (___): 1. No acute abnormality in the abdomen or pelvis to explain patient's reported back pain and fever. Specifically, no evidence of hydronephrosis or perinephric abnormality. No fracture. 2. Nonobstructive nephrolithiasis. 3. Sigmoid colonic diverticulosis without evidence of diverticulitis. 4. No evidence of acute appendicitis. 5. A small focus of gas in the bladder is nonspecific but likely related to instrumentation. Please correlate clinically. ==================== DISCHARGE LABS ==================== ___ 09:15AM BLOOD WBC-4.2 RBC-3.42* Hgb-10.4* Hct-32.6* MCV-95 MCH-30.4 MCHC-31.9* RDW-14.1 RDWSD-49.4* Plt ___ ___ 09:15AM BLOOD Glucose-105* UreaN-28* Creat-0.8 Na-145 K-4.4 Cl-107 HCO3-24 AnGap-14 ___ 09:15AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Lidocaine 5% Ointment 1 Appl TP TID 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Amiodarone 200 mg PO DAILY 7. Rivaroxaban 20 mg PO DAILY 8. Rosuvastatin Calcium 5 mg PO QPM 9. Torsemide 10 mg PO EVERY OTHER DAY 10. TraMADol 50 mg PO Q12H:PRN Pain - Moderate 11. Omeprazole 20 mg PO DAILY 12. Levothyroxine Sodium 200 mcg PO DAILY 13. Vitamin D ___ UNIT PO 1X/WEEK (___) 14. Loratadine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Cephalexin 500 mg PO Q6H Last day: ___ RX *cephalexin 500 mg 1 capsule(s) by mouth Every 6 hours Disp #*14 Capsule Refills:*0 3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth Every 6 hours Disp #*20 Tablet Refills:*0 4. Allopurinol ___ mg PO DAILY 5. Amiodarone 200 mg PO DAILY 6. Levothyroxine Sodium 200 mcg PO DAILY 7. Lidocaine 5% Ointment 1 Appl TP TID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Lisinopril 20 mg PO DAILY 10. Loratadine 10 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Rivaroxaban 20 mg PO DAILY 14. Rosuvastatin Calcium 5 mg PO QPM 15. Torsemide 10 mg PO EVERY OTHER DAY 16. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: PRIMARY: - Cellulitis - Urinary tract infection SECONDARY: - Lymphedema 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 (SINGLE VIEW) INDICATION: ___ with fever and chills and back pain// ?pna COMPARISON: Prior study is dated ___ FINDINGS: AP portable upright view of the chest. The lungs are clear bilaterally. The cardiomediastinal silhouette is stable. No large effusion or pneumothorax. No signs of congestion or edema. Bilateral AC joint arthropathy noted. IMPRESSION: No acute intrathoracic process. Specifically, no signs of pneumonia. Radiology Report EXAMINATION: CT abdomen and pelvis without intravenous contrast INDICATION: ___ with midline spinal tenderness of L2-L4, right CVAT, fever.// ?pyelonephritis, kidney or ureteral stone, hydronephrosis, diverticulitis, occult spinal fracture TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 730 mGy-cm. COMPARISON: CT abdomen and pelvis ___ CT abdomen and pelvis ___ FINDINGS: LOWER CHEST: There is mild atelectasis in the bilateral lower lobes. There is no pericardial or pleural effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. Sub-capsular calcification at the dome (series 2:5), is unchanged from CT abdomen pelvis ___. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There are multiple simple cysts in the bilateral kidneys measuring up to 2.4 cm across maximal diameter in the upper pole of the right kidney (series 601: 46). There is an exophytic intermediate density rounded focus in the lower pole the left kidney measuring 1.5 cm across maximal diameter (series 2:30) which is grossly unchanged as compared to CT ___, likely representing a hemorrhagic or proteinaceous cyst. There are multiple nonobstructive calculi in the bilateral kidneys measuring up to 7 mm in the lower pole of the left kidney (series 601:36). There is no hydronephrosis or perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. There is extensive sigmoid diverticulosis evidence of diverticulitis. The appendix is not visualized but there is no secondary sign of acute appendicitis. PELVIS: There is a small focus of gas in the anti dependent portion of the bladder (series 2:59). There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is unremarkable. There is pelvic floor descent. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There are 2 aneurysms measuring 1.9 cm (series 2:21) and 1.1 cm a partially calcified (series 2:24) likely rising from the superior mesenteric arteries and common hepatic arteries, respectively, unchanged from CT abdomen pelvis ___. The abdominal aorta is tortuous. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There is levoscoliosis centered T12-L1. There are moderate to severe degenerative changes of the lumbar spine. There are moderate to severe degenerative changes of bilateral left greater than right hip joints. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute abnormality in the abdomen or pelvis to explain patient's reported back pain and fever. Specifically, no evidence of hydronephrosis or perinephric abnormality. No fracture. 2. Nonobstructive nephrolithiasis. 3. Sigmoid colonic diverticulosis without evidence of diverticulitis. 4. No evidence of acute appendicitis. 5. A small focus of gas in the bladder is nonspecific but likely related to instrumentation. Please correlate clinically. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chills, Lower back pain Diagnosed with Urinary tract infection, site not specified, Cellulitis of left lower limb temperature: 100.9 heartrate: 56.0 resprate: 16.0 o2sat: 98.0 sbp: 185.0 dbp: 59.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at ___. Please see below for information on your time in the hospital. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you were having chills and back pain WHAT HAPPENED IN THE HOSPITAL? - We found that you had an skin infection called cellulitis - We also found that you had a infection in your urine - We gave you antibiotics by IV to treat this, and once you got better we gave you antibiotic by mouth WHAT SHOULD I DO WHEN I GO HOME? - Your should continue to take your antibiotics as prescribed - You should follow up in ___ clinic to help with the swelling in your leg We wish you the best! -Your Care Team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / gluten / lactose / lactulose Attending: ___. Chief Complaint: Umbilical Laparoscopic Incision Site Pain Major Surgical or Invasive Procedure: None History of Present Illness: Per Colorectal Surgery Admit Note: ___ w chronic slow transit constipation s/p laparoscopic subtotal colectomy ___ w post-op ileus and unexpected viable intrauterine pregnancy (now ~___ wks pregnant) p/w pain at her umbilical incision that has been increasing since she was discharged on ___. Pt reports pain to the right of her umbilical incision that has been increasing to the point where she can no longer walk or move, prompting her presentation to the ED. Pt states her other incisions have minimal to no pain. Other than the incisional pain, pt has been well. No changes in medications. Some nausea in the AM, which she attributes to her pregnancy, but no emesis. Moving her bowels. Eating and drinking without issue. No fevers or chills. Past Medical History: 1) Constipation 2) Depression 3) Remote history of eating disorder ___ years ago, now resolved. Past Surgical History: 1) Foot surgery Social History: ___ Family History: Significant for prostate cancer (paternal grandfather) and breast cancer (maternal grandmother, two aunts). Physical Exam: Discharge Physical Exam General: Doing well, eating a regular diet, tolerating pain medications without issue, ambulating with only small amount of splinting of abdomen VSS Neuro: A&OX3 Cardio/Pulm: RRR, no increased shortness of breath, no increased work of breathing And: lap sites healing well, specifically umbilical site with small amount of eschar, healthing, no purulent drainage or sign of infection, lower abdomen slightly round, minimally tender to palpation, no obvious bulging of the incison line or umbilicus suggesting significant hernia. ___: no lower extremity edema Pertinent Results: ___ 12:00AM BLOOD WBC-7.1 RBC-3.48* Hgb-10.6* Hct-30.1* MCV-87 MCH-30.5 MCHC-35.2* RDW-13.0 Plt ___ ___ 12:00AM BLOOD Neuts-71.8* ___ Monos-3.9 Eos-1.2 Baso-0.5 ___ 12:00AM BLOOD Glucose-95 UreaN-9 Creat-0.4 Na-135 K-3.7 Cl-103 HCO3-20* AnGap-16 ___ 12:00AM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.5 Mg-1.8 MRI of Abdomen ___ MRI ABDOMEN W/O CONTRAST Study Date of ___ 12:09 ___ IMPRESSION: 1. Small hernia at the umbilicus containing mesenteric fat and postsurgical change. No fluid collection or bowel is seen within this small hernia. 2. Mildly dilated small bowel is slightly improved from the prior CT and may represent a resolving ileus or partial small bowel obstruction. 3. Small to moderate amount of free fluid adjacent to the inferior liver and extending along the right pericolic gutter, slightly decreased compared to prior CT. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Duloxetine 30 mg PO DAILY 2. Acetaminophen 325-650 mg PO Q6H:PRN pain 3. LOPERamide 1 mg PO DAILY 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. Pyridoxine 25 mg PO Q6H 6. Ranitidine 150 mg PO DAILY 7. Unisom (doxylamine) (doxylamine succinate) 25 mg oral QHS 8. Lorazepam 0.5 mg PO Q4H:PRN anxiety Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Duloxetine 30 mg PO DAILY 3. LOPERamide 1 mg PO DAILY 4. Lorazepam 0.5 mg PO Q4H:PRN anxiety 5. Pyridoxine 25 mg PO Q6H 6. Ranitidine 150 mg PO DAILY 7. Prenatal Vitamins 1 TAB PO DAILY 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Unisom (doxylamine) (doxylamine succinate) 25 mg oral QHS 10. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain take this for the shortest amount of time only, do not drink alcohol or drive a car while taking RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Umbilical Incision Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI abdomen without contrast. INDICATION: Increasing incisional pain within the umbilicus in a patient status post laparoscopic subtotal colectomy for slow transit and constipation in ___. TECHNIQUE: Multiplanar T1 and T2 weighted sequences of the abdomen were obtained in a 1.5 Tesla magnet without the administration of IV contrast. COMPARISON: CT abdomen/ pelvis from ___. FINDINGS: The liver is homogeneous and normal in signal intensity without a gross mass. There is no intra or extrahepatic biliary duct dilation. The gallbladder is without stone or wall thickening. A small to moderate amount of free fluid is seen in the inferior perihepatic region and right pericolic gutter, similar to that seen on the prior CT. The spleen is homogeneous and normal in size. The pancreas demonstrates no focal mass, peripancreatic stranding, fluid collection, or ductal dilation. The adrenal glands are normal in size and configuration. The kidneys are symmetric and normal in size, without hydronephrosis. Foci of T2 hyperintensity in the left kidney are consistent with tiny simple renal cysts. The aorta is normal in caliber. There is no retroperitoneal or mesenteric lymph node enlargement. The patient is status post subtotal colectomy. Small bowel in the right lower quadrant and epigastric region remain dilated, measuring up to 4.5 cm (8:6), slightly improved compared to the prior CT. At the periumbilical incision site, there is mild herniation of the underlying mesenteric fat and adjacent soft tissue signal with susceptibility artifact, likely reflective of postsurgical changes. No bowel is seen within this small hernia, and there is no fluid collection. A gravid uterus is partially imaged. No osseous lesion concerning for infection or malignancy is identified. IMPRESSION: 1. Small hernia at the umbilicus containing mesenteric fat and postsurgical change. No fluid collection or bowel is seen within this small hernia. 2. Mildly dilated small bowel is slightly improved from the prior CT and may represent a resolving ileus or partial small bowel obstruction. 3. Small to moderate amount of free fluid adjacent to the inferior liver and extending along the right pericolic gutter, slightly decreased compared to prior CT. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with OTH CURR COND-ANTEPARTUM, ABDOMINAL PAIN OTHER SPECIED temperature: 97.3 heartrate: 79.0 resprate: 16.0 o2sat: 99.0 sbp: 104.0 dbp: 71.0 level of pain: 7 level of acuity: 3.0

You were admitted to the hospital with pain at the umblicial site from your prior Total Abdominal Colectomy for Chronic constipation. You had an MRI for imaging as you are pregnant which showed a small umbilical incision hernia which will improve on your own. Your pain is relatively well controlled with oral pain medication. You will be sent home with a small amount of oral pain medication. You will likely have pain as you heal from your surgery and your abdomen expands from the developing baby. You will be sent home with a small amount of the pain medication Dilaudid. Please take this exactly as prescribed. Do not drive a car or drink alcohol while taking this medication. Please only take this medication as needed, try tylenol for pain first and then, if you still have pain take the small dose of dilaudid. The OB team has approved the medication for a short amount of time only in regaurds to safety in pregnancy. Please monitor your bowel function closely. Please continue to titrate the liquid imodium a you have been at home. Please call the office if you have more than 1200cc of stool out in 24 hours. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have ___ laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. ___ Dr. ___. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fall from standing Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old male smoker with a history of metastatic throat cancer s/p laryngeal tracheal resection, s/p removal of L lower jaw, who presented via EMS for evaluation of AMS s/p fall with positive head strike on ___. Per patient's family, he was noted to have continually ingested EtOH through out the day. Per EMS, family notes the patient had a mechanical fall from standing, with positive head strike, and subsequently exhibited altered mental status with slurred speech. Upon these findings, the family notified EMS, who states the patient was alert and oriented x3 upon their arrival. En route, the patient was dehydrated but otherwise hemodynamically stable, and Mr. ___ received 700 mls fluid en route to the ED. Upon arrival to ED Triage, the patient became hypotensive, and displayed episodic AMS with slurred speech. Past Medical History: Throat cancer s/p resection, chemo, radiation ___ years ago AAA s/p open repair R knee meniscus surgery alcohol abuse Social History: ___ Family History: unknown Physical Exam: PE: Upon admission ___ AVSS A&O x 3 C-collar in place Slightly ucomfortable lying in bed PE: Upon discharge ___ VS: 97.3, 125/75, 79, 18, 99%RA A&O x 3 C-collar in place Relatively comfortable sitting in chair Pertinent Results: ___ 05:38PM PO2-91 PCO2-30* PH-7.29* TOTAL CO2-15* BASE XS--10 COMMENTS-GREEN TOP ___ 05:38PM GLUCOSE-96 LACTATE-5.1* NA+-128* K+-4.5 CL--97 ___ 05:38PM HGB-10.2* calcHCT-31 O2 SAT-90 CARBOXYHB-6* MET HGB-0 ___ 05:38PM freeCa-0.94* ___ 05:30PM UREA N-21* CREAT-1.3* ___ 05:30PM estGFR-Using this ___ 05:30PM LIPASE-71* ___ 05:30PM ASA-NEG ___ ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 05:30PM WBC-4.9 RBC-2.84* HGB-10.1* HCT-33.4* MCV-118* MCH-35.5* MCHC-30.2* RDW-13.1 ___ 05:30PM PLT COUNT-171 ___ 05:30PM ___ PTT-22.7* ___ ___ 05:30PM ___-SPINE W/O CONTRAST Study Date of ___ IMPRESSION: 1. Bilateral C6 laminar fractures and obliquely oriented fracture of the right C7 articular pillar/superior articular facet, with extension into the transverse process, as described above. If neurologic symptoms are present, MRI is recommended for better characterization. 2. Nondisplaced fractures of the left fifth and sixth, and possibly the third transverse processes without extension to the transverse foramina. 3. Medial left first and second rib fractures. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ IMPRESSION: No acute intracranial abnormality. Small left occipital scan laceration, closed with staples. No evidence of underlying fracture Medications on Admission: Acetaminophen 325-650 mg PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain do not exceed >4g per 24 hours 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain do not drive or use machinery while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID constipation Duration: 2 Weeks do not use when having loose stool RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: head laceration left medial rib fractures of ribs 1 and 2 a fracture of bilateral C6 laminae with extension into C6-7 facet and anterolisthesis of C6 on C7 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Trauma. TECHNIQUE: Supine view of the chest. Supine view of the pelvis. COMPARISON: None. Correlation is made to same day CT of the chest abdomen and pelvis. FINDINGS: The view of the chest is limited due to overlying trauma board. Known left first and second rib fractures are better seen on CT scan. Lungs are grossly clear, hyperinflated. The cardiomediastinal silhouette is within normal limits. Single view of the pelvis is also limited by trauma board. There is no definite fracture. Degenerative changes noted in the lumbar spine. IMPRESSION: Limited views of the chest and pelvis demonstrating no definite acute abnormalities, left rib fractures better seen by CT. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ s/p fall, hypotensive // Eval for injury TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base through the vertex, without IV administration of contrast. Reformatted coronal and sagittal and thin-section bone algorithm-reconstructed images were acquired, and all images are viewed in brain and bone window on the workstation. DOSE: DLP (mGy-cm): 1014.9. CTDIvol (mGy): 55.8. COMPARISON: None. FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or acute vascular territorial infarction. The ventricles and sulci are prominent, in keeping with age related global atrophy. Periventricular and subcortical white matter hypodensities reflect the sequelae of chronic small vessel ischemic disease. Right parietal encephalomalacia may be from prior infarct. There is no shift of the normally midline structures.The basal cisterns appear patent and there is preservation of the gray-white matter differentiation. A small left occipital laceration is present, closed with skin staples (2b:20). No underlying fractures identified.The included paranasal sinuses, right mastoid air cells, and middle ear cavities are clear. Partial opacification of the left mastoids is noted. The orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Small left occipital scan laceration, closed with staples. No evidence of underlying fracture. Radiology Report EXAMINATION: CT C-SPINE WITHOUT CONTRAST. INDICATION: ___ s/p fall, hypotensive // Eval for injury TECHNIQUE: Axial helical MDCT images were obtained of the cervical spine. Reformatted coronal and sagittal images were also reviewed. DOSE: DLP: 946.6 mGy-cm. COMPARISON: The study is read in conjunction with concurrently obtained CT of the head and CT of the torso. FINDINGS: Nondisplaced fractures are noted through the bilateral C6 lamina (02:54), with an adjacent obliquely oriented fracture of the right C7 articular pillar/superior articular facet (2:56,58; 602:24), with extension into the right C7 transverse process (02:57). Nondisplaced fractures through the left fifth and sixth transverse processes and possibly the left third transverse process are also noted, with no evidence of extension into the transversarium foramen at those levels. The overall cervical lordosis is preserved, with no evidence of spondylolisthesis. The vertebral body heights and disc spaces are maintained. No critical spinal canal stenosis is identified. A calcified disc osteophyte complex at the C3-4 level is also noted. There is no prevertebral soft tissue edema. Acute posterior left first and second rib fractures are identified. Medial left first and second rib fractures are present (2:73, 2:67). Bilateral apical emphysematous changes and pleural parenchymal scarring is present. Atherosclerotic calcifications seen at the carotid bulbs bilaterally. The thyroid gland is somewhat atrophic, with subcentimeter nodularity noted in the isthmus (2:68) and right thyroid lobe (2:67). Postsurgical changes of left neck dissection is identified, submandibular gland is not clearly seen. Postsurgical changes involving possible graft of the left mandible is only partially visualized. Mastoid tips are partially opacified. IMPRESSION: 1. Bilateral C6 laminar fractures and obliquely oriented fracture of the right C7 articular pillar/superior articular facet, with extension into the transverse process, as described above. If neurologic symptoms are present, MRI is recommended for better characterization. 2. Nondisplaced fractures of the left fifth and sixth, and possibly the third transverse processes without extension to the transverse foramina. 3. Medial left first and second rib fractures. NOTIFICATION: The changes in the above impression from the original wet read were communicated to Dr. ___ by Dr. ___ in person at 20:45, at the time of attending review. Radiology Report EXAMINATION: CT CHEST, ABDOMEN, AND PELVIS INDICATION: Trauma. TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis was performed following IV contrast administration with multiplanar reformations provided. COMPARISON: The study is read in comparison with concurrently obtained CT of cervical spine. FINDINGS: CHEST: The thoracic aorta is normal in course and caliber without evidence of focal injury, dissection, or aneurysm. Moderate atherosclerotic calcifications are noted in the coronary arteries, aortic annulus, and aortic arch. There is no mediastinal hematoma. The airways centrally patent. The main pulmonary artery and central branches appear patent. The heart is normal in size and shape. No pleural or pericardial effusion is seen. Severe bilateral apical predominant emphysematous changes are present, with no evidence of pleural effusion or pneumothorax. No concerning nodules or masses are identified. A subcentimeter hypodense nodule in the right thyroid lobe is incidentally noted (2:1). ABDOMEN: The liver and spleen appear intact without focal abnormality, except for a subcentimeter right hepatic lobe hypodensity (2:61), too small to characterize. There is no intra or extrahepatic biliary ductal dilatation, and the portal veins appear patent. The gallbladder, pancreas, and right adrenal gland appear normal. A 1.2 cm nodule seen within the left adrenal gland which is incompletely characterized on this contrast-enhanced exam. Bilateral renal cysts are noted (2:65, 2:68) as well as other hypodensities which are too small to characterize. Otherwise, the kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis or focal lesion of concern. The intra-abdominal aorta contains moderate atherosclerotic calcium burden, with a patent celiac axis, superior mesenteric and inferior mesenteric artery. There is no abdominal aortic aneurysm. There is no retroperitoneal hematoma or lymphadenopathy. No free air or free fluid is seen. The stomach is distended with air and ingested material, and the duodenum and small bowel are moderately distended with air, with no evidence of focal injury or mechanical obstruction. The intra-abdominal loops of large bowel are unremarkable. PELVIS: Loops of small and large bowel demonstrate no signs of obstruction. There is no evidence of mesenteric injury. Foley catheter seen within the decompressed bladder. There is no pelvic free fluid. BONES: Multiple healed left sided rib fractures are seen (2:19, 2:25). Degenerative changes in the lumbar spine include disc height loss at the L4-5 level, with adjacent endplate sclerosis and anterior osteophytosis. Transitional lumbosacral anatomy include a partially sacralized L5 vertebral body on the left (601b:38). Acute left second and first rib fractures are better seen on CT of the cervical spine. IMPRESSION: 1. Left first and second rib fractures are better seen on concurrent CT cervical spine. No other evidence of acute traumatic injury in the chest, abdomen or pelvis. 2. Severe emphysema. 3. Coronary artery atherosclerotic disease. 4. Gastric distention, with mild dilation of small bowel loops, with no evidence of mechanical obstruction, likely ileus. 5. 1.2 cm left adrenal nodule, statistically benign likely an adenoma but incompletely characterized on this single phase exam. 6. Nodular thyroid. NOTIFICATION: The above findings and changes from the original wet read were communicated by Dr. ___ to Dr. ___ telephone at approximately 20:45, at the time of attending review. Radiology Report EXAMINATION: MR CERVICAL SPINE W/O CONTRAST INDICATION: ___ year old man +ETOH s/p fall with confirmed bilateral c6 laminar fx, R c7 articular pillar fracture // evaluate ligamentous injury / further define fx TECHNIQUE: Routine MRI of the cervical spine using sagittal and axial T1, T2 and STIR images COMPARISON: Prior CT scan of the cervical spine dated ___. FINDINGS: There are fractures of the bilateral C6 lamina, the right superior facet of C7, and the right inferior facet of C5 as was seen on recent prior CT scan. There is increased fluid within the facet joints noted on the right at C6-C7 and C7-T1. There is an anterior wedge fracture of the T1 vertebral body with hyperintensity seen in this region on IDEAL images consistent with a recent fracture which, given the clinical history, is likely acute. Mild anterior subluxation of C6 on C7 is again noted. There is also anterior dislocation of the right superior facet of C7. The craniovertebral junction is unremarkable. The cord is normal in signal intensity and morphology. There are small midline disc protrusions at C3-C4, C4-C5, and C5-C6 which are narrowing the anterior CSF space without contacting the cord. The visualized soft tissues of the neck are unremarkable. IMPRESSION: 1. Anterior wedge fracture of the T1 vertebral body with associated hyperintensity seen on ideal images. Given the clinical history, this likely represents an acute fracture. 2. Fractures of the bilateral C6 lamina, right C7 superior facet, and right C5 inferior facet as seen on prior CT scan. 3. Small midline disc protrusions at C3-C4, C4-C5, and C5-C6 without cord deformity or abnormal cord signal. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, ALTERED Diagnosed with FX C6 VERTEBRA-CLOSED, UNSPECIFIED FALL, FX C7 VERTEBRA-CLOSED, OPEN WOUND OF SCALP temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

You were brought to the hospital on ___ after two unwitnessed falls from standing height. You suffered a head laceration, left medial rib fractures of ribs 1 and 2 and a fracture of bilateral C6 laminae with extension into C6-7 facet and anterolisthesis of C6 on C7 for which you need to wear a collar for 8 weeks. Please call Dr. ___ as seen below if having increased neck pain. Keep the collar on at all times. Be sure to follow up with your XRAYS that are scheduled for you to have in 2 weeks. You are now stable and ready to be discharged from the hospital . Please adhere to the following instructions regarding your discharge. Rib Fractures: * Your injury caused 2 rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Please follow up with Spine and ACS. Your appointments have already been scheduled as seen below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left buttock wound Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o appendectomy for perforated appendicitis complicated by ARDS, ECMO, and subsequent renal failure and right hip disarticulation who returns today for left buttock wound. He has had a pressure sore there for some time and has daily ___ care and was noted to have increasing redness and warmth around the area. He denies any fevers, chills, or foul odor drainage. He does report that he was putting extra pressure on this area over the last few says while working out. He is now home, off all dialysis, and otherwise feels well. Past Medical History: large B cell lymphoma- in remission Allergic Rhinitis Hx of Orchitis ADD Perforated appendicitis Right hip disarticulation Social History: ___ Family History: No known family history of leukemia or lymphoma. Has a sister with melanoma. Physical Exam: Discharge Physical Exam: Vitals: T 98.8 HR 103 BP 96/52 RR 20 100RA GEN: A&O, NAD HEENT: normocephalic/atraumatic, EOMI, PERRLA, moist mucous membranes CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Extremiteis: on left buttock small 2cm open decubitus ulcer on left buttock with surrounding induration and erythema. It is warm but nothing currently draining, it is not fluctuant or boggy Neuro: A&OX3, sensorimotor function intact Pertinent Results: Lab Results: ___ 07:30AM BLOOD WBC-12.8* RBC-3.94* Hgb-11.3* Hct-35.2* MCV-89 MCH-28.7 MCHC-32.1 RDW-14.1 RDWSD-45.6 Plt ___ ___ 06:20AM BLOOD WBC-10.4* RBC-3.91* Hgb-11.2* Hct-34.6* MCV-89 MCH-28.6 MCHC-32.4 RDW-14.1 RDWSD-45.3 Plt ___ ___ 11:21AM BLOOD WBC-9.7 RBC-3.83*# Hgb-10.8*# Hct-33.9*# MCV-89 MCH-28.2 MCHC-31.9* RDW-14.2 RDWSD-45.2 Plt ___ ___ 07:30AM BLOOD Glucose-85 UreaN-13 Creat-1.3* Na-138 K-4.6 Cl-99 HCO3-24 AnGap-20 ___ 06:20AM BLOOD Glucose-96 UreaN-12 Creat-1.2 Na-138 K-4.4 Cl-101 HCO3-25 AnGap-16 ___ 11:21AM BLOOD Glucose-92 UreaN-11 Creat-0.9# Na-138 K-4.9 Cl-100 HCO3-26 AnGap-17 Imaging Results: US BUTTOCKS, SOFT TISSUE LEFT Study Date of ___ 1:43 ___ IMPRESSION: No drainable fluid collection. Soft tissue heterogeneity may reflect the presence of edema versus phlegmon. MRI MSK PELVIS W&W/O CONTRAST Study Date of ___ 11:32 AM IMPRESSION: Findings are compatible with a large area of phlegmon interdigitating within the left gluteal muscular fibers spanning an area of 9.1 x 3.3 cm. No evidence of osteomyelitis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 100 mg PO TID 2. Heparin 5000 UNIT SC BID 3. LORazepam 0.5 mg PO QID PRN anxiety 4. Milk of Magnesia 30 mL PO Q6H:PRN constipation 5. Omeprazole 20 mg PO DAILY 6. Senna 17.2 mg PO BID 7. Nephrocaps 1 CAP PO DAILY 8. Bisacodyl 10 mg PO DAILY:PRN constipation 9. Fexofenadine 180 mg PO DAILY:PRN allergies 10. Triple Antibiotic (neomycin-bacitracnZn-polymyxnB) 3.5mg-400 unit- 5,000 unit/gram topical TID 11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 12. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Bisacodyl 10 mg PO DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Fexofenadine 180 mg PO DAILY:PRN allergies 6. Gabapentin 100 mg PO TID 7. LORazepam 0.5 mg PO QID PRN anxiety 8. Omeprazole 20 mg PO DAILY 9. Senna 17.2 mg PO BID 10. Triple Antibiotic (neomycin-bacitracnZn-polymyxnB) 3.5mg-400 unit- 5,000 unit/gram topical TID Discharge Disposition: Home With Service Facility: ___ ___: Left buttock phlegmon, possible myonecrosis, not a drainable fluid collection 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: US BUTTOCKS, SOFT TISSUE LEFT INDICATION: ___ year old man with left buttock sore and induration// fluid collection? TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the left gluteal area. COMPARISON: None FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the left gluteal area. A defect of the skin is seen representing the sore in this area. There is subcutaneous edema and ill-defined heterogeneous, hypoechoic area as in the subcutaneous tissue underlying this defect. No discrete fluid collections are seen.. IMPRESSION: No drainable fluid collection. Soft tissue heterogeneity may reflect the presence of edema versus phlegmon. Radiology Report EXAMINATION: MRI of the Pelvis INDICATION: ___ year old man with left buttock wound and surrounding erythema and induration// soft tissue infection? fluid collection? TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis were acquired in a 1.5 T magnet. Intravenous contrast: 7 mL Gadavist. COMPARISON: Ultrasound left buttock soft tissues ___ FINDINGS: RECTUM AND INTRAPELVIC BOWEL: No bowel obstruction. BLADDER AND DISTAL URETERS: Within normal limits PROSTATE, SEMINAL VESICLES, AND SCROTUM: Within normal limits LYMPH NODES: There are mildly enlarged pelvic and left inguinal lymph nodes which are likely reactive. VASCULATURE: Vasculature is patent. OSSEOUS STRUCTURES AND SOFT TISSUES: There is extensive edema and inflammation within the left gluteal musculature corresponding to the site of the patient's cutaneous defect. Within this region, there is ill-defined fluid with adjacent enhancement but no discrete defined enhancing rim measuring over an area of approximately 9.1 x 3.3 cm compatible with phlegmon. Patient is status post right BKA with resection of the right femoral head. Again seen is ill-defined mild stranding and enhancement surrounding the right hip joint. No evidence of osteomyelitis on today's study. IMPRESSION: Findings are compatible with a large area of phlegmon interdigitating within the left gluteal muscular fibers spanning an area of 9.1 x 3.3 cm. No evidence of osteomyelitis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Buttock pain, Wound eval Diagnosed with Cutaneous abscess of buttock temperature: 98.2 heartrate: 113.0 resprate: 18.0 o2sat: 100.0 sbp: 117.0 dbp: 69.0 level of pain: 4 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you here at ___. You were admitted for a left buttock wound that may be developing into a pressure ulcer. Ultrasound and MRI demonstrated a large phlegmon in that location. Interventional Radiology was consulted but reported that there was no fluid collection that they could drain. After discussion it was determined that you would go home with oral antibiotics for 10 days and close follow-up with Acute Care Surgery clinic this week to re-evaluate the wound. Please follow the below 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.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / lidocaine / mexiletine / Gentamicin / Avelox / generic levothyroxine Attending: ___ ___ Complaint: recurrent diverticulits Major Surgical or Invasive Procedure: ___ Laparoscopic sigmoid resection. ___ Laparoscopic washout, placement of drain and diverting ileostomy. History of Present Illness: Per Colorectal Surgery Consultation Note: HPI: ___ w one prior episode of uncomplicated sigmoid diverticulitis treated at an OSH approximately 2 months ago, who was admitted to medicine service on ___ w one day of severe lower abdominal pain, found on CT scan to have uncomplicated sigmoid diverticulitis. Patient was placed on IV Unasyn but kept on a regular diet and continues to complain of severe lower abdominal pain with little improvement. Given patient's recent history of diverticulitis and lack of improvement on this hospitalization, colorectal surgery is consulted for further recommendations on management. The patient had his first episode of diverticulitis approximately 2 months ago when he presented to ___ with severe RLQ abdominal pain and CT confirmed uncomplicated sigmoid diverticulitis. He was given a 10 day course of PO cipro/flagyl and discharged from the ED, but returned 6 days later with worsening pain. At this point the CT was repeated and unchanged. He was admitted and treated with IV Unasyn for 6 days, then discharged home on a 2 week course of PO cipro and flagyl. He reports being completely pain and symptom free for approximately 7 weeks. About one week ago, he began experiencing bloating sensation and increased stool frequency, but no diarrhea. Of note, the patient has a history of small intestinal bacterial overgrowth which had been treated with rifaximin, and the symptoms seemed consistent with his prior episodes. However, two days prior to admission, the patient began experiencing severe b/l lower abdominal pain, which prompting him to come to the ED at ___. CT scan here again demonstrated sigmoid diverticulitis without evidence of perforation, abscess, or fluid collection. Patient reportedly had normal colonoscopy in ___ at ___, including no evidence of diverticulosis. He denies fevers, chills, unintentional weight loss, BRBPR or melena. Past Medical History: PMH: - multiple cardiac arrests, s/p PCI in ___ - small intestinal bacterial overgrowth syndrome - sinusitis - hypothyroidism - HTN - HLD - glaucoma PSH: sinus surgery, multiple PCI and cardiac stents, last in ___, Laparoscopic washout, placement of drain and diverting ileostomy Social History: ___ Family History: Father and brother w hx of diverticulitis. No history of IBD or GI malignancies Physical Exam: General at discharge: Pt doing well, tolerating regular diet, pain improved VSS Neuro: A&OX3 Cardio/Pulm: no chest pain or shortness of breath Abd: obese, soft, minimally tender, surgical sites intact, ostomy intact, JP drain in place Pertinent Results: ___ 04:32AM BLOOD WBC-8.8 RBC-3.38* Hgb-10.0* Hct-28.7* MCV-85 MCH-29.5 MCHC-34.7 RDW-14.9 Plt ___ ___ 05:46AM BLOOD WBC-11.8* RBC-4.10* Hgb-12.0* Hct-35.6* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.8 Plt ___ ___ 06:38PM BLOOD WBC-11.9* RBC-3.98* Hgb-11.6* Hct-33.6* MCV-85 MCH-29.1 MCHC-34.4 RDW-14.1 Plt ___ ___ 05:40AM BLOOD WBC-11.3* RBC-4.04* Hgb-11.7* Hct-34.8* MCV-86 MCH-28.9 MCHC-33.5 RDW-14.3 Plt ___ ___ 05:20AM BLOOD WBC-8.6 RBC-3.72* Hgb-11.0* Hct-32.1* MCV-86 MCH-29.7 MCHC-34.4 RDW-14.5 Plt ___ ___ 12:45PM BLOOD WBC-9.7 RBC-3.83* Hgb-11.1* Hct-32.5* MCV-85 MCH-29.1 MCHC-34.3 RDW-14.0 Plt ___ ___ 07:20AM BLOOD WBC-9.5 RBC-3.72* Hgb-10.9* Hct-32.6* MCV-88 MCH-29.3 MCHC-33.4 RDW-14.7 Plt ___ ___ 07:20AM BLOOD WBC-9.5 RBC-3.70* Hgb-10.8* Hct-32.3* MCV-87 MCH-29.3 MCHC-33.5 RDW-14.0 Plt ___ ___ 05:00AM BLOOD WBC-11.6* RBC-3.74* Hgb-11.3* Hct-32.7* MCV-88 MCH-30.2 MCHC-34.5 RDW-14.5 Plt ___ ___ 06:40AM BLOOD WBC-12.6* RBC-3.86* Hgb-11.1* Hct-33.6* MCV-87 MCH-28.9 MCHC-33.1 RDW-14.7 Plt ___ ___ 10:50PM BLOOD WBC-14.4* RBC-4.13* Hgb-12.2* Hct-35.4* MCV-86 MCH-29.4 MCHC-34.3 RDW-13.9 Plt ___ ___ 06:50AM BLOOD WBC-14.4* RBC-4.19* Hgb-12.3* Hct-35.6* MCV-85 MCH-29.2 MCHC-34.5 RDW-14.1 Plt ___ ___ 05:49AM BLOOD WBC-11.4* RBC-4.18* Hgb-12.3* Hct-35.8* MCV-86 MCH-29.3 MCHC-34.3 RDW-15.0 Plt ___ ___ 04:32AM BLOOD Glucose-93 UreaN-21* Creat-2.6* Na-141 K-4.1 Cl-110* HCO3-21* AnGap-14 ___ 03:59PM BLOOD Glucose-117* UreaN-23* Creat-3.0* Na-139 K-3.8 Cl-105 HCO3-21* AnGap-17 ___ 05:46AM BLOOD Glucose-108* UreaN-21* Creat-3.1*# Na-139 K-4.0 Cl-104 HCO3-24 AnGap-15 ___ 05:40AM BLOOD Glucose-100 UreaN-9 Creat-1.3* Na-139 K-3.9 Cl-104 HCO3-25 AnGap-14 ___ 05:20AM BLOOD Glucose-109* UreaN-6 Creat-0.9 Na-141 K-3.7 Cl-106 HCO3-24 AnGap-15 ___ 07:10AM BLOOD Glucose-110* UreaN-9 Creat-0.8 Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 ___ 12:45PM BLOOD Glucose-103* UreaN-12 Creat-0.7 Na-139 K-3.7 Cl-105 HCO3-22 AnGap-16 ___ 07:20AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-26 AnGap-14 ___ 07:20AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-144 K-3.8 Cl-108 HCO3-25 AnGap-15 ___ 05:40PM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-142 K-3.8 Cl-107 HCO3-24 AnGap-15 ___ 04:32AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0 ___ 03:59PM BLOOD Calcium-8.3* Phos-3.8 Mg-1.9 ___ 05:46AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.2 ___ 05:40AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.2 ___ 05:20AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.3 Mg-2.2 Iron-30* ___ 05:20AM BLOOD calTIBC-207* Ferritn-437* TRF-159* ___ 12:45PM BLOOD calTIBC-191* Ferritn-561* TRF-147* ___ 12:45PM BLOOD Triglyc-133 HDL-16 CHOL/HD-6.7 LDLcalc-64 ___ 07:20AM BLOOD Triglyc-139 HDL-11 CHOL/HD-9.2 LDLcalc-62 CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6:30 ___ IMPRESSION: Findings consistent with acute uncomplicated sigmoid diverticulitis. CT ABD & PELVIS WITH CONTRAST Study Date of ___ 10:54 AM IMPRESSION: 1. Extravasation of rectal contrast at the anastomotic site consistent with moderate- sized anastomotic leak that tracks superior to the anastomosis. Large amount of free air surrounding the anastomosis and within the peritoneum, retroperitoneum and tracking into the mediastinum. 2. Fluid collection in the anterior pelvis superior to the anastomosis measuring 6.1 x 3.4 cm. CHEST PORT. LINE PLACEMENT Study Date of ___ 2:18 ___ IMPRESSION: Interval placement of right subclavian PICC line which has its tip in the mid SVC. Cardiac and mediastinal contours are stable. Residual but improved bibasilar streaky opacities suggestive of atelectasis. No pulmonary edema or pneumothorax. RENAL U.S. Study Date of ___ 9:30 AM IMPRESSION: No evidence of hydronephrosis bilaterally.. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Fexofenadine 180 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Acebutolol 200 mg PO DAILY 6. ClonazePAM 0.5 mg PO BID 7. Omeprazole 40 mg PO DAILY 8. Pulmosal (sodium chloride) 7 % inhalation prn 9. Levothyroxine Sodium 200 mcg PO Q ___ 10. Levothyroxine Sodium 300 mcg PO Q ___ 11. Vitamin D 3000 UNIT PO DAILY 12. Cyanocobalamin Dose is Unknown PO DAILY 13. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram) transdermal daily 14. Travatan Z (travoprost) 1% ophthalmic ___ Discharge Medications: 1. Acebutolol 200 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. ClonazePAM 0.5 mg PO BID 4. Fexofenadine 180 mg PO DAILY 5. Levothyroxine Sodium 200 mcg PO Q ___ 6. Levothyroxine Sodium 300 mcg PO Q ___ 7. Omeprazole 40 mg PO DAILY 8. Vitamin D 3000 UNIT PO DAILY 9. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg in 24 hours or drink alcohol RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*0 10. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills:*0 11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain do not drink alcohol while taking this medication RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 12. LOPERamide 2 mg PO BID please monitor your ileostomy output. RX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*1 13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 14. Psyllium Wafer 1 WAF PO BID RX *psyllium [Metamucil] 1.7 g 1 wafer(s) by mouth twice a day Disp #*60 Wafer Refills:*1 15. travoprost 0.004 % ___ continue home med 16. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram) transdermal daily 17. Aspirin 325 mg PO DAILY 18. Pulmosal (sodium chloride) 7 % inhalation prn 19. sodium chloride 0.9 % 20 ml into JP drain daily Please flush JP drain with 20ml of sterile normal saline and draw back as instructed RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 20 ml JP drain once a day Disp #*60 Syringe Refills:*1 20. Outpatient Lab Work Please draw a creatinine on ___, at d/c creat is 2.6, please call ___ if not returning to normal, it has improved prior to discharge. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Diverticulitis with anastomotic leak after sigmoid colectomy. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new R PICC // 47cm R basilic DL PICC - ___ ___ Contact name: ___: ___ R basilic DL PICC - ___ ___ COMPARISON: Comparison to prior study dated ___ at 12:33 FINDINGS: Portable AP upright chest from ___ at 14:28 is submitted. IMPRESSION: Interval placement of right subclavian PICC line which has its tip in the mid SVC. Cardiac and mediastinal contours are stable. Residual but improved bibasilar streaky opacities suggestive of atelectasis. No pulmonary edema or pneumothorax. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ with refractory diverticulitis worsening on IV abx now s/p laparoscopic sigmoid colectomy s/p leak w diverting ileostomy and JP drain in left lower quadrant with a rapidly rising creatinine to 3.1 // bilateral renal ultrasound to rule out 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 12.8 cm. There is a left renal lower pole cyst measuring 8.6 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is partially filled and otherwise normal. IMPRESSION: No evidence of hydronephrosis bilaterally.. Radiology Report INDICATION: Left lower quadrant pain. History of diverticulitis. COMPARISON: None. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained with intravenous contrast. Sagittal and coronal reformations were also performed. FINDINGS: The visualized lung bases appear clear. There are no pleural effusions. Coronary artery calcifications are noted. The liver shows a few subcentimeter hypodense foci that are too small to characterize, but doubtful in clinical significance. The gallbladder, pancreas, adrenal glands, and spleen appear within normal limits. The kidneys are also unremarkable aside from a moderately large but simple cyst arising from the left lower pole, which measures up to 82 x 70 mm in the axial ___. The stomach and small bowel appear within normal limits. Along the mid sigmoid colon there is an area of focal fat stranding about diverticula in the mid sigmoid with adjacent fascial thickening. Findings are most consistent with sigmoid diverticulitis. There is no free air or fluid collection. The distal ureters, bladder, prostate, and seminal vesicles are unremarkable. Patchy vascular calcification is noted. The major mesenteric arteries and veins appear patent. There is no lymphadenopathy or ascites. There are no suspicious lytic or blastic bone lesions. The L5-S1 interspace is mildly narrowed with a vacuum disc phenomenon. Lower thoracic interspaces are also mildly narrowed. IMPRESSION: Findings consistent with acute uncomplicated sigmoid diverticulitis. DOSE: 1057.1 mGy-cm. Radiology Report INDICATION: ___ year old man with dyspnea and low grade temp on POD3 // evaluation of acute intrapulmonary process FINDINGS: Heart is upper limits of normal in size. Lungs are clear except for linear bibasilar opacities suggestive of atelectasis. COMPARISON: None available. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ M POD4 lap sigmoid colectomy for refractory diverticulitis now febrile 101 and increasing pain. Please give IV and Rectal contrast. // Evaluation of acute intra-abdominal process, fluid collection and exam of anastomosis. TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous contrast administration with split bolus technique.Oral contrast was administered. Subsequently the patient returned to the department and a non contrast CT pelvis followed by a CT pelvis after the administration of rectal contrast was obtained. Coronal and sagittal reformations were performed and submitted to PACS for review. DOSE: DLP: 1053.9 mGy-cm (abdomen and pelvis. COMPARISON: The abdomen pelvis from ___ FINDINGS: ABDOMEN: There is atelectasis at the lung bases. Pneumomediastinum is seen tracking along the esophagus and in the anterior epicardial space. The liver enhances homogenously without any focal lesions or intra or extrahepatic biliary dilatation. The main portal vein is patent. The gallbladder is distended but there is no evidence of wall thickening or pericholecystic fluid. The pancreas, spleen and adrenal glands are unremarkable. The kidneys enhance and excrete contrast symmetrically without any hydronephrosis. 8.1 x 7.0 cm cyst is noted arising from the lower pole of the left kidney. The stomach and small bowel are unremarkable and nonobstructed. There is no free fluid within the abdomen. There is a large amount of pneumoperitoneum tracking in the anterior pararenal space, around the pancreas, extending into the diaphragmatic hiatus and within the anterior abdomen. The aorta is of normal caliber without evidence of aneurysm there is mild atherosclerotic disease. PELVIS: Rectal contrast was administered. An anastomosis is identified at the rectosigmoid junction (series 7:31). A large amount of extraluminal air is present within the pelvis. Extraluminal rectal contrast is present tracking just posterior to the anastomosis (07:28) and superior to the anastomotic site (07:24). This collection of extraluminal contrast measures approximately 6.1 x 0.8 cm. Superior to this extraluminal contrast is a fluid collection in the anterior pelvis measuring 6.1 x 3.4 cm. There is no peripheral enhancement and no oral contrast in this region. The sigmoid colon is thickened likely due to adjacent inflammation. A Foley catheter is present within the bladder which is predominately collapsed. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Small foci of air are noted in the midline and right lateral anterior abdominal wall. IMPRESSION: 1. Extravasation of rectal contrast at the anastomotic site consistent with moderate- sized anastomotic leak that tracks superior to the anastomosis. Large amount of free air surrounding the anastomosis and within the peritoneum, retroperitoneum and tracking into the mediastinum. 2. Fluid collection in the anterior pelvis superior to the anastomosis measuring 6.1 x 3.4 cm. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ ___ telephone at 05:00 on ___ immediately after completion of the exam appear Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with refractory diverticulitis now s/p laparoscopic sigmoid colectomy w diverting ileostomy POD 5. Pt developing persistent abdominal/L flank pain. Please give po IV contrast // Assess for fluid collection 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: 941.3 mGy-cm (abdomen and pelvis. COMPARISON: CT abdomen and pelvis from ___ FINDINGS: ABDOMEN: There is bibasilar atelectasis. The visualized heart and pericardium are unremarkable. Again seen is a large amount of pneumoperitoneum in the anterior abdomen, surrounding the pancreas and within the left pericolic region. The liver enhances homogenously without any focal lesions or intra or extrahepatic biliary dilatation. The main portal vein is patent. The gallbladder, pancreas, spleen and adrenal glands are unremarkable. The kidneys enhance and excrete contrast symmetrically without any hydronephrosis. A cyst arising from the lower pole of the left kidney measures 7.9 x 7.2 cm. GI: Patient is status post sigmoidectomy with a diverting ileostomy for an anastomotic leak. Oral contrast is seen within the stomach, small bowel and parts of the colon. The diverting ileostomy is present in the right lower quadrant without evidence of obstruction. An anastomosis is present at the rectosigmoid junction. There is no definite evidence of extraluminal contrast to suggest leak. There are multiple loops of dilated small bowel in the left abdomen without a definite transition point, likely due to an ileus. There is persistent fluid within the pelvis and free A drain is present within the pelvis. PELVIS: The bladder has air within it. The rectum is unremarkable. Suture lines are noted at the distal sigmoid colon. A drain is placed within the pelvis and there is a small amount of fluid, mesenteric stranding and locules of air likely from recent surgery. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. There is a 3.4 x 2.7 cm fluid collection with air in the right anterior abdominal wall likely related to recent surgery. IMPRESSION: 1. Loops of dilated small bowel in the left abdomen without a definite transition likely due to ileus. No evidence of obstruction. 2. Status post sigmoid resection with diverting loop ileostomy. No evidence of leak of oral contrast. Large amount of intra and retroperitoneal free air as seen previously. 3. Small fluid collection in the low right anterior abdominal wall likely due to recent surgery. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with DIVERTICULITIS OF COLON temperature: 98.0 heartrate: 64.0 resprate: 15.0 o2sat: 100.0 sbp: 153.0 dbp: 65.0 level of pain: 6 level of acuity: 3.0

___ were admitted to the hospital after a Laparoscopic Colectomy for surgical management of your Diverticulitis. Unfortunately, have this surgery ___ developed a leak at the anastomosis in the Colon and this required a second surgery and drain to control the infection as well as a diverting ileostomy. ___ were given antibiotics through your IV and now your will take antibiotics by mouth until your follow-up appointment with Dr. ___ will take Cipro and Flagyl. The drain will stay in place at least until your follow-up with Dr. ___. The drain is draining a small amount ___ have recovered from this procedure well and ___ are now ready to return home. Drain irrigation instructions: Remove bulb drain and flush tube with 20cc sterile normal saline towards patient, then draw 20cc fluid back into syringe. Replace bulb drain to suction. ___ can shower with the drain in. Clean around the jp drain site with sterile normal saline once daily and apply a new gauze dressing and secure with paper tape. The drain is draining a small amount of stool from the leak, pus, and small amounts of blood/abdominal fluid. Please record the output from the drain on the provided sheet and bring with ___ to your clinic appointment. Please call our office if ___ have any of the following issues: increased pain at the drain site, drainage of bright red blood, more than 150cc from the drain in 24 hours, difficulty flushing the drain, or any concerning symptoms or worries. ___ unfortunately had a kidney injury from dehydration, with ct contrast dye, and vancomycin. This is returning to normal. ___ must have a creatinine level drawn at your primary care providers office on ___. They can call our office if the number has not decreased to under 1.0. At discharge it is 2.6 however, it will still take a number of days to improve. Please be aware of your urine outout. If ___ feel as though your output is decreasing, please call the office. Please call if: urine is dark orangy brown, output is low, burning with urination, or lower abdominal pain. Do not take Motrin for pain. Hold of taking lisinopril until clears by primary care provider. ___ have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. ___ may return home to finish your recovery. Please monitor your bowel function closely. If ___ have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. ___ have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. Continue to take the medications to control the ostomy output (imodium/metamucil wafers). The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. Currently your ileostomy is allowing the surgery in your large intestine to heal, which does take some time. ___ will come back to the hospital for reversal of this ileostomy when decided by Dr. ___, Dr. ___ Dr. ___. At your follow-up appointment in the clinic, we will decide when is the best time for your second surgery. Until this time there is healthy intestine that is still functioning as it normally would. This functioning healthy intestine will continue to produce mucus. Some of this mucus may leak or ___ may feel as though ___ need to have a bowel movement - ___ may sit on the toilet and empty this mucus as though ___ were having a bowel movement, it is not abnormal to have some leakage of mucus from the rectum, please place a gauze pad in your underwear if this is happening. If ___ change this pad more than ___ times daily please call the office. ___ have ___ laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. And there is a larger incision near your umbilical site, the staples were removed from this. These are healing well however it is important that ___ monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if ___ develop any of these symptoms or a fever. ___ may go to the emergency room if your symptoms are severe. ___ may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. ___ will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. ___ may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. ___ Dr. ___. Thank ___ for allowing us to participate in your care! Our hope is that ___ will have a quick return to your life and usual activities. Good luck!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdomnal pain, nausea, vomiting Major Surgical or Invasive Procedure: EGD - ___ EUS - ___ History of Present Illness: ___ y/o F PMH of ___'s thyroiditis, past abdominal surgeries (hysterectomy/cholecystectomy) and anxiety who presents for worsening of her chronic abdominal pain that she has had since ___ after a bout of C.diff at ___ ___ to abx treatment she received while being treated for pyelonephritis. The C.diff resolved but states that she has had residual abdominal pain described most mid-epigastric, extending around her R side to her back, presently a ___ with improvement of ___. Nothing particularly makes it better besides not eating and pain is worse with eating. Denies any fevers or chills, GERD-like symptoms, CP or SOB. No sick contacts or change in diet/meds, just a remote history of travel in ___ in ___. She had diarrhea for a few months but states that now the stool is just soft, consistency of pudding, but no blood/greenish stools. She states she has had nausea and nonbilious/nonbloody vomiting over the same period of time only with eating/drinking and has only been able to drink occasional Naked juice shakes. She still has an appetite but reports having a recent weight loss 10 lbs the past month with a 20 pound loss since ___. Endorses night sweats. Cancer screening up to date with last colonoscopy at 50 that was unremarkable and normal mammogram. All pap smears have been normal. Of note, she recently had a EGD at ___ with evidence of gastritis. A biopsy was performed but unknown results. At the time recommended to use Ranitidine for 3 months treatment. Had a MRCP at some point but no gallstones noted. Past Medical History: Past Medical History: Congenital L Renal Agenesis ___'s Thyroid - thyroidism Anxiety Subdural aneurysm in sinus cavity h/o acute pancreatitis in ___ Multiple UTI's and C.diff in ___ Past Surgical History: L5-S5 Fusion for verterbral collapse in ___ Hysterectomy ___ Cholecystectomy ___ Social History: ___ Family History: Family History: Father died of colon cancer at ___ Paternal GF, nephew and sister with UC Brother with diverticulosis Mother died of emphysema, had diverticulitis Physical Exam: ADMISSION EXAM: Physical Exam: Vitals - 97.6 120/83 68 18 100/RA. General - Alert&orientedx3 in no acute distress HEENT - Sclera anicteric, MMM mildly tachy, oropharynx clear Neck - supple, JVP not elevated, no LAD Lungs - Clear to auscultation bilaterally, no wheezes, rales, ronchi CV - Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen - soft, non-distended, hyperactive bowel sounds present but no high pitched sounds, no rebound tenderness or guarding, no organomegaly, from mid to deep palpation there was tenderness along the mid-epigastric region across to the R flank along the rib cage and to the back. Mild tenderness on deep palpation of the lower abdominal quadrants but not focal to any specific area like McBurney's point. Negative Rovsing's sign. GU - no foley Ext - warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro - CNs2-12 intact, motor function grossly normal Skin - no rashes or lesions, olive colored skin but no jaundice and does not appear bronze particularly in non-sun exposed areas DISCHARGE EXAM: Pertinent Results: ___ 06:30AM BLOOD WBC-4.2 RBC-4.01* Hgb-11.7* Hct-33.7* MCV-84 MCH-29.2 MCHC-34.7 RDW-13.0 Plt ___ ___ 06:30AM BLOOD Glucose-76 UreaN-7 Creat-0.6 Na-144 K-3.8 Cl-108 HCO3-27 AnGap-13 ___ 06:00AM BLOOD ALT-55* AST-35 LD(LDH)-150 ___ 12:55PM BLOOD ALT-55* AST-22 AlkPhos-87 TotBili-0.3 ___ 12:55PM BLOOD Lipase-30 ___ 06:00AM BLOOD calTIBC-259* VitB12-417 Folate-11.3 Ferritn-83 TRF-199* ___ 06:00AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 Iron-115 ___ 06:00AM BLOOD TSH-10* ___ 01:10PM BLOOD IgA-140 ___ 01:10PM BLOOD tTG-IgA-4 EUS (___): Impression: Common Bile Duct: The bile duct was dilated to 8 mm but was otherwise normal without any intrinsic stones or sludge. Pancreas: The pancreas parenchyma, pancreas duct, and ___ vasculature were normal. Ampulla: Normal ampulla. Otherwise normal upper EUS to second part of the duodenum. Recommendations: The findings do not account for the symptoms. Return to hospital floor. ___ with Dr. ___ ___ (___): Impression: Normal EGD to third part of the duodenum with biopsies (biopsy, biopsy) Recommendations: Will follow up biopsy report and inform patient. Proceed with EUS today. Return to hospital floor. ___ with Dr. ___. CT Scan (___): IMPRESSION: 1. No acute intra-abdominal process to explain the patient's symptoms. Appendix not definitely seen without inflammatory changes in the right lower quadrant to suggest appendicitis. Moderate fecal load. 2. Mild intrahepatic biliary prominence may be normal in the setting of cholecystectomy. Correlate with labs to determine the role of MRCP. 3. Absent left kidney. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Diazepam 5 mg PO QHS Anxiety 3. Ranitidine 300 mg PO DAILY 4. Ondansetron 4 mg PO Q 8H 5. Gabapentin 600 mg PO BID Discharge Medications: 1. Diazepam 5 mg PO QHS Anxiety 2. Gabapentin 600 mg PO BID 3. Ranitidine 300 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day Disp #*30 Capsule Refills:*3 5. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*60 Tablet Refills:*1 6. Senna 1 TAB PO BID Constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice a day Disp #*30 Tablet Refills:*1 7. Levothyroxine Sodium 75 mcg PO DAILY RX *levothyroxine 75 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 8. Ondansetron 4 mg PO Q 8H RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8 hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Weight loss and pain. Assess for pancreatitis, appendicitis or mass. TECHNIQUE: CT images were obtained from the lung bases to the pubic symphysis following the uneventful intravenous administration of Omnipaque contrast medium. Multiplanar reformations were prepared. COMPARISON: None. FINDINGS: CT ABDOMEN WITH CONTRAST: The imaged lung bases are clear without pleural or pericardial effusion. The liver is normal attenuation. Mild intrahepatic biliary ductal dilatation could be normal in a post cholecystectomy state. The portal and hepatic veins appear patent. A tiny hepatic hypodensity (2:19) is too small to be accurately characterize by CT. The pancreas, spleen and right adrenal gland are unremarkable. The left adrenal gland has a pancake morphology in the setting of an absent left kidney. The right kidney enhances and excretes contrast appropriately without hydronephrosis. The stomach and small bowel are largely unremarkable. The appendix is not definitively identified though there is no right lower quadrant stranding to suggest appendicitis. A moderate fecal load is seen in the colon. There is no mesenteric or retroperitoneal adenopathy. No free air or free fluid is seen in the abdomen. The aorta and major branches are patent and normal in caliber without significant atherosclerotic calcification. CT PELVIS WITH CONTRAST: The bladder and rectum are unremarkable. The uterus is either surgically absent or atrophic. Surgical clips are seen in the left adnexa. There is no pelvic or inguinal adenopathy. No pelvic free fluid is seen. OSSEOUS STRUCTURES: No suspicious lytic or blastic bony lesion is seen to suggest osseous malignancy. Posterior rod and screw fusion at L5-S1 is noted without hardware related complications. IMPRESSION: 1. No acute intra-abdominal process to explain the patient's symptoms. Appendix not definitely seen without inflammatory changes in the right lower quadrant to suggest appendicitis. Moderate fecal load. 2. Mild intrahepatic biliary prominence may be normal in the setting of cholecystectomy. Correlate with labs to determine the role of MRCP. 3. Absent left kidney. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN EPIGASTRIC temperature: 98.6 heartrate: 80.0 resprate: 16.0 o2sat: 96.0 sbp: 164.0 dbp: 87.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, You were admitted for abdominal pain and nausea. During your time here you were given several medications to alleviate your pain and control the nausea. Your symptoms on presentation were suggestive of a gastrointestinal disease called GASTROPARESIS (your stomach and gut moves slower). When we treated you with a medication that promotes movement of your gut, you felt better and were able to eat some food and keep it down. We conducted lab tests to evaluate you for other possible autoimmune diseases such as Celiac's and we did not find anything irregular. You had an imaging study (CT Scan of your abdomen and pelvis) that came back with no abnormalities. You also had an endoscopy which did not reveal abnormalities. The GI (stomach and gut) doctors recommended that ___ with them in outpatient clinic. They will determine if a gastric emptying study or other examination such as colonscopy will be needed. Your TSH level was high during admission, so we increased your Levothyroxine dose to 75mcg. Please ___ with your primary care physician for continued maintenance of your hypothyroidism. Please take these NEW medications: - Reglan 10 mg before every meal and bedtime to help your gut and stomach move food better to reduce nausea and vomiting. - Docusate Sodium 100 mg twice a day as needed for constipation. This medication helps soften your stool. - Senna 1 tablet twice a day as needed for constipation. Please CHANGE the dose of the following medications: - Take 75 mcg of Levothyroxine daily Please ___ with your gastroenterologist and primary care physicians with appointments scheduled.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Codeine / Percocet / Bactrim DS / vancomycin Attending: ___ Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a ___ year-old male who presents with weakness since waking up yesterday morning. He has a history of hypereosinophilia (HES) which he states causes him vague diffuse body pains and weakness (despite now normal eosinophil count), and he has been in rehab since discharge from this hospital on ___. He was initially admitted at this last hospitalization for joint pains and worsening lower extremity ulcers. At that time he was also found to have a DVT and was placed on coumadin after heparin bridge. Pt states that he woke up 1 day PTA and noticed he had wet the bed. He then tried to get up but felt too weak to stand. He required help getting to the commode and was unable to maintain standing posture for more than a few seconds. He says he was weak before but this is a new feeling. He feels weak all over but left is weaker than right side, and this is new. Denies headache, numbness, tingling, parasthesias, or worsening joint pain. Neuro ROS: Positive for wakness. Negative for headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies numbness, parasthesiae. No bowel incontinence. General ROS: no 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 habits. No dysuria. Endorses chronic diffuse arthralgias or myalgias. Denies rash. Past Medical History: --Hypereosinophilic Syndrome (see OMR for full details) --Lower Extremity Cellulitis --Venous stasis ulcers -- RLE non-healing chronic venous stasis ulcers w/ recurrent infections (cultures in the past have grown CoNS, MSSA, pseduomonas, GBS, E. coil, enterobacter, VRE and bacteroides), ulcer debridement w/ skin graft/wound vac ___, debridement ___, STSG ___. --Right thigh DVT ___ which was thought to be ___ HES --Sciatica --Hypertension --Bilateral knee osteoarthritis --GERD --OSA on CPAP --Remote hx of eczema --Hx of C5-C6 fracture in ___ --Bilateral inguinal hernia repair at age ___ or ___ --Blood clot removed from anterior shin on right leg, s/p trauma --Bilateral ear implants to correct cartilage defect in pinna --Lymph node biopsy ___ (cat scratch fever) --Rotator cuff repair ___ --Lap band bariatric surgery ___ Social History: ___ Family History: No early deaths. Father died at ___ of MI. Mother died at ___ of CHF. No family history of hematological disease or heme malignancies, mother with rheumatological disease. Physical Exam: Physical Exam: Vitals: T: 97.9, P: 80, R:16 BP: 113/62 SaO2: 95% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no LAD. No nuchal rigidity Pulmonary: lcta b/l Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft, NT/ND, +BS, obese Extremities: warm, edematous, chronic venous stasis changes bilat ___ ___: no rashes or lesions noted, ecchymoses from heparin on arms. Neurologic: Mental Status: Awake, alert, oriented to person, place and date. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Able to follow both midline and appendicular commands. No right-left confusion. Able to register 3 objects and recall ___ at 5 minutes. No evidence of apraxia or neglect Language: speech is clear, fluent, nondysarthric with intact naming, repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to read without difficulty. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk, tone throughout. Exam severely limited by shoulder and knee pain bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 3 ___ ___ 3 4 4 4 4 5 5 R 4 ___ ___ 3 4 4 4 4 5 5 Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. DTRs: Bi Tri ___ Pat Ach L 3 2 3 2 1 R 3 2 3 2 1 Plantar response was flexor bilaterally. No cross adductors or clonus. Coordination: No intention tremor or dysmetria on finger-nose, FNF and RAM on right, but refuses to do left arm due to pain. Cannot lift either leg high enough to do HKS. Gait: deferred Discharge exam: Afebrile, VSS. General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no LAD. No nuchal rigidity Pulmonary: lcta b/l Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft, NT/ND, obese Extremities: warm, edematous, chronic venous stasis changes bilat ___ ___: no rashes or lesions noted, ecchymoses from heparin on arms. Neurologic: Mental Status: Awake, alert, oriented to person, place and date. Language: speech is clear, fluent, nondysarthric with intact naming, repetition and comprehension. Normal prosody. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without 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: Normal bulk, tone throughout. Exam severely limited by shoulder and knee pain bilaterally.. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 4 ___ ___ 3 4 4 4 4 5 5 R 4 ___ ___ 3 4 4 4 4 5 5 Sensory: No focal deficits. DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. Coordination: No intention tremor or dysmetria on finger-nose, FNF and RAM on right, but much slower with left arm due to pain. Cannot lift either leg high enough to do HKS. Pertinent Results: ___ 09:45AM CHOLEST-124 ___ 09:45AM %HbA1c-5.2 eAG-103 ___ 09:45AM TRIGLYCER-74 HDL CHOL-43 CHOL/HDL-2.9 LDL(CALC)-66 ___ 09:45AM TSH-1.6 ___ 01:12AM LACTATE-1.4 ___ 12:30AM GLUCOSE-107* UREA N-28* CREAT-0.8 SODIUM-131* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-26 ANION GAP-15 ___ 12:30AM ALT(SGPT)-12 AST(SGOT)-12 ALK PHOS-71 TOT BILI-0.5 ___ 12:30AM LIPASE-58 ___ 12:30AM ALBUMIN-3.4* CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-2.0 ___ 12:30AM WBC-3.3* RBC-3.70* HGB-10.2* HCT-32.2* MCV-87 MCH-27.6 MCHC-31.7 RDW-17.1* ___ 12:30AM NEUTS-93.5* LYMPHS-2.6* MONOS-3.3 EOS-0.2 BASOS-0.2 ___ 12:30AM PLT COUNT-433 ___ 12:30AM ___ PTT-36.1 ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atovaquone Suspension 1500 mg PO DAILY 3. Calcium Carbonate 500 mg PO QID 4. Citalopram 20 mg PO DAILY 5. Furosemide 20 mg PO DAILY Please hold for SBP <100. 6. Gabapentin 600 mg PO TID 7. Levofloxacin 500 mg PO Q24H 8. Lisinopril 40 mg PO DAILY Please hold for SBP <100. 9. Lorazepam 1 mg PO HS:PRN Insomnia Please hold for oversedation or RR <10. 10. Nystatin Oral Suspension 5 mL PO QID Mouth pain 11. OLANZapine 5 mg PO HS 12. Omeprazole 40 mg PO DAILY 13. PredniSONE 5 mg PO DAILY 14. ValGANCIclovir 900 mg PO Q24H 15. Vitamin D 800 UNIT PO DAILY 16. HYDROmorphone (Dilaudid) ___ mg IV Q6H:PRN Pain/premedicate before dressing changes 17. Acetaminophen 650 mg PO Q6H 18. Docusate Sodium 100 mg PO BID 19. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain 20. Miconazole Powder 2% 1 Appl TP BID:PRN fungal rash 21. Morphine SR (MS ___ 30 mg PO Q12H 22. Polyethylene Glycol 17 g PO DAILY:PRN constipation 23. Senna 1 TAB PO BID:PRN Constipation 24. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush 25. Warfarin 2.5 mg PO DAILY16 please titrate dose for INR goal ___, since INR 2.8 and rising, dose is reduced to 2.5mg for ___ and ___ and can resume ___ if he is in steady range Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY 3. Atovaquone Suspension 1500 mg PO DAILY 4. Calcium Carbonate 500 mg PO QID 5. Citalopram 20 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Furosemide 20 mg PO DAILY Please hold for SBP <100. 8. Gabapentin 600 mg PO TID 9. HYDROmorphone (Dilaudid) ___ mg IV Q6H:PRN Pain/premedicate before dressing changes 10. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain 11. Levofloxacin 500 mg PO Q24H 12. Lisinopril 40 mg PO DAILY Please hold for SBP <100. 13. Lorazepam 1 mg PO HS:PRN Insomnia Please hold for oversedation or RR <10. 14. Miconazole Powder 2% 1 Appl TP BID:PRN fungal rash 15. Morphine SR (MS ___ 30 mg PO Q12H 16. Nystatin Oral Suspension 5 mL PO QID Mouth pain 17. OLANZapine 5 mg PO HS 18. Omeprazole 40 mg PO DAILY 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation 20. PredniSONE 5 mg PO DAILY 21. Senna 1 TAB PO BID:PRN Constipation 22. ValGANCIclovir 900 mg PO Q24H 23. Vitamin D 800 UNIT PO DAILY 24. Warfarin 3 mg PO DAILY16 please titrate dose for INR goal ___, since INR 2.6 on admission, we kept his dose at 3mg daily during this admission Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Weakness - generalized 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: New left-sided weakness. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. Coronal, sagittal, thin-section bone reconstruction algorithm images were acquired. COMPARISON: NECT of the head ___. FINDINGS: There is no hemorrhage, edema, mass effect, or evidence of infarction. Subtle hypodensity in the posterior limb of the right internal capsule may be due to artifact and is not appreciated on NECT of the head of ___. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. Gray-white matter differentiation is preserved. The calvaria are unremarkable. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. Previously noted polypoidal lesion in nasopharynx is again noted. IMPRESSION: 1. No acute intracranial abnormality. 2. Subtle hypodensity in the posterior limb of the right internal capsule may be due to artifact. Recommend correlating this with neurologic deficits. Radiology Report INDICATION: Weakness. Evaluation for pneumonia. ___. FINDINGS: Portable AP radiograph demonstrates no focal consolidation, pleural effusion, or pneumothorax. Lung volumes are low with mild elevation of the left hemidiaphragm. The cardiomediastinal silhouette is normal. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Question stroke. COMPARISON: CT from ___ and ___. TECHNIQUE: Axial CT images were acquired through the head without intravenous contrast. Thereafter, images were acquired through the head and neck following the uneventful intravenous administration of iodine-based contrast. From these latter images, multiplanar maximum intensity projection reformats, as well as three-dimensional vascular reconstructions, volume-rendered images and curved reformatted images were created. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage, edema, mass effect or vascular territorial infarction. Ventricles and sulci are normal in size and in configuration. A polypoid lesion sitting within the nasopharynx described on previous CT examinations is redemonstrated (series 2, image 1). There is mild mucosal thickening in the superior aspect of the frontal sinus, as well as posteriorly in the left aspect of the sphenoid sinus. Mastoid air cells are clear. CT ANGIOGRAM OF THE HEAD AND NECK: Images at the upper thorax up to the thoracic inlet are limited to streak artifact, likely secondary to patient habitus. That being said, there is a normal three-vessel branching pattern to the aortic arch. The origin of both common carotids is normal, as is that of the left vertebral artery, though this latter is difficult to evaluate secondary to the technical matters discussed above. In addition, note is made of a markedly diminutive right vertebral artery, the origin of which is not clearly visualized. The aortic bifurcations are clear bilaterally and there is no hemodynamically significant stenosis. The minimum diameter of the right internal carotid artery proximally is 8.8 mm, in comparison to the diameter of 4.1 mm distally. Similar measurements on the left are 9.6 mm proximally and 4.5 mm distally. Intracranial circulation reveals a moderate amount of atherosclerotic calcification along the cavernous portions of the internal carotid arteries bilaterally. Anatomy is conventional in orientation. There are no luminal caliber irregularities to suggest thromboembolic filling defect, dissection or aneurysm. Soft tissue structures of the neck reveal bilateral palatine tonsilliths. There is no space-occupying mass in the neck or lymphadenopathy by size criteria. The thyroid is notable for a posterior nodule extending from the right lobe, the precise margins of which are difficult to measure given the artifact at this level. Imaged portions of the lung apices are clear as are imaged portions of the mediastinum. Degenerative changes are present in the spine, though there is no suspicious sclerotic or lytic lesion. IMPRESSION: 1. No acute intracranial hemorrhage or evidence of vascular territorial infarction. If concern persists, and the patient is able, would consider MRI for further evaluation. 2. No evidence of aneurysm, pseudoaneurysm, dissection or thromboembolic filling defect. Notably, the level of the thoracic inlet is limited due to streak artifact and thus the origin of the diminutive right vertebral artery and normal caliber left vertebral artery is not well evaluated. 3. Right posterior thyroid nodule. Precise margination is difficult given the streak artifact. If not already performed, would recommend comparison to thyroid function tests and thyroid sonography on a non-urgent basis. 4. Soft tissue in the nasopharynx, likely a polyp. If relevant clinically, this could be correlated to direct examination. Radiology Report HISTORY: ___ male with recent possible right-sided stroke, now with new changes in mental status. Assess for hemorrhage given anticoagulation. COMPARISON: Non-contrast head CT from ___. TECHNIQUE: MDCT axial images of the brain were obtained without intravenous contrast. Coronal and sagittal reformations were prepared. NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass, mass effect, or infarction. Previously described subtle hypodensity in the posterior limb of the right internal capsule is not evident on the current study and likely reflected artifact previously. Gray-white matter differentiation is preserved. Ventricles and sulci are normal in size and configuration. There is no shift of the usually midline structures. Suprasellar and basilar cisterns are widely patent. There is no scalp hematoma or acute skull fracture. A polypoid lesion within the nasopharynx is unchanged from prior examination (2:1). The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No evidence of hemorrhage or infarction. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: WEAKNESS Diagnosed with OTHER MALAISE AND FATIGUE temperature: 96.3 heartrate: 98.0 resprate: 16.0 o2sat: 95.0 sbp: 124.0 dbp: 57.0 level of pain: 0 level of acuity: 2.0

You presented to the emergency department for diffuse weakness, and a CT of your head was initially concerning for a possible small stroke. You were admitted to the stroke service and received a CT-angiogram, and this was not revealing for a new stroke. Additionally, the final read from the CT you had in the ED returned as negative for stroke as well. Your blood work was overall reassuring, and you are already receiving medications to help prevent future strokes (aspirin and warfarin). Your weakness is thought to be secondary to your underlying medical conditions (HES) and perhaps deconditioning or mild dehydration. We felt your exam improved while in the hospital and you also reported you felt your weakness was improved. We will discharge you back to your rehab facility with the same medications you were on before.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Ultram Attending: ___. Chief Complaint: low back and left thigh pain Major Surgical or Invasive Procedure: drainage of superficial seroma History of Present Illness: ___ F recently discharged 8 days ago s/p two-staged anterior and posterior L4-S1 fusion by Dr. ___ had been recovering well for the first week after surgery but reports worsening pain over the last week. The pain is particularly in her left thigh. She came into the ED for further evaluation. She has full strength and intact sensation throughout. No bowel or bladder changes. The pain feels similar to when she previously expereinced a PE. Given her recent surgery, ortho spine was consulted. Past Medical History: HTN HLD hypothyroidism anxiety Social History: ___ Family History: noncontributory Physical Exam: On examination the patient is well developed, well nourished, A&O x3 in NAD. AVSS. Range of motion of the lumbar spine is somewhat limited on flexion, extension and lateral bending due to pain. Ambulating well with the assistance of a walker and ___, with lumbar corset brace for support. Gross motor examination reveals good strength throughout the bilateral lower extremities. There is no clonus present. Sensation is intact throughout all affected dermatomes. The anterior and posterior lumbar incisions are clean, dry and intact without erythema, edema or drainage. The patient is voiding well without a foley catheter. Pertinent Results: ___ 03:55AM BLOOD WBC-9.8 RBC-3.51* Hgb-11.0* Hct-33.6* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.9 Plt ___ Radiology Report EXAMINATION: MR ___ AND W/O CONTRAST INDICATION: ___ year old woman with back pain/seroma/s/p lumbar fusion // hematoma vs. infection hematoma vs. infection TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging wasperformed. Post-contrast images were obtained. COMPARISON: No prior MRI. Prior x-ray dated ___. FINDINGS: Patient is status post L4-S1 posterior spinal fusion with interbody spacers. Alignment is maintained. There is abnormal T2/STIR signal in the L1 and L2 vertebral bodies with post-contrast enhancement within these vertebral bodies as well as within the intervertebral disc space. There is signal abnormality noted in the L4 through S1 vertebral bodies which is likely postoperative all the infection cannot be entirely excluded. There is a central/left paracentral disc protrusion at L1-L2 without significant spinal canal stenosis. There is disc bulge at L2-L3 without significant spinal canal stenosis. There is no canal compromise in the region of surgery. There is clumping of the nerve roots noted beginning at L4 and extending through to the level of S1 suspicious for arachnoiditis. Postoperative images reveal enhancing tissue in the operative bed and epidural space which is most likely postoperative granulation tissue. There is a superficial collection in the posterior subcutaneous tissues which measures 12.0 cm SI by 5.7 cm TV and is likely postoperative. A right-sided extra renal pelvis is incidentally noted. IMPRESSION: 1. Abnormal T2 signal and enhancement within the L1 and L2 vertebral bodies with post-contrast enhancement also noted within the L1-L2 intervertebral disc space. While these findings could be seen in degenerative disease, infection cannot be excluded. Comparison to prior studies would be useful. 2. Patient is status post L4-S1 posterior spinal fusion. There is no canal compromise in the region of surgery There is mild clumping of the nerve roots in this region suggesting a arachnoiditis. 3. 12.0 cm SI x 5.7 cm TV fluid collection in the posterior subcutaneous tissues likely postoperative Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with left leg pain. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow and augmentation of the left common femoral, superficial femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. The right common femoral vein was not able to be imaged secondary to patient discomfort. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT) INDICATION: History: ___ with lower back pain 2 weeks post op from L4-S1 fusion. TECHNIQUE: AP and lateral radiographs of the lumbar spine. COMPARISON: Intraoperative radiograph ___ FINDINGS: 5 non-rib-bearing lumbar vertebral bodies are present. There has been L4-S1 posterior spinal fusion with interbody spacers. Hardware appears satisfactory in alignment with no perihardware lucency. Morcellized bone graft is noted lateral to the fusion hardware. Loss of disc height at L1-2 with endplate sclerosis is unchanged from ___. No evidence of fracture. Vascular calcifications of the abdominal aorta noted. No significant sacroiliac joint sclerosis. Radiopaque density to the left of the L2-3 interspace may represent an ingested pill. IMPRESSION: Status post L4-S1 posterior spinal fusion with no evidence of hardware complication or acute traumatic injury. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Leg numbness, L Leg pain Diagnosed with LUMBAGO, ARTHRODESIS STATUS temperature: 99.0 heartrate: 92.0 resprate: 18.0 o2sat: 99.0 sbp: 146.0 dbp: 86.0 level of pain: 10 level of acuity: 2.0

ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks. ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. You will be more comfortable if you do not sit or stand more than ~45 minutes without changing positions. BRACE: You have been given a brace. This brace should be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. WOUND: Remove the external dressing in 2 days. If your incision is draining, cover it with a new dry sterile dressing. If it is dry then you may leave the incision open to air. Once the incision is completely dry, (usually ___ days after the operation) you may shower. Do not soak the incision in a bath or pool until fully healed. If the incision starts draining at any time after surgery, cover it with a sterile dressing. Please call the office. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. MEDICATIONS: You should resume taking your normal home medications. Refrain from NSAIDs immediately post operatively. You have also been given Additional Medications to control your post-operative pain. Please allow our office 72 hours for refill of narcotic prescriptions. Please plan ahead. You can either have them mailed to your home or pick them up at ___ ___, ___. We are not able to call or fax narcotic prescriptions to your pharmacy. In addition, per practice policy, we only prescribe pain medications for 90 days from the date of surgery.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cephalexin Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ TAVR ___ Tunneled HD line History of Present Illness: Mr. ___ is a ___ year-old ___ speaking male with PMH notable for triple-vessel CAD s/p DES to OM2 on ___, severe AS, Stage V CKD (not yet on HD), T2DM, EtOH cirrhosis, and L ACA CVA (___) who initially presented to the ED with chest pain. He reports substernal chest pain that began this afternoon while at rest. It is unclear whether he took nitroglycerin at home. He reports compliance with his home aspirin/Plavix. His wife called EMS and he was taken to the ___ ED. While in route, patient received nitroglycerin gtt, which was stopped on arrival to the ___ ED. Notably, he was recently admitted to ___ from ___ for chest pain c/w unstable angina. After discussion with his outpatient nephrologist, he underwent coronary angiography and was found to have 3VD, s/p DES to OM. He was started on aspirin/Plavix at this time and continued on his home metoprolol and statin. Regarding his severe AS, plan was for outpatient follow-up for consideration of TAVR vs. SAVR. On arrival to the ED, initial vitals BP 107/53 HR 87 RR 22 O2 98% RA. Initial labs notable for: - WBC 8/.7, Hgb 8.7, INR 1.1 - pro-BNP 9850 - ALT 55, AST 64, AP 91, Tbili 0.3, - trop-T 0.1, MB 7 - BUN 72, Cr 6.2, glucose 57, AG 27 - Lactate 5.3 ECG: STE aVR 3mm with diffuse depressions --> CODE STEMI called Consults: - Cardiology: Bedside echo with hypokinesis of anterior wall and mild collapse of IVC. Recommend admission to CCU for possibly STEMI Patient received: - 1L NS, IV morphine sulfate 4mg x1, heparin gtt, IV ondansetron 4mg x1 Transfer vitals: BP 88/51 HR 82 RR 20 O2 97% RA On arrival to the CCU, patient reports that his chest pain has resolved. He denies abdominal pain but endorses intermittent nausea. His wife is at the bedside and endorses the above history. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: . CVD Risk Factors - HTN - HLD - T2DM - Stage V CKD - Former tobacco use 2. Cardiac History - CAD with 3VD s/p DES to ___ - Severe aortic stenosis 3. Other PMH - L ACA CVA (___) - Depression - EtOH cirrhosis - BPH Social History: ___ Family History: Father MI ___, Mother stroke ___ Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== VS: 97.8 109/68 (82) 83 17 93% 2L NC GENERAL: Well-appearing, well-developed male, in NAD HEENT: NC/AT, EOMI, PERRL anicteric sclera, dry MM NECK: Supple. JVP 10cm at 90 degrees CARDIAC: RRR, grade IV/VI systolic murmur heard best at LUSB with radiation to carotids LUNGS: CTAB, breathing comfortably on RA, no wheezes, rhonci, or rales ABDOMEN: Soft, non-tender, non-distended, active bowel sounds, no appreciable hepatomegaly EXTREMITIES: No c/c/e SKIN: Warm, well-perfused, no rashes PULSES: Distal pulses palpable and symmetric NEURO: Alert, answers to name, moving all extremities with purpose, no facial asymmetry ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: Temp: 98.7 (Tm 99.3), BP: 127/66 (107-129/54-69), HR: 73 (63-74), RR: 18 (___), O2 sat: 97% (95-100), O2 delivery: RA GENERAL: Well-appearing, well-developed male, resting comfortably in bed at HD NECK: Supple. JVP 8-10 cm at 45 degrees. CARDIAC: RRR, grade ___ systolic murmur heard best at LUSB LUNGS: faint bibasilar crackles, breathing comfortably, no wheezes or rhonchi anteriorly ABDOMEN: Soft, non-tender, non-distended, active bowel sounds, no appreciable hepatomegaly EXTREMITIES: trace BLE edema SKIN: Warm, well-perfused, spider angioma right chest. NEURO: Alert, answers to name, moving all extremities with purpose, no facial asymmetry Pertinent Results: =============== ADMISSION LABS: =============== ___ 01:15AM ___ PTT-26.7 ___ ___ 01:15AM PLT COUNT-184 ___ 01:15AM NEUTS-75.6* LYMPHS-16.1* MONOS-4.7* EOS-1.6 BASOS-1.3* IM ___ AbsNeut-6.57* AbsLymp-1.40 AbsMono-0.41 AbsEos-0.14 AbsBaso-0.11* ___ 01:15AM WBC-8.7 RBC-2.93* HGB-8.7* HCT-26.8* MCV-92 MCH-29.7 MCHC-32.5 RDW-13.2 RDWSD-44.4 ___ 01:15AM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-5.4* MAGNESIUM-2.3 ___ 01:15AM CK-MB-7 proBNP-9850* ___ 01:15AM cTropnT-0.10* ___ 01:15AM ALT(SGPT)-55* AST(SGOT)-64* CK(CPK)-146 ALK PHOS-91 TOT BILI-0.3 ___ 01:15AM estGFR-Using this ___ 01:15AM GLUCOSE-57* UREA N-72* CREAT-6.2* SODIUM-145 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-13* ANION GAP-27* ___ 01:37AM LACTATE-5.3* ___ 04:15AM LACTATE-5.9* =============== DISCHARGE LABS: =============== ___ 01:30AM BLOOD WBC-8.4 RBC-2.27* Hgb-6.8* Hct-20.2* MCV-89 MCH-30.0 MCHC-33.7 RDW-12.9 RDWSD-41.6 Plt ___ ___ 01:30AM BLOOD ___ PTT-60.9* ___ ___ 01:30AM BLOOD Glucose-92 UreaN-47* Creat-5.0* Na-137 K-3.9 Cl-97 HCO3-26 AnGap-14 ___ 01:30AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3 ============= MICROBIOLOGY: ============= ___ 2:22 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 2:23 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:22 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:24 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:49 am BLOOD CULTURE Source: Venipuncture #1. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH ====================== IMAGING/OTHER STUDIES: ====================== ___ Duplex Dop Abd/Pel Limited Normal appearance of hepatic parenchyma. Unchanged bilobed hepatic cyst in the left hepatic lobe. Patent portal vein. No ascites. Relatively normal appearance of the gallbladder. Trace pericholecystic fluid may be related to reported underlying liver disease versus cardiac insufficiency. ___ TTE The left atrial volume index is mildly increased. The right atrium is mildly enlarged. There is no evidence of an atrial septal defect or patent foramen ovale by 2D/color Doppler or agitated saline at rest and with maneuvers. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild (non-obstructive) focal basal septal hypertrophy. The visually estimated left ventricular ejection fraction is 65%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal with a mildly dilated descending aorta. The aortic valve leaflets are severely thickened. There is severe aortic valve stenosis (valve area index less than 0.6 cm2/m2). There is mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. The transmitral E-wave deceleration time is short (<140ms). There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. There is a trivial pericardial effusion. ___ Aorta and Branches Extensive atherosclerotic calcification within the abdominal aorta without evidence of abdominal aortic aneurysm. ___ TTE The left atrium is normal in size. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is 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 63 %. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch is mildly dilated. There is no evidence for an aortic arch coarctation. A ___ 3 aortic valve bioprosthesis is present. The prosthesis is well seated with normal leaflet motion and gradient. There is a paravalvular jet of mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial 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 a trivial pericardial effusion. Liver cyst(s) are seen. ___ Tunneled Dialysis Line Patent left internal jugular vein. Final fluoroscopic image showing 23 cm tunneled dialysis catheter with tip terminating in the right atrium. 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. Medications on Admission: 1. Clopidogrel 75 mg PO DAILY 2. Sodium Bicarbonate 650 mg PO TID 3. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild 4. Allopurinol ___ mg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Clotrimazole Cream 1 Appl TP BID:PRN fungal 8. Cyanocobalamin 1000 mcg PO DAILY 9. Donepezil 10 mg PO DAILY 10. Fexofenadine 180 mg PO DAILY 11. HydrALAZINE 50 mg PO Q6H 12. Metoprolol Succinate XL 100 mg PO DAILY 13. Nephrocaps 1 CAP PO DAILY 14. Rosuvastatin Calcium 40 mg PO QPM 15. Tamsulosin 0.4 mg PO DAILY 16. Vitamin D ___ UNIT PO DAILY 17. Fish Oil (Omega 3) ___ mg PO BID 18. Multi-Vitamins with Iron (pediatric multivit-iron-min) ___ mg oral DAILY Discharge Medications: 1. Carvedilol 12.5 mg PO BID 2. Lanthanum 500 mg PO TID W/MEALS 3. sevelamer CARBONATE 800 mg PO TID W/MEALS 4. Warfarin 3 mg PO DAILY16 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild 7. amLODIPine 10 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. Clotrimazole Cream 1 Appl TP BID:PRN fungal 10. Cyanocobalamin 1000 mcg PO DAILY 11. Donepezil 10 mg PO DAILY 12. Fexofenadine 180 mg PO DAILY 13. Fish Oil (Omega 3) ___ mg PO BID 14. Multi-Vitamins with Iron (pediatric multivit-iron-min) ___ mg oral DAILY 15. Nephrocaps 1 CAP PO DAILY 16. Rosuvastatin Calcium 40 mg PO QPM 17. Tamsulosin 0.4 mg PO DAILY 18. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ================== PRIMARY DIAGNOSES: ================== Undifferentiated shock Type II non-ST elevation myocardial infarction Severe aortic stenosis, status post transcatheter aortic valve replacement Chronic kidney disease, initiated on hemodialysis Aspiration pneumonia Paroxysmal atrial fibrillation ====================== CHRONIC/STABLE ISSUES: ====================== Coronary artery disease with known three vessel disease, status post drug eluting stent to OM2 Hypertension Normocytic anemia Ethanol cirrhosis Type II diabetes mellitus Benign prostatic hypertrophy 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: ___ year old man with CAD, severe AS, ESRD here with hypotension c/f infection vs. cardiogenic shock.// concern for infection concern for infection IMPRESSION: Compared to chest radiographs since ___ most recently ___. Moderate cardiomegaly has increased, mild pulmonary edema is new. No appreciable pleural effusion. No pneumothorax. Rightward deviation and left-sided indentation of the cervical trachea may be slightly more pronounced today than in ___, usually due to an enlarged thyroid. Most recent thyroid ultrasound was performed ___ showing bilateral thyroid nodules. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with etoh cirrhosis, here with hypotension c/f infection vs. cardiogenic shock, assess for ascites for diagnostic tap, if possible// ascites TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Multiple prior comparisons, most recent from ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is bilobed hepatic cyst in the left hepatic lobe with thin septation, not significantly changed dating back ___. There is no concerning focal liver mass.. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 4 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. 3 mm gallbladder polyp is seen along the body of the gallbladder. Trace pericholecystic fluid is seen. 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. Spleen length: 10.7 cm KIDNEYS: Limited views of the right kidney show no hydronephrosis. Again seen is a 2.5 cm simple cyst in the lateral aspect of the right kidney. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Normal appearance of hepatic parenchyma. Unchanged bilobed hepatic cyst in the left hepatic lobe. Patent portal vein. No ascites. 2. Relatively normal appearance of the gallbladder. Trace pericholecystic fluid may be related to reported underlying liver disease versus cardiac insufficiency. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with respiratory distress and worsening hypoxia// interval change interval change IMPRESSION: Compared to chest radiographs ___ and ___. Since ___ the then new pulmonary vascular congestion in the left lung and moderate enlargement of cardiac silhouette of both cleared. However there is now relatively uniform severe opacification on the right that I hesitate to attribute to either pleural effusions since the examination is reported as having been performed with the patient upright or pneumonia in the absence of air bronchograms or obscuration of any contours in the right hemithorax. RECOMMENDATION(S): Chest CT. Repeat chest radiograph to see if chest CT scanning is indicated. NOTIFICATION: The findings were discussed with ___., M.D. by ___ ___, M.D. on the telephone on ___ at 9:33 am, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with severe AS, NSTEMI, low grade fever WBC and new consolidation// PNA? Please sit up as much as possible during film PNA? Please sit up as much as possible during film IMPRESSION: Compared to chest radiographs ___. Mild cardiomegaly has increased. Consolidation in the right midlung is more clearly defined, probably pneumonia. Lower lobe findings could be a combination of asymmetric edema and pleural effusion, as well as pneumonia. No left pleural abnormality. No pneumothorax. Rightward shift of the trachea at the thoracic inlet is attributable to enlarged thyroid. Patient had thyroid ultrasound on ___ describing multinodular goiter. Radiology Report EXAMINATION: AORTA AND BRANCHES INDICATION: ___ year old man with severe aortic stenosis// TAVR vascular access sizing TECHNIQUE: Grayscale and color Doppler ultrasound of the abdominal aorta was performed. COMPARISON: None. FINDINGS: The aorta measures 2.6 cm in the proximal portion, 2.8 cm in mid portion and 2.4 cm in the distal abdominal aorta. The lumen of the aorta measures 1.7 cm in the proximal portion, 2.2 cm in the midportion, and 2.0 cm in the distal portion. There is severe calcified atherosclerotic plaque. Wall-to-wall color flow is seen within the aorta with appropriate arterial waveforms. The right common iliac artery measures 1.6 cm and the left common iliac artery measures 1.8 cm. The lumen of the right common iliac artery measures 1.1 cm and the lumen of the left common iliac artery measures 1.3 cm. The right kidney measures 9.7 cm and the left kidney measures 9.1 cm. Bilateral kidneys appear mildly atrophic without hydronephrosis. IMPRESSION: Extensive atherosclerotic calcification within the abdominal aorta without evidence of abdominal aortic aneurysm. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p TAVR placement with cough// evidence of pneumonia/ pulm edema? evidence of pneumonia/ pulm edema? IMPRESSION: Comparison to ___. The pre-existing parenchymal opacity at the right lung bases has completely cleared. On the current image, there is no evidence of parenchymal abnormalities. No pulmonary edema. No pneumonia. No pleural effusions. Stable borderline size of the cardiac silhouette. No pneumothorax. Radiology Report INDICATION: ___ with PMH notable for triple-vessel CAD s/p DES to OM2 on ___, severe AS, DM with worsening CKD-5 now requiring initiation of HD.// placement of LEFT tunneled dialysis catheter COMPARISON: Radiograph of the chest dated ___ TECHNIQUE: OPERATORS: Dr. ___ radiologist, performed the procedure. ANESTHESIA: Intravenous administration of 50 mcg of fentanyl was performed 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, ortho solution, 1% lidocaine CONTRAST: 10 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 11.1 min, 94 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 left upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a Amplatz wire was advanced however would not passed easily into the IVC. A MPA catheter and Glidewire were used to attempt to get access to the IVC. Due to difficulty, a small contrast injection was performed which demonstrated position within the atrium and the hepatic veins. Ultimately, a hepatic vein was selected and the Amplatz wire was passed into the a hepatic vein. 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 using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the Amplatz 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. 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 left internal jugular vein. Final fluoroscopic image showing 23 cm tunneled dialysis 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: M Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Unstable angina, Athscl heart disease of native coronary artery w/o ang pctrs, Chest pain, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: UTA level of acuity: 2.0

Dear ___, WHY YOU CAME TO THE HOSPITAL - You came to ___ as you had chest pain. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were found to have a heart attack. This was thought to be largely due to a bad heart valve, in addition to your coronary artery disease. Your heart valve was replaced. - Your kidney function worsened, and you were started on dialysis. - You were treated for a pneumonia. WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL? - It is important the rehab arrange follow-up with your PCP when you are discharged - You need to follow-up with your cardiologist as arranged - You will start dialysis at ___ dialysis ___ and attend every ___ - It is important you continue to take all your medications as prescribed It was our pleasure taking care of you. We wish you all the best! Your ___ Healthcare Team MEDICATION CHANGES: [] changed allopurinol to 100mg every other day [] started carvedilol 12.5mg twice daily [] started lanthanum 500mg three times daily with meals [] started sevelamer 800mg three times daily with meals [] started warfarin 3mg daily; next INR recheck ___ [] stopped aspirin 81mg daily [] stopped hydralazine 50mg every six hours [] stopped metoprolol succinate 100mg daily [] stopped sodium bicarbonate 650mg three times daily

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: H 1 blocker / H 2 blockers / sulfites / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Celebrex Attending: ___. Chief Complaint: RUQ Pain Major Surgical or Invasive Procedure: Port Placement History of Present Illness: ___ yo gentleman with newly diagnosed pancreatic cancer, high CEA, liver lesion, starting FOLFIRINOX, presenting with CT finding showing possible reactivated TB during chemotherapy presenting with RUQ pain after liver biopsy 2 days prior. He had been taking PO hydromorphone with minimal effect, and felt pain worsenining; was told to come into the ED. Denies fevers, chills, CP/SOB. He does endorse constipation for five days, and has been taking colace/senna at home. In the ED, CT scan performed which showed new small amounts of nonhemorrhagic perihepatic ascites and new nonhemorrhagic pelvic free fluid, with persistent pancreatic fluid collections. He was noted in clinic to have CT with possible TB, and was placed in a TB rule out room. Past Medical History: ONC HISTORY (per OMR): ___ y/o pharmacist who was well until ___ when he started to develop diffuse, low-level abdominal pain which insidiously became more severe with radiation to back, bloating, early satiety, abnormal bowels, and weight loss. He was seen by his PCP and CT scan was performed in ___ that showed changes of necrotizing pancreatitis with fluid collection around the pancreas and cavernous thrombosis of the portal vein. Referred to Dr. ___ pancreatitis w/u unremarkable (no gallstones, normal labs, no new meds, or viral prodrome). PV changes felt to be chronic and heme w/u was recommended to r/o hypercoagulable state. Conservative management was recommended with 6-week f/u MRCP. His symptoms improved and interval MRCP performed on ___ which showed an infiltrative mass in the body of the pancreas extending into the neck and out of the pancreas with extensive vascular involvement, and liver (segment 4A) and peritoneal (2 small nodules) lesions concerning for metastatic disease. Underwent EUS on ___ which showed an >4cm mass in the pancreatic neck extending to the head and duodenum. Extensive cystic changes around the pancreas limited further characterization of the mass (largest cyst 5cmwith significant solid component) and peripancreatic fluid collections ranging from 2-5cm. Multiple varices were noted at the porta-hepatis. FNA of the pancreas, body showed malignant cells consistent with adenocarcinoma. From ___ CA ___: ___ In addition to the pancreatic mass, MRCP showed 8 x 12 mm hypoenhancing lesion in segment 4a concerning for metastatic disease and biopsy was recommended. He had a CT chest on ___ which showed a small cavity with surrounding micronodules in the right upper lobe concerning possibly related to old tuberculosis. He works in the ___ hospital. He report annual TB testing has been negative. He does related chronic sinusitis with surgery in the past and reportedly colonized with pseudomonas. PMH/PSH: Depression, arthritis, allergic rhinitis, IBS, GERD, exercise-induced asthma, h/o rheumatic fever (childhood), L achilles tear, b/l arthroscopies, deviated septum repair Social History: ___ Family History: Father with prostate and kidney CA (late ___. Brother with colon cancer (diagnosed age ___. Sister died of unprovoked PE. Physical Exam: General: NAD VITAL SIGNS: 98.5 ___ 18 97%RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: CTAB ABD: Soft, ND, no masses or hepatosplenomegaly, mild tenderness to palpation in RUQ. LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficits. Pertinent Results: ___ 04:20PM BLOOD WBC-8.4 RBC-4.62 Hgb-13.4* Hct-41.5 MCV-90 MCH-29.0 MCHC-32.3 RDW-12.8 RDWSD-42.1 Plt ___ ___ 07:02AM BLOOD WBC-5.5 RBC-4.33* Hgb-12.6* Hct-38.6* MCV-89 MCH-29.1 MCHC-32.6 RDW-12.7 RDWSD-41.7 Plt ___ ___ 07:02AM BLOOD Glucose-108* UreaN-12 Creat-0.6 Na-139 K-4.5 Cl-102 ___ 04:20PM BLOOD ALT-160* AST-48* AlkPhos-183* TotBili-1.0 ___ 07:02AM BLOOD ALT-62* AST-25 AlkPhos-364* TotBili-0.8 ___ 07:02AM BLOOD Mg-2.0 CT Abd: 1. New small amount of nonhemorrhagic perihepatic ascites. 2. New small amount of predominantly nonhemorrhagic pelvic free fluid, with a small hematocrit level in the deep pelvis. 3. Redemonstration of a known pancreatic head mass, better characterized on prior MRCP. 4. Multiple stable pancreatic walled off fluid collections with surrounding peripancreatic stranding. 5. Stable cavernous transformation of the portal vein. Evaluation of known superior mesenteric vein thrombosis and splenic vein thrombosis is limited however, there is attenuation of the splenic vein, likely secondary to known thrombosis. 6. Persistent enlargement of the left adrenal gland, concerning for metastatic disease as characterized on prior MRCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole 2 mg PO DAILY 2. ClonazePAM 0.5 mg PO QHS:PRN insomnia 3. Creon 12 2 CAP PO TID W/MEALS 4. Cetirizine 10 mg PO Q12H 5. Venlafaxine XR 300 mg PO DAILY 6. Omeprazole 20 mg PO DAILY Discharge Medications: 1. ARIPiprazole 2 mg PO DAILY 2. Cetirizine 10 mg PO Q12H 3. ClonazePAM 0.5 mg PO QHS:PRN insomnia 4. Creon 12 2 CAP PO TID W/MEALS 5. Venlafaxine XR 300 mg PO DAILY 6. 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 7. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 8. Polyethylene Glycol 17 g PO BID:PRN Constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily Disp #*30 Packet Refills:*0 9. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 4 mg PO Q8H:PRN Nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 12. Pyridoxine 50 mg PO DAILY RX *pyridoxine 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 13. Isoniazid ___ mg PO DAILY RX *isoniazid ___ mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pancreatic Cancer Latent TB Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with history of pancreatic adenocarcinoma s/p recent biopsy with acute onset abdominal pain. // abdominal pain TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis from ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. There is moderate amount of stool in the ascending colon. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Nonobstructive bowel gas pattern. Moderate amount of stool in the ascending colon. Radiology Report EXAMINATION: Abdomen and pelvic CT. INDICATION: NO_PO contrast; History: ___ with s/p liver biopsy severe RUQ abdominal painNO_PO contrast // eval for perforation 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 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP = 18.1 mGy-cm. 2) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 12.4 mGy (Body) DLP = 669.7 mGy-cm. Total DLP (Body) = 688 mGy-cm. COMPARISON: MRCP from ___ and abdominal/pelvic CTA from ___. FINDINGS: LOWER CHEST: There is minimal bibasilar atelectasis. There is no pleural or pericardial effusion, ABDOMEN: HEPATOBILIARY: 12 mm hypodensity within segment 4 of the liver is again present, and remains concerning for metastatic disease as characterized on prior dedicated MRCP. The liver otherwise demonstrates homogenous attenuation throughout. There is no evidence of new focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. There is a mall a small amount of non hemorrhagic perihepatic ascites. PANCREAS: Known pancreatic head mass is better characterized on MRCP dated ___, now measuring approximately 3.5 x 3.1 cm. There are multiple peripancreatic fluid collections, the largest encasing the pancreatic tail and measuring 4.4 x 2.9 cm, which overall remain stable since prior CT examination. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right adrenal gland is normal in size and shape. There is persistent enlargement of the left adrenal gland, measuring 12 x 10 mm and showing increased attenuation URINARY: There is a 19 mm hypodensity upper pole of the right kidney which is likely a renal cyst. The kidneys are of normal and symmetric size with normal nephrogram. There is otherwise no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is a small amount of predominantly nonhemorrhagic pelvic free fluid, with a a small hematocrit level noted within the deep pelvis. REPRODUCTIVE ORGANS: The prostate gland is mildly enlarged. LYMPH NODES: There are multiple small retroperitoneal and mesenteric lymph nodes. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. There is cavernous transformation of the portal vein. Evaluation of known superior mesenteric vein thrombosis and splenic vein thrombosis is limited. However, there is attenuation of the splenic vein, likely secondary to known thrombosis. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. New small amount of nonhemorrhagic perihepatic ascites. 2. New small amount of predominantly nonhemorrhagic pelvic free fluid, with a small hematocrit level in the deep pelvis. 3. Redemonstration of a known pancreatic head mass, better characterized on prior MRCP. 4. Multiple stable pancreatic walled off fluid collections with surrounding peripancreatic stranding. 5. Stable cavernous transformation of the portal vein. Evaluation of known superior mesenteric vein thrombosis and splenic vein thrombosis is limited however, there is attenuation of the splenic vein, likely secondary to known thrombosis. 6. Persistent enlargement of the left adrenal gland, concerning for metastatic disease as characterized on prior MRCP. NOTIFICATION: The findings were discussed with Dr. ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:30 AM, 20 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) IN O.R. INDICATION: ___ male with left port placement. TECHNIQUE: Multiple fluoroscopic images of the chest. COMPARISON: Chest radiograph dated ___. FINDINGS: The final image shows a left Port-A-Cath with the tip terminating in the region of the cavoatrial junction. IMPRESSION: Left Port-A-Cath placement with the final image showing the tip terminating in the region the cavoatrial junction. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with pancreatic cancer, rule out TB, now s/p portacath placement. // Assess for pneumothorax, portacath location. Contact name: ___: ___ Assess for pneumothorax, portacath location. IMPRESSION: The left subclavian Port-A-Cath extends to the mid to lower portion of the SVC. No evidence of procedure related pneumothorax. No evidence of acute cardiopulmonary disease. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Right sided abdominal pain Diagnosed with Unspecified abdominal pain temperature: 97.7 heartrate: 104.0 resprate: 18.0 o2sat: 100.0 sbp: 113.0 dbp: 75.0 level of pain: 2 level of acuity: 3.0

You were admitted with abdominal pain likely due to a recent liver biopsy and your underlying pancreatic cancer. You were also having constipation which has now improved. A port was placed as previously scheduled. You were also tested for TB given a concerning finding on your chest CT and started on treatment for latent TB.

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, lightheadedness, fainting during nuclear stress test Major Surgical or Invasive Procedure: s/p pacemaker implantation History of Present Illness: ___ year old man with CAD s/p DES to LAD and LCx (___ ___, NIDDM, HLD, & HTN p/w syncope for 45 sec today during outpatient nuclear stress test. Patient describes going to the test at 10am this morning, without having anything to eat/drink for 12 hours. He was feeling otherwise well and had the dye infusion for 45 minutes. He then proceeded to have the basal rest images performed and about ___ minutes into it, patient began to see purple, and soon after passed out with no recollection of other symptoms. He denied having any CP, SOB, n/v, palps, diaphoresis, lightheadedness, dizziness, vertigo prior to passing out. When he came to, patient began to experience nausea but NO other symptom. Defibrillator pads were placed on the patient but was not used as patient spontaneously converted into a sinus rhythm after about a 45 sec pause. The test was then canceled and pt brought to ED. Pt presented to cardiologist Dr. ___ on ___ c/o increasing DOE for past several months, no chest pain, but similar to his presentation in ___ to ___ where 4 stents were placed in the LAD and LCx. Last stress test ___ suggested inferolateral ischemia and medical therapy was initiated. . Over the past year, he has reported increasing shortness of breath when he exerts himself, particularly when he is swimming. He does not report chest pain and has not had any associated numbness, lightheadedness, or syncope. The dyspnea resolves when he stops exerting himself. During last clinic visit, Dr. ___ ___ the options of proceeding directly to cardiac catheterization versus obtaining an exercise sestamibi stress test to document the location of any potential coronary ischemia. Patient prefered to proceed with a stress test first. . In the ED, initial vitals were 55 125/66 18 99% 10L Non-Rebreather. Patient denied CP, but stated that he had SOB after passing out. Also had some mild lower abd pain. Labs notable for lactate 3.4, d-dimer ___, Cr 1.2, BUN 21, HCO3 19, INR 1.0, trop <0.01, HCT 40.6. Received zofran 4mg x1. Vitals prior to transfer: 97.8. HR:71 (sinus). BP: 104/58. O2: 98% 3LNC. RR: 18. . On arrival to the floor, patient VSS, completely asx, just hungry. No recent illness, diarrhea, nausea, no recent travel. . ROS as above, otherwise negative. Past Medical History: 1. CARDIAC RISK FACTORS: NIDDM, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: Three Vessel CAD with 4 DES to mLAD and mCX AAA repair with endovascular graft (___) 3. OTHER PAST MEDICAL HISTORY: COPD with emphysema - FEF25-75% 20% of predicted. FEV1 2.45 L - 91% predicted. Mild hyrdronephrosis 50pack year h/o smoking, quit ___ yrs ago prostate cancer s/p xrt hypothyroidism Social History: ___ Family History: There is a family history of hypertension, diabetes, and heart disease but not of stroke. His mother died at ___ years of bowel cancer. His father died at age ___ years of an MI. His sister is healthy. Physical Exam: Admission PEx: VS: 97.4 133/64 80 96%RA I/O: 1000/600 GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with no JVD. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. +2dp SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge PEx: VS: 96.8 123/63 73 16 94%RA Weight 88kg GENERAL: NAD. Oriented x3. NECK: Supple, no JVP. 6-7 cm suprasternal soft tissue mass, non tender, non mobile. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs. superficial tenderness over PPM area, bandaged, c/d/i LUNGS: CTAB, no rales, crackles or wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Palpable distal pulses SKIN: No stasis dermatitis, ulcers. Pertinent Results: Labs on Admission: ___ 12:00PM BLOOD WBC-5.8 RBC-4.70 Hgb-13.9* Hct-40.6 MCV-86 MCH-29.6 MCHC-34.3 RDW-13.9 Plt ___ ___ 12:00PM BLOOD Neuts-61.1 ___ Monos-4.9 Eos-1.3 Baso-0.6 ___ 12:00PM BLOOD ___ PTT-29.0 ___ ___ 12:00PM BLOOD Glucose-206* UreaN-21* Creat-1.2 Na-135 K-4.8 Cl-103 HCO3-19* AnGap-18 ___ 12:00PM BLOOD proBNP-172 ___ 12:00PM BLOOD cTropnT-<0.01 ___ 12:00PM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 ___ 12:00PM BLOOD D-Dimer-2151* ___ 12:10PM BLOOD Lactate-3.4* ___ 01:20PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 01:20PM URINE Hours-RANDOM Labs on Discharge: ___ 06:50AM BLOOD WBC-5.6 RBC-4.41* Hgb-13.1* Hct-39.0* MCV-88 MCH-29.6 MCHC-33.5 RDW-13.9 Plt ___ ___ 06:50AM BLOOD Glucose-216* UreaN-17 Creat-1.1 Na-137 K-4.1 Cl-102 HCO3-26 AnGap-13 ___ 06:50AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9 Imaging/Procedures: EKG ___: Sinus rhythm @58. Occasional ventricular premature beat. Generalized low QRS voltages. No previous tracing available for comparison. CXR: No acute cardiopulmonary process. CTA Chest/Abd: IMPRESSION: 1. No pulmonary embolism. Infrarenal abdominal aortic aneurysm with evidence of endoleak, likely type II from a right-sided lumbar artery. No evidence of impending hemorrhage. 2. Linear lucency in the left first rib appears to be well-corticated and may represent remote fracture. 3. A linear lucency in the left S1 with no evidence of cortication may represent a more recent traumatic fracture. Please correlate with clinical history. 4. Thickened bladder wall likely represents combination of collapse and hypertrophy from chronic outlet obstruction due to enlarged prostate, but cannot exclude infectious process. Please correlate with urine analysis. EKG ___: Sinus rhythm with ventricular premature beats and demand atrial pacing. Generalized low QRS voltage. Compared to the previous tracing of ___ demand atrial pacing and ventricular premature beats are new. QRS voltage is lower. CXR ___: A dual-chamber pacemaker is present, with one lead in the right ventricle, the other in the right atrium. No pneumothorax is present. The lung fields are clear. Medications on Admission: ATENOLOL 25 mg Tablet daily ATORVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - one Tablet(s) by mouth daily CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - one Tablet(s) by mouth daily ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg Tablet Extended Release 24 hr - one Tablet(s) by mouth daily NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually daily ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - one Tablet(s) by mouth daily GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet - one Tablet(s) by mouth twice daily GLYBURIDE-METFORMIN - 5 mg-500 mg Tablet - one Tablet(s) by mouth twice daily LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet - one Tablet(s) by mouth daily OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily PIOGLITAZONE [ACTOS] - (Prescribed by Other Provider) - 30 mg Tablet - one Tablet(s) by mouth daily TERAZOSIN - (Prescribed by Other Provider) - 5 mg Capsule - one Capsule(s) by mouth daily CALCIUM CARBONATE [CALCIUM 500] - (Prescribed by Other Provider) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Tablet, Chewable - one Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 6 doses. Disp:*6 Capsule(s)* Refills:*0* 4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain, SOB: can repeat every five minutes up to 3 pills total. If taking ___ pill, please call ___. 9. glyburide-metformin ___ mg Tablet Sig: One (1) Tablet PO twice a day. 10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. 14. Calcium+D Oral 15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain for 10 days. Disp:*qs Tablet(s)* Refills:*0* 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. linagliptin 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Syncope asystole Secondary: Diabetes Mellitus type 2 Coronary Artery Disease Hypertension ___ Prostatic Hyperplasia Abdominal Aortic Aneurysm Chronic Obstructive Pulmonary Disease Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Chest frontal AP portable view. CLINICAL INFORMATION: ___ male with history of shortness of breath and bradycardia. COMPARISON: None. FINDINGS: AP portable views of the chest were obtained. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Calcification of the aorta is likely present. There is no widening of the mediastinum. Degenerative changes are seen at the acromioclavicular joints. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: History of AAA repair and chest pain. Please evaluate for dissection or AAA leak. COMPARISON: No prior studies available for comparison. TECHNIQUE: Intravenous contrast was administered and arterial phase imaging was acquired. Non-contrast axial images were acquired through the chest. FINDINGS: CTA: The pulmonary vasculature shows no filling defect to suggest pulmonary embolism. Significant arthrosclerotic changes are noted throughout the coronary vessels, particularly the left anterior descending and the left coronary artery. Atherosclerosis is seen throughout the thoracic and abdominal aorta, extending into the bilateral iliacs and femoral arteries. The patient is status post aorto-biiliac endovascular stent with stent positioned immediately inferior to the left renal artery. A 4.5 x 4.8 x 4.4 cm infrarenal abdominal aortic aneurysm with hyperdensity evident within the aneurysmal sac well inferior to the presumed junction of the aorto and iliac graft junction. Hyperdensity appears to extend from a right lumbar collateral vessel (3:144). No surrounding mesenteric changes to suggest impending rupture of aneurysmal sac. The ostia of the renal, celiac, and superior mesenteric arteries appears widely patent. CT CHEST: No focal pulmonary opacifications or nodules evident. Diffuse predominantly upper lobe centrilobular and paraseptal emphysematous changes noticed with bullous emphysema noted anteriorly bilaterally. Minimal dependent atelectatic changes are noted in the posterior aspect of the lungs. The heart size is normal without pericardial effusion. There is a small hiatal hernia. CT ABDOMEN: Although this exam is not tailored for evaluation of the intra-abdominal parenchyma, there is no discrete lesion identified within the liver. There is no intrahepatic or extrahepatic biliary ductal dilatation. The gallbladder is unremarkable. The pancreas and spleen are normal. The bilateral adrenal glands are normal. The bilateral kidneys are normal in size and excrete contrast symmetrically. Multiple simple renal cysts are identified in both kidneys. No stones are evident. There is no hydronephrosis or hydroureter identified. The stomach, small and large bowel are unremarkable. There is no retroperitoneal, mesenteric, or portacaval lymphadenopathy evident. CT PELVIS: The appendix is visualized and is unremarkable. The rectum and sigmoid colon are unremarkable. The bladder wall appears somewhat thickened. This may reflect collapse around an inserted Foley catheter or hypertrophy due to chronic outlet obstruction due to an enlarged prostate measuring 6 cm in its greatest dimension. The seminal vesicles are unremarkable. There is no pelvic sidewall or inguinal lymphadenopathy evident. There is no free fluid in the pelvis. OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions evident. A well-corticated linear lucency is noted in the left first rib anteriorly, likely represents a remote fracture(3:2). In addition, there is a linear lucency with cortical stepoff noted within the left posterior bridge of S1 with no evidence of bony healing and may represent a more recent trauma. Please correlate clinically. IMPRESSION: 1. No pulmonary embolism. Infrarenal abdominal aortic aneurysm with evidence of endoleak, likely type II from a right-sided lumbar artery. No evidence of impending hemorrhage. 2. Linear lucency in the left first rib appears to be well-corticated and may represent remote fracture. 3. A linear lucency in the left S1 with no evidence of cortication may represent a more recent traumatic fracture. Please correlate with clinical history. 4. Thickened bladder wall likely represents combination of collapse and hypertrophy from chronic outlet obstruction due to enlarged prostate, but cannot exclude infectious process. Please correlate with urine analysis. Radiology Report CLINICAL HISTORY: Pacemaker placed. Check position. CHEST, PA AND LATERAL A dual-chamber pacemaker is present, with one lead in the right ventricle, the other in the right atrium. No pneumothorax is present. The lung fields are clear. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: S/P SYNCOPAL/BRADY Diagnosed with SYNCOPE AND COLLAPSE, CARDIAC DYSRHYTHMIAS NEC, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: nan heartrate: 55.0 resprate: 18.0 o2sat: 99.0 sbp: 125.0 dbp: 66.0 level of pain: 13 level of acuity: 1.0

It was a pleasure to take care of you at ___ ___. You were admitted for a couple of long pauses in your heart rate and syncope, likely vasovagal in nature. This means that a trigger, (usually emotional like fear or physical like straining) causes changes in your vascular system such that your heart rate and blood pressure drops. We have placed a pacemaker to keep your heart rate regular, which should help should future episodes occur. . Please decrease aspirin to 81mg daily. Please take clindamycin 300mg every six hours through ___. You may also take tylenol ___, ___ every ___ hours as needed for pain. . Please continue taking all of your medications as previously prescribed and attend your outpatient follow up clinic visits as detailed below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Hydrocodone / Zestril Attending: ___. Chief Complaint: Chest Pain/Fracture Tibia/Suicidal Ideation Major Surgical or Invasive Procedure: ORIF left leg (___) History of Present Illness: ___ homeless female with HCV, CAD s/p NSTEMI,polysubstance abuse, s/p R TKR, L knee injury in ___ who presents with chest pain s/p cocaine ingestion brought in by ambulance after being found in the ___ area intoxicated now found to have fractured left tibia. Patient states she was having chest pain before coming to the hospital unable to describe the pain as she was intoxicated and generally is a poor historian. Chest pain has now resolved on admission. She drank approximately half a pint of hard alcohol some point prior to admission, unknown time of last drink. She denies any other ingestions. In the ED she was found to have positive Utox for cocaine and opiates. She reports having had fall approximately ___ wks ago and hurting her left leg. She has been using a wheelchair that she found on the streets to get around and has been unable to walk. She describes severe pain in her left leg. She was seen at outside clinic where plain films were not performed. As per the ortho note she has been intermittently walking on leg with pain. Also noted to have DVT on previous admission which is now resolved as per imaging done in ED. In the ED, initial vital signs were: 97.2 76 146/78 18 97%. In the ED she stated her chest pain had improved. She denied sob, abdominal pain, nausea or vomiting. CXR was obtained, Troponins were 0.03 and 0.02. She was evaluated by psychiatry and now on ___ for suicidal ideation and plan to overdose on her pills. Evaluated by orthopedics in the ED that recommended Xray and CT imaging. Per ortho: will likely need total knee replacement possibly on this admission. She was given lovenox 40mg x1 for PPX in the ED. As per psychiatry patient needs to be admitted for SI once medically cleared.No psych facility would accept patient with restrictions of mobility and contact precautions except for Deac 4 no bed there until ___ and decision was made to admit patient to medicine. On Transfer Vitals were: 79 148/86 19 98% RA. On the floor patient was complaining of left knee pain. No chest pain, shortness of breath. Continues to endorse suicidal ideation. Patient is notably a poor historian. Past Medical History: -Polysubstance abuse (crack, EtOH, ?heroin) -Benign Hypertension -Hyperlipidemia -Asthma -Hepatitis C -Depression -H/o endocarditis x 2 (last in ___ -Bilateral DVT ___, took 4 months of coumadin) -Coronary artery disease s/p NSTEMI in ___ -PFO (per discharge summary ___ -H/o CVA: L ?___ stroke (___) per NSU note ___ (but per neurology review of prior CT head: L inferior MCA division stroke) with L facial droop -"Rheumatoid arthritis" ___ inpatient evaluation showed neg CCP, mildly elevated RF, and osteoarthritic changes but no erosions suggestive of inflammatory arthropathy on hand, knee, or foot x-rays. -PPD positive s/p Isoniazid treatment x 6 months -Right breast cancer s/p resection and subsequent mastectomy (DFCI) -S/p L eye enucleation ___ (possibly ___ infxn) -S/p ex-lap after abdominal stab wound -SVC draining into rt coronary sinus - Affective Dysregulation: Recent admission to psych given suicidal thoughts on the medical floor (without organized plan), psych was unclear whether there was a primary mood disorder. Seroquel beneficial. Social History: ___ Family History: Per prior notes, father with diabetes ___. Mother and brother with alcoholism. Son with OCD. Physical Exam: ADMISSION EXAM: ====================== Vitals - T: 98.7 BP: 150/75 HR: 74 RR: 19 02 sat: 98%RA GENERAL: NAD, elderly woman laying in bed HEENT: AT/NC, L eye enucleate, anicteric sclera, pink conjunctiva, MMM, no upper teeth, few bottom teeth intact NECK: nontender supple neck, no appreciable JVD CARDIAC: RRR, loud ___ holosystolic murmur heard throughout the precordium, S1 markedly diminished, normal S2, no gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: midline scar; nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: RLE s/p knee replacement, nontender, nonerythematous. LLE very tender to touch, visible deformity below the knee grossly swollen in comparison to RLE, both legs appear to be swollen L>R. Knee itself is tender. PULSES: 2+ ___ pulses bilaterally NEURO: CN II-XII intact, AxOx3 SKIN: warm and well perfused, no excoriations or lesions, no rashes, multiple healed scars DISCHARGE EXAM: ======================== T 98.3 HR 70 BP 122/80 RR 18 100% on RA NAD, A+OX3 LLE: Wounds well healed with no surrounding erythema or discharge Unlocked ___ in place Compartments soft and compressible WWP toes SILT over S/S/SP/DP/T distributions Motor intact GSC, TA, ___ Pertinent Results: ADMISSION LABS: ====================== ___ 04:00AM BLOOD WBC-2.8* RBC-3.90* Hgb-10.5* Hct-34.7* MCV-89 MCH-26.9* MCHC-30.2* RDW-18.1* Plt ___ ___ 04:00AM BLOOD Neuts-39.4* Lymphs-46.4* Monos-7.3 Eos-6.7* Baso-0.3 ___ 04:00AM BLOOD ___ PTT-28.3 ___ ___ 04:00AM BLOOD Glucose-76 UreaN-18 Creat-1.5* Na-140 K-3.6 Cl-103 HCO3-23 AnGap-18 ___ 04:00AM BLOOD ASA-NEG Ethanol-90* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:17AM BLOOD Lactate-2.2* ___ 09:20AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 09:20AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM ___ 09:20AM URINE RBC-0 WBC-12* Bacteri-FEW Yeast-NONE Epi-17 ___ 09:20AM URINE 3PhosX-OCC ___ 09:20AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG PERTINENT LABS: ====================== ___ 04:00AM BLOOD cTropnT-0.03* ___ 09:50AM BLOOD cTropnT-0.02* DISCHARGE LABS: ====================== ___ 08:30AM BLOOD WBC-3.6* RBC-3.40* Hgb-9.3* Hct-30.6* MCV-90 MCH-27.5 MCHC-30.5* RDW-16.4* Plt ___ ___ 08:30AM BLOOD Glucose-81 UreaN-18 Creat-1.3* Na-139 K-4.8 Cl-104 HCO3-27 AnGap-13 IMAGING: ====================== Left Knee & Tibia X-rays (___) - Radiology Report 1. No evidence of hardware complication. 2. Callus formation around the proximal tibial and fibular fractures, similar to ___. 3. Severe tricompartmental degenerative joint disease. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H pain 2. Amlodipine 10 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 5. Glycerin Supps ___AILY constipation 6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath 7. Nicotine Patch 14 mg TD DAILY 8. Polyethylene Glycol 17 g PO DAILY constipation 9. Senna 8.6 mg PO BID:PRN constipation 10. Aripiprazole 10 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Diltiazem Extended-Release 120 mg PO DAILY 13. Docusate Sodium 100 mg PO BID:PRN constipation 14. QUEtiapine Fumarate 25 mg PO BID 15. Calcium Carbonate 500 mg PO BID 16. Loratadine 10 mg PO DAILY 17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 18. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Pain Discharge Medications: 1. Apixaban 5 mg PO BID Duration: 3 Months Last dose to be given on ___ RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*44 Tablet Refills:*0 2. Acetaminophen 1000 mg PO Q8H pain 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 4. Amlodipine 10 mg PO DAILY 5. Aripiprazole 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Diltiazem Extended-Release 120 mg PO DAILY 9. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*0 10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath 11. Nicotine Patch 14 mg TD DAILY 12. QUEtiapine Fumarate 25 mg PO BID 13. Senna 8.6 mg PO BID:PRN constipation 14. Glycerin Supps ___AILY constipation 15. Loratadine 10 mg PO DAILY 16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 17. Polyethylene Glycol 17 g PO DAILY constipation 18. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q3H Disp #*80 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left subacute proximal tibia fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph. INDICATION: History: ___ with CP after cocaine // evidence of pneumonia or pneumothorax TECHNIQUE: PA and lateral views of the chest. COMPARISON: Chest radiographs dated ___, CT chest dated ___. FINDINGS: Interval development of mild interstitial pulmonary edema. There is no lobar consolidation, pneumothorax, or pleural effusion. Mild cardiomegaly is stable. The aortic arch is calcified. The enlarged right hila is unchanged from ___, better characterized on prior CT chest. IMPRESSION: Mild cardiomegaly and mild interstitial pulmonary edema. Radiology Report EXAMINATION: DX KNEE AND TIB/FIB INDICATION: ___ female with pain/inability to walk // rule out fracture TECHNIQUE: Five views of the left knee and ankle. COMPARISON: Radiographs from ___ and ___. FINDINGS: There is a transversely oriented fracture through the proximal left tibia and fibula with posterior angulation of the tibial fracture, new from ___. However, there is associated callus formation suggesting a non-acute fracture. Lucencies can represent physiologic changes but pathologic fracture cannot be excluded. There continues to be severe tricompartmental degenerative changes within the knee. IMPRESSION: 1. Subacute transverse fractures of the proximal tibia and fibula with posterior angulation of tibial fracture. Lucencies in the fracture site can represent physiologic changes but pathologic fracture cannot be excluded. 2. Severe tricompartmental degenerative changes of the left knee. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:21 AM, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with left leg pain and unclear compliance with anticoagulation from pop DVT identified in ___ // Rule out DVT or prorgession from pop DVT from ___ TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Bilateral lower extremity venous duplex from ___ FINDINGS: There is normal respiratory variation in the common femoral veins bilaterally. There is normal compressibility and flow in the left common femoral vein. Proximal/mid/distal superficial femoral vein is fully compressible. Normal compressibility and wall-to-wall flow is demonstrated in the left popliteal vein. The study could not be completed as a result of patient discomfort. Therefore, the calf veins were not assessed and augmentation of femoral vein could not be performed. IMPRESSION: Limited exam due to patient discomfort. No evidence of deep venous thrombosis in the left lower extremity veins to the level of the popliteal vein. The calf veins were not assessed. Radiology Report EXAMINATION: CT LOW EXT W/O C LEFT INDICATION: ___ year old woman with left subacute proximal tib fracture // further clarification of fracture pattern (Please obtain CT scan of left knee down to the lower third of tibia) TECHNIQUE: Contiguous axial multidetector CT images from the left distal femur to the mid tibia/fibula without intravenous contrast. Multiplanar reformations. Total DLP: 1484 mGy-cm COMPARISON: Knee radiographs same day and earlier radiographs including ___ FINDINGS: There is a subacute fracture of the proximal left tibia and fibula with exuberant surrounding periosteal new bone. The fracture line and cortical discontinuity is still visible. There is mild impaction and mild varus angulation of the distal tibia with little displacement. There is no cortical bridging. Severe degenerative changes with subchondral sclerosis, subchondral cyst formation and osteophyte are most prominent in the medial compartment. Intra-articular body is demonstrated along the anterior aspect of the lateral compartment (series 800b, image 38). A moderate-sized left knee joint effusion is present. There is fragmentation of the medial tibial plateau, with a triangular articular fragment measuring 2.6 x 1.5 cm (series 7, image 92, series 800b, image 35). This appears similar allowing for difference in technique to previous radiograph from ___. IMPRESSION: 1. Subacute left tibial and fibular shaft fractures with callus formation. 2. Severe tricompartmental osteoarthritis, and there is nonacute fragmentation of the medial tibial plateau with a triangular articular fragment arising from the anteromedial aspect of the medial tibial plateau. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with tib/fib fx, prolonged immobility. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: Left lower extremity duplex dated ___ FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, superficial femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower extremity veins. Radiology Report HISTORY: ORIF. FINDINGS: Images from the operating suite show placement of a fixation device about previously described fracture of the proximal tibia. Adjacent fibular fracture is seen. Further information can be gathered from the operative report. Radiology Report INDICATION: ___ year old woman with proximal tibia fx s/p ORIF, rule out DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: Multiple prior lower extremity DVT study stricter comparison made to study from ___. FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral, superficial femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal compressibility, flow and augmentation in the left common femoral and proximal and mid superficial femoral veins. Flow was seen within the left popliteal vein. Compressibility, flow and augmentation was not performed in the distal superficial femoral vein, popliteal vein, and calf veins due to lack of patient cooperation. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Very limited assessment of the left lower extremity veins due to lack of patient cooperation. No evidence of deep vein thrombosis in the left common femoral and proximal and mid superficial femoral veins. The remaining lower extremity veins were not visualized. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT INDICATION: ___ 2 wks s/p L tibia ___ plate. TECHNIQUE: Left knee, three views. COMPARISON: ___. FINDINGS: Again seen is callus formation around the transverse fractures of the proximal tibia and fibula, similar to prior. Lateral cortical plate and screws are now seen across the proximal tibia. There is no perihardware lucency. Severe tricompartmental degenerative changes are again seen along with a moderate-sized joint effusion. IMPRESSION: 1. No evidence of hardware complication. 2. Callus formation around the proximal tibial and fibular fractures, similar to ___. 3. Severe tricompartmental degenerative joint disease. Radiology Report INDICATION: ___ 2 wks s/p L tibia ___ plate // fx healing f/u COMPARISON: Prior exam from ___. FINDINGS: In this patient with recent ORIF, there is a lateral plate and screw fixation traversing the fracture in the proximal shaft of the tibia. Alignment is near anatomic. Bones are diffusely demineralized. Soft tissues are prominent. Degenerative changes of the left knee are again noted, severe. IMPRESSION: Left tibial fracture post ORIF, near anatomic alignment. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Right sided chest pain Diagnosed with CHEST PAIN NOS, DRUG ABUSE NEC-UNSPEC temperature: 97.2 heartrate: 76.0 resprate: 18.0 o2sat: 97.0 sbp: 146.0 dbp: 78.0 level of pain: 13 level of acuity: 3.0

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

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: phenobarbital Attending: ___. Chief Complaint: Nausea/Vomiting and Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ year old man with a history of HIV (CD4 306 on ___, VL 200K ___ on ART), adrenal insufficiency on hydrocortisone/midodraine and alcohol withdrawal c/b hallucinosis in the past with recent admission for such who presents with back pain, acute hepatitis. Mr ___ describes 3 days of symptoms of nausea, vomiting, back pain and fever. Describes his fever as shaking chills and sweating, but did not formerly take his temperature. He says he takes the medications he is supposed to and only drank about two beers a day, last drink yesterday. Unable to keep much else down otherwise. Denied drinking any other substances or any other forms of alcohol. Reports a mild frontal headache and chronic lower back pain, which has worsened within the past 3 days. Denies any numbness or weakness or vision change. Denies any loss of bowel or bladder control. Denies passing out or falling, waking up in unusual positions. No other drugs than what he was supposed to have been prescribed. No recent trauma. No recent travel. ED COURSE - Initial VS: 10 99.2 110 118/78 16 96% RA - No exam documented - Labs notable for ALT: 1017 AP: 223 Tbili: 0.4 Alb: 3.9 AST: 2650 Lip: 68 EtOH 296. H/H ___ Eos% 15 (AbsEo 79) 2 bands / 1 atyp on diff. Urine barbituates positive. AG 19 U/A blood SM RBC 1 lactate 2.3 - RUQUS, CT head, and CXR without acute process - Pt was given 1000cc NS, folate, thiamine, and reglan - VS prior to transfer: 0 97.9 84 150/86 15 100% RA Past Medical History: HIV+ Hypertension Adrenal insufficiency ___ hypopituitarism Neuropathy Chronic lower back pain Alcohol misuse Social History: ___ Family History: Notable for an older brother with diabetes ___. Physical Exam: ADMISSION GEN: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, VFF without diploplia or blurry vision on exam, PERRL, neck supple, JVP not elevated CV: tachy, regular, nl S1 + S2, no murmurs, rubs, gallops Lungs: Faint rales in b/l bases, improve with cough, intermittent cough throughout exam Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Back: focal spinous process over L4-5, no paraspinal tenderness. No CVAT. No intbility, stop off. 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. GU: Normal rectal tone, empty vault. Enlarged prostate DISCHARGE Vitals: 98.5 ___ 18 96 RA GEN: Very fatigued with the covers pulled over his head. HEENT: No oral lesions. No thrush. Poor dentition ___: RRR, no MRG RESP: No increased WOB, no wheezing, rhonchi or crackles ABD: Soft, NTND. Liver edge felt under costal margin. No splenomegaly EXT: Warm, no edema MSK: Previously TTP over L4-L5 spinous process. No paraspinal muscle tenderness NEURO: Responding minimally due to fatigue. No inducible asterixis on exam. Skin: No rash. Pertinent Results: ADMISSION ======================= ___ 01:10AM BLOOD WBC-4.8 RBC-3.99* Hgb-11.4* Hct-34.0* MCV-85 MCH-28.6 MCHC-33.5 RDW-14.8 RDWSD-45.5 Plt ___ ___ 01:10AM BLOOD Neuts-27* Bands-2 ___ Monos-8 Eos-15* Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.39* AbsLymp-2.30 AbsMono-0.38 AbsEos-0.72* AbsBaso-0.00* ___ 01:10AM BLOOD ___ PTT-28.9 ___ ___ 01:10AM BLOOD Glucose-74 UreaN-5* Creat-0.6 Na-133 K-3.6 Cl-91* HCO3-23 AnGap-23* ___ 01:10AM BLOOD ALT-1017* AST-2650* CK(CPK)-557* AlkPhos-223* TotBili-0.4 ___ 01:10AM BLOOD Lipase-68* ___ 09:50AM BLOOD Albumin-3.4* Calcium-7.2* Phos-1.9* Mg-1.6 UricAcd-9.3* ___ 01:10AM BLOOD Osmolal-356* ___ 01:10AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG PERTINENT ========================= ___ 10:05AM BLOOD WBC-5.1# Lymph-37 Abs ___ CD3%-95 Abs CD3-1792 CD4%-10 Abs CD4-189* CD8%-83 Abs CD8-1569* CD4/CD8-0.12* ___ 01:10AM BLOOD Neuts-27* Bands-2 ___ Monos-8 Eos-15* Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.39* AbsLymp-2.30 AbsMono-0.38 AbsEos-0.72* AbsBaso-0.00* ___ 09:40PM BLOOD Glucose-188* UreaN-4* Creat-0.5 Na-125* K-3.8 Cl-89* HCO3-25 AnGap-15 ___ 01:10AM BLOOD ALT-1017* AST-2650* CK(CPK)-557* AlkPhos-223* TotBili-0.4 ___ 01:10AM BLOOD Lipase-68* ___ 09:50AM BLOOD cTropnT-<0.01 ___ 09:40PM BLOOD Calcium-7.6* Phos-1.4* Mg-2.0 ___ 01:10AM BLOOD calTIBC-224* Ferritn-6046* TRF-172* ___ 09:50AM BLOOD Hapto-110 ___ 03:05PM BLOOD %HbA1c-5.3 eAG-105 ___ 03:05PM BLOOD Triglyc-256* HDL-13 CHOL/HD-11.5 LDLcalc-86 ___ 01:10AM BLOOD Osmolal-356* ___ 03:05PM BLOOD Osmolal-274* ___ 05:31AM BLOOD TSH-1.9 ___ 09:50AM BLOOD Cortsol-20.1* ___ 01:10AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* IgM HAV-Negative ___ 03:05PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 03:05PM BLOOD ___ ___ 03:05PM BLOOD IgG-2208* ___ 01:10AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:50AM BLOOD Acetmnp-NEG ___ 03:05PM BLOOD Acetmnp-NEG ___ 01:10AM BLOOD HCV Ab-Negative ___ 08:42PM URINE Hours-RANDOM UreaN-139 Creat-38 Na-117 ___ 12:16AM URINE Hours-RANDOM UreaN-357 Creat-100 Na-41 ___ 08:42PM URINE Osmolal-333 ___ 12:16AM URINE Osmolal-305 ___ 01:30AM URINE bnzodzp-NEG barbitr-POS* opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 10:05AM BLOOD WBC-5.1# Lymph-37 Abs ___ CD3%-95 Abs CD3-1792 CD4%-10 Abs CD4-189* CD8%-83 Abs CD8-1569* CD4/CD8-0.12* ___ 01:10AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* IgM HAV-Negative ___ 01:10AM BLOOD HCV Ab-Negative Test Result Reference Range/Units CERULOPLASMIN 28 ___ mg/dL ALPHA-1-ANTITRYPSIN QN 105 83-199 mg/dL IMMUNOGLOBULIN G SUBCLASS 1 1622 H 382-929 mg/dL IMMUNOGLOBULIN G SUBCLASS 2 195 L 241-700 mg/dL IMMUNOGLOBULIN G SUBCLASS 3 211 H ___ mg/dL IMMUNOGLOBULIN G SUBCLASS 4 44 ___ mg/dL IMMUNOGLOBULIN G, SERUM 2283 H ___ mg/dL STRONGYLOIDES AB IGG NEGATIVE ============================= DISCHARGE ============================= ___ 05:42AM BLOOD WBC-6.2 RBC-3.64* Hgb-10.6* Hct-32.0* MCV-88 MCH-29.1 MCHC-33.1 RDW-15.2 RDWSD-48.2* Plt ___ ___ 05:42AM BLOOD Neuts-13* Bands-0 Lymphs-56* Monos-24* Eos-4 Baso-2* Atyps-1* ___ Myelos-0 AbsNeut-0.81* AbsLymp-3.53 AbsMono-1.49* AbsEos-0.25 AbsBaso-0.12* ___ 05:42AM BLOOD Glucose-86 UreaN-8 Creat-0.5 Na-136 K-4.5 Cl-102 HCO3-25 AnGap-14 ___ 05:42AM BLOOD ALT-214* AST-128* AlkPhos-140* TotBili-0.2 ___ 05:42AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.0 ============================= IMAGING ============================= ___ Imaging CT HEAD W/O CONTRAST IMPRESSION: 1. Chronic appearing right parietal infarct. 2. Chronic left maxillary sinus disease. 3. No clear acute intracranial abnormality on noncontrast head CT. Of note MRI would be more sensitive for the detection of intracranial infection. ___ Imaging LIVER OR GALLBLADDER US 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. No cholelithiasis or biliary dilatation. ___ Imaging LUMBO-SACRAL SPINE (AP IMPRESSION: Superior endplate scalloping involving T12, L1, L2, and L4 and probably also to a lesser degree at L3 and L5, compatible with multiple, subtle, nonacute vertebral body fractures. In retrospect, the appearances are similar to ___, including discogenic and facet degenerative changes and retrolisthesis at L5/S1. If clinically indicated, MRI could help for further assessment. Mild degenerative changes about both SI joints, similar to prior. Faint aortic calcification, an unusual finding in someone of this age. Is the patient a diabetic or do they have vasculopathy ___ Imaging DUPLEX DOPP ABD/PEL IMPRESSION: 1. Patent hepatic vasculature. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 3. Mild gallbladder wall edema, likely reactive in the setting of acute hepatitis. ___ Imaging MR ___ & W/O CONT IMPRESSION: 1. No evidence for abscess formation. 2. Multilevel degenerative changes, most severe at the L5-S1 level with moderate to severe bilateral neural foraminal narrowing at this level. 3. Grade 1 retrolisthesis of L5 on S1, with ___ type 1 changes at this level. ============================= MICRO ============================= HIV-1 Viral Load/Ultrasensitive (Final ___: 222,000 copies/ml. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. HBV Viral Load (Final ___: HBV DNA detected, less than 20 IU/mL. ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 91 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Hydrocortisone 5 mg PO QAM 3. Hydrocortisone 2.5 mg PO QPM 4. Midodrine 5 mg PO TID 5. Mirtazapine 15 mg PO QHS 6. Multivitamins 1 TAB PO DAILY 7. Thiamine 100 mg PO DAILY 8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes, blurry vision 9. Nicotine Patch 7 mg TD DAILY 10. Darunavir 800 mg PO QAM 11. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 12. RiTONAvir 100 mg PO DAILY 13. Gabapentin Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes, blurry vision RX *dextran 70-hypromellose [Artificial Tears] 0.1 %-0.3 % ___ drops per eye PRN Refills:*0 2. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Hydrocortisone 5 mg PO QAM RX *hydrocortisone 5 mg 1 tablet(s) by mouth qam Disp #*30 Tablet Refills:*0 4. Hydrocortisone 2.5 mg PO QPM RX *hydrocortisone 5 mg 0.5 (One half) tablet(s) by mouth qpm Disp #*15 Tablet Refills:*0 5. Midodrine 5 mg PO TID RX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 6. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Nicotine Patch 7 mg TD DAILY RX *nicotine 7 mg/24 hour As directed once a day Disp #*2 Each Refills:*0 8. 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 9. Citalopram 20 mg PO DAILY RX *citalopram 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. Acetaminophen 650 mg PO Q8H:PRN Pain 11. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 12. Sodium Chloride Nasal ___ SPRY NU QID:PRN Nasal congestion Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Acute hepatitis Hyponatremia Nutritional Deficiency Alcohol Abuse Suicidal Ideation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with hiv, fever, // eval for pna TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: The heart is not enlarged. Within limits of plain film radiography, no hilar or mediastinal lymphadenopathy is detected. No CHF , focal infiltrate or consolidation, pleural effusion or pneumothorax detected. IMPRESSION: No acute intrathoracic process identified. In particular, no infiltrate or consolidation detected. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with hiv, fever, // eval for infection TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.5 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: Hypodensity in the right parietal lobe with encephalomalacia is likely related to old infarct. There is no evidence of hemorrhage, edema, or mass/mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. There is mucosal thickening of the left maxillary sinus with hyperostosis of the sinus compatible chronic sinus disease. The remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Chronic appearing right parietal infarct. 2. Chronic left maxillary sinus disease. 3. No clear acute intracranial abnormality on noncontrast head CT. Of note MRI would be more sensitive for the detection of intracranial infection. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with n/v and elevated LFTs // eval for cholecystitis or CBD dilation TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis dated ___ and abdominal ultrasound dated ___ FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 6 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The head, body, and tail of the pancreas are within normal limits, without masses or pancreatic ductal dilatation. SPLEEN: Normal echogenicity, measuring 10.1 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. No cholelithiasis or biliary dilatation. Radiology Report EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE. INDICATION: ___ year old man with HIV, poorly controlled, fevers, lumbar back pain // ? abscess. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of 6 mL of Gadavist contrast agent. COMPARISON: Lumbar spine radiographs ___. FINDINGS: Limited examination secondary to patient motion artifact. There is minimal grade 1 retrolisthesis of L5 on S1. As seen on prior lumbar radiograph, there is demonstration of endplate scalloping of the L1, L2, L4 and L5 vertebral bodies. There is loss of intervertebral disc height at the L5-S1 level, with associated T1 hypointense and T2/STIR hyperintense signal of the endplates at this level, likely reflecting type ___ ___ changes. Vertebral body and intervertebral disc signal intensity appear otherwise normal. The spinal cord appears normal in caliber and configuration. There is no evidence of infection or neoplasm. At the T12-L1, L1-L2, and L2-L3, there is no significant spinal canal stenosis or neural foraminal narrowing. At the L3-L4 level, there is mild facet hypertrophy causing mild bilateral neural foraminal narrowing. There is no spinal canal stenosis. At the L4-L5 level, there is minimal disc bulge and facet hypertrophy resulting in mild bilateral neural foraminal narrowing. There is no spinal canal stenosis. At the L5-S1 level, there is central disc protrusion which contacts the traversing nerve roots bilaterally and results in mild anterior thecal sac deformity. There is narrowing of the right and left lateral recesses with moderate to severe bilateral neural foraminal narrowing. The sacroiliac joints and the visualized paravertebral structures are unremarkable. IMPRESSION: 1. No evidence for abscess formation. 2. Multilevel degenerative changes, most severe at the L5-S1 level with moderate to severe bilateral neural foraminal narrowing at this level. 3. Grade 1 retrolisthesis of L5 on S1, with ___ type 1 changes at this level. Radiology Report EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT) INDICATION: ___ year old man with HIV p/w n/v/d and low back pain ___ years with TTP over L4-L5 spinous process // evaluate for fracture COMPARISON: Lumbar spine films dated ___ FINDINGS: There are 5 non-rib-bearing vertebral bodies. Mild superior endplate scalloping at multiple vertebral body levels is noted. This appears to involve T12, L1, L2, and L4 and possibly L3 and L5. Loss of vertebral body height is most pronounced at L1 and L2, where it represents approximately 33% loss of vertebral body height. No obvious retropulsion. There is mild disc space narrowing and minimal spurring and suspected grade 1 retrolisthesis at L5/S1. As before, the L3/4 and L4/5 disc spaces appear widened, though this could be artifact due to changes in surrounding vertebral bodies. Disc heights are otherwise preserved without other levels of spondylolisthesis. Mild moderate facet arthrosis is seen from L3 through S1. Previously suggested spondylolysis at L5 is not clearly identified on this exam, but could be obscured by overlapping bony structures. The spinous processes, including L4 and L5, are grossly unremarkable. Small amounts of scattered aortic calcification are noted. Mild degenerative changes about both SI joints again noted. IMPRESSION: Superior endplate scalloping involving T12, L1, L2, and L4 and probably also to a lesser degree at L3 and L5, compatible with multiple, subtle, nonacute vertebral body fractures. In retrospect, the appearances are similar to ___, including discogenic and facet degenerative changes and retrolisthesis at L5/S1. If clinically indicated, MRI could help for further assessment. Mild degenerative changes about both SI joints, similar to prior. Faint aortic calcification, an unusual finding in someone of this age. Is the patient a diabetic or do they have vasculopathy? NOTIFICATION: The impression and recommendation above was entered by Dr. ___ ___ on ___ at 15:08 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ man with acute hepatitis. Evaluate hepatic vein patency (was excluded on prior study). TECHNIQUE: Targeted grayscale, color, and spectral Doppler evaluation of the right upper abdomen was performed. COMPARISON: Abdominal ultrasound dated ___. FINDINGS: Liver: The hepatic parenchyma is diffusely echogenic. No focal liver lesions are identified. No ascites. Bile ducts: No intrahepatic biliary ductal dilation. The common hepatic duct measures 4 mm. Gallbladder: The gallbladder edema is mild, likely reactive in the setting of acute hepatitis. No abnormal wall thickening or stones. Pancreas: The imaged portion of the pancreas appears within normal limits, with portions of the pancreatic uncinate and tail obscured by overlying bowel gas. No main pancreatic ductal dilation. Spleen: The spleen was not imaged. Kidneys: Limited views of the right kidney do not show hydronephrosis. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is approximately 20 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent. Splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: 1. Patent hepatic vasculature. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 3. Mild gallbladder wall edema, likely reactive in the setting of acute hepatitis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with HIV, adrenal insufficiency and ETOH w/d with new fever // Eval for infection Eval for infection IMPRESSION: In comparison with the study of earlier in this date, there are slightly lower lung volumes. No evidence of acute focal pneumonia, vascular congestion, or pleural effusion. Gender: M Race: BLACK/CARIBBEAN ISLAND Arrive by AMBULANCE Chief complaint: Back pain Diagnosed with Dorsalgia, unspecified, Alcohol abuse with intoxication, unspecified temperature: 99.2 heartrate: 110.0 resprate: 16.0 o2sat: 96.0 sbp: 118.0 dbp: 78.0 level of pain: 10 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you during your hospitalization. You came because you were having back pain and nausea and were found to have inflammation of your liver. We did a lot of blood tests and imaging studies which did not show a definitive cause of your liver inflammation. We also gave you medicine to prevent you from withdrawing from alcohol. We think this may have been a reaction to medication you received during your last hospitalization called phenobarbital.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy with lysis of adhesions. History of Present Illness: ___ w/ metastatic rectal carcinoid tumor s/p open LAR w/ colonic J pouch, segment VII liver resection, and sigmoid colostomy for symptoms of obstruction on ___. Was previously doing fine and now has presented with 1 day history of bloating, nausea, obstipation, and left sided abdominal pain. History obtained through phone interpreter. Past Medical History: Illness: HTN, DM2, Metastatic carcinoid tumor of the rectum Past Medical History: Open low anterior resection with colonic J pouch to low rectal anastomosis ___, segment 7 liver resection for metastatic carcinoid tumor ___ PSHx: end sigmoid colostomy ___, ___, segment 7 liver resection ___, ___, open LAR w/ J pouch ___, ___, hysteroscopy with polypectomy and dilatation and curettage ___, ___ Medications: Amlodipine ?dose, glipizide 10', lisinopril 40', metformin 1000'', sunitinib 37.5' (2 weeks on, 1 week on), calcium-vitamin D3, vitamin B12 Allergies: NKDA Social History: ___ Family History: Her mother died at age ___ from bronchitis and her father who died at age ___ from old age. Physical Exam: Gen: Well appearing, in no acute distress Cardiac: Normal s1 and s2, no MRG Pulm: Clear to auscultation bilaterally GI: Abdomen soft, mildly distended, nontender. Lap site clean, dry and intact. Pertinent Results: ___ 06:26AM BLOOD WBC-3.2* RBC-2.35* Hgb-8.2* Hct-24.6* MCV-105* MCH-34.9* MCHC-33.3 RDW-14.3 RDWSD-54.9* Plt Ct-79* ___ 05:40AM BLOOD WBC-3.8* RBC-2.52* Hgb-8.7* Hct-26.5* MCV-105* MCH-34.5* MCHC-32.8 RDW-14.5 RDWSD-55.4* Plt Ct-81* ___ 06:44AM BLOOD WBC-4.1 RBC-2.44* Hgb-8.4* Hct-26.0* MCV-107* MCH-34.4* MCHC-32.3 RDW-15.2 RDWSD-59.5* Plt Ct-71* ___ 06:55AM BLOOD WBC-4.0 RBC-3.02* Hgb-10.6* Hct-31.7* MCV-105* MCH-35.1* MCHC-33.4 RDW-15.2 RDWSD-58.0* Plt Ct-92* ___ 03:15PM BLOOD WBC-7.0# RBC-3.51* Hgb-12.4 Hct-35.5 MCV-101* MCH-35.3* MCHC-34.9 RDW-14.9 RDWSD-54.8* Plt ___ ___ 03:15PM BLOOD Neuts-63.0 ___ Monos-2.9* Eos-0.0* Baso-0.1 Im ___ AbsNeut-4.41# AbsLymp-2.36 AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01 ___ 06:26AM BLOOD Plt Ct-79* ___ 05:40AM BLOOD Plt Ct-81* ___ 06:44AM BLOOD Plt Ct-71* ___ 11:05AM BLOOD ___ PTT-27.7 ___ ___ 06:26AM BLOOD Glucose-174* UreaN-6 Creat-0.7 Na-137 K-4.0 Cl-107 HCO3-24 AnGap-10 ___ 05:40AM BLOOD Glucose-133* UreaN-7 Creat-0.8 Na-137 K-3.9 Cl-106 HCO3-24 AnGap-11 ___ 06:44AM BLOOD Glucose-128* UreaN-20 Creat-0.9 Na-140 K-3.8 Cl-109* HCO3-27 AnGap-8 ___ 06:55AM BLOOD Glucose-126* UreaN-18 Creat-0.9 Na-142 K-3.8 Cl-109* HCO3-25 AnGap-12 ___ 03:15PM BLOOD Glucose-130* UreaN-13 Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-20* AnGap-20 ___ 11:05AM BLOOD ALT-14 AST-27 AlkPhos-46 TotBili-0.9 ___ 03:15PM BLOOD ALT-16 AST-28 AlkPhos-54 TotBili-1.1 ___ 11:05AM BLOOD Lipase-14 ___ 03:15PM BLOOD Lipase-28 ___ 06:26AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.0 ___ 05:40AM BLOOD Calcium-7.9* Mg-2.1 ___ 06:44AM BLOOD Calcium-7.4* Phos-2.2*# Mg-2.0 ___ 06:55AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.9 ___ 03:15PM BLOOD Albumin-4.4 ___ 03:15PM BLOOD HoldBLu-HOLD ___ 03:15PM BLOOD LtGrnHD-HOLD ___ 03:19PM BLOOD Lactate-3.0* CT ___: 1. Findings concerning for closed loop small bowel obstruction with "whirl" sign in the right mid abdomen. Moderate volume abdominal ascites noted. Difficult to exclude early bowel ischemia. 2. Gastric distention with possible stricture at the level of the pylorus. 3. Multiple liver lesions compatible with known sites of metastasis. 4. Postsurgical changes including end colostomy, ___ pouch. 5. Duplicated right renal collecting system with mild fullness of the lower pole moiety, unchanged. 6. Mild thickening of the distal esophagus could reflect esophagitis. Medications on Admission: Amlodipine 0 mg PO Frequency is Unknown GlipiZIDE 10 mg PO DAILY Lisinopril 40 mg PO DAILY MetFORMIN (Glucophage) 1000 mg PO BID Cyanocobalamin 1000 mcg PO DAILY Sutent 37.5 mg capsule Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #*30 Tablet Refills:*0 3. Amlodipine 0 mg PO Frequency is Unknown 4. GlipiZIDE 10 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Cyanocobalamin 1000 mcg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Carcinoid tumor and small-bowel obstruction related to internal hernia. 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: ___ year old woman with history of metastatic neuroendocrine tumor, transfer from outside hospital with report of bowel obstruction. TECHNIQUE: CT performed at an outside hospital with oral and intravenous contrast material with axial, coronal and sagittal reformations. DOSE: Dose DLP: ___ mGy-cm COMPARISON: Prior CT (SPECT) from ___ as well as a MRI of the abdomen from ___ 4 FINDINGS: LOWER CHEST: The imaged lung bases are clear aside from mild dependent atelectasis. The imaged portion of the heart is unremarkable. Mild thickening of the distal esophagus may reflect esophagitis. ABDOMEN: HEPATOBILIARY: Multiple hypodense liver lesions are compatible with metastasis as seen on prior imaging studies. The largest lesion is seen within segment 8 measuring approximately 4.7 x 4.7 cm. The main portal vein is patent. There is stable mild prominence of the common bile duct measuring up to 8 mm. The gallbladder appears normal. PANCREAS: The pancreas enhances normally without ductal dilation or discrete focal lesion. 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: Duplicated right renal collecting system is noted with stable mild fullness of the lower pole moiety and ureter without discrete distal obstruction. No worrisome renal lesion is seen. Bilateral perinephric stranding is seen, unchanged from prior and nonspecific. GASTROINTESTINAL: The stomach is distended containing contrast and ingested material. There is mild narrowing at the level of the gastric antrum though contrast is seen passing through this level into small bowel. The duodenum appears normal. There is progressive dilation of small bowel loops which can be traced to a point of abrupt caliber transition in the right mid abdomen where there is a 360 degree "whirl" of the mesentery and small bowel. There are 2 discrete transition point both centered at the mesenteric whirl, best seen on series 2 image 59. Findings are concerning for a closed loop obstruction. Mesenteric free fluid is small to moderate in volume. No evidence of hypoenhancing small bowel to suggest ischemia. Distal small bowel is entirely decompressed. The appendix is normal. The colon is unremarkable and contains a mild fecal load. An end colostomy is seen in the left mid abdominal wall. No definite evidence for malignant obstruction or mesenteric mass. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder appears moderately distended and normal. The uterus and adnexal structures appear unremarkable. There is a ___ pouch at the distal colon/rectum. Presacral soft tissue thickening may reflect treatment related changes. No free fluid tracks into the lower pelvis. No pelvic sidewall adenopathy is seen. No inguinal hernia or adenopathy. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions. IMPRESSION: 1. Findings concerning for closed loop small bowel obstruction with "whirl" sign in the right mid abdomen. Moderate volume abdominal ascites noted. Difficult to exclude early bowel ischemia. 2. Gastric distention with possible stricture at the level of the pylorus. 3. Multiple liver lesions compatible with known sites of metastasis. 4. Postsurgical changes including end colostomy, ___ pouch. 5. Duplicated right renal collecting system with mild fullness of the lower pole moiety, unchanged. 6. Mild thickening of the distal esophagus could reflect esophagitis. NOTIFICATION: Findings were discussed in person with Dr. ___. Gender: F Race: ASIAN - CHINESE Arrive by AMBULANCE Chief complaint: SBO, Transfer Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 98.0 heartrate: 76.0 resprate: 18.0 o2sat: 98.0 sbp: 171.0 dbp: 88.0 level of pain: 13 level of acuity: 2.0

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

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Codeine / Topamax / Dilaudid / Percocet Attending: ___. Chief Complaint: Right hip & labial numbness, back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o R thalamic stroke (___) and C4-5/C5-6 DDD presents with ___ weeks of LBP radiating across top of buttock that started a couple days after doing some cleaning and bending over, and 1 day of progressive numbness across her right hip that travels down to her right groin and labia, stating it now feels like "if I touch it I might as well be touching another person because I cannot feel it." She also has numbness over her proximal right anterior thigh, which has developed since coming to the ED. Denies any new weakness or difficulty walking, denies any loss of strength, and no new bowel or frank bladder incontinence. Of note, she also had a colonscopy yesterday. Because of her symptoms she called her neurologist, Dr. ___ advised her to come to the ED for evaluation. Past Medical History: Right thalamic stroke (___), melanoma ___ and C5-6 DDD, trigeminal neuralgia, occipital neuralgia, myofascial pain, postherpetic neuralgia, urge incontinence, HTN, HLD, NASH, ? ___ disease Social History: ___ Family History: Non-contributory Physical Exam: On admission: O: T 98.4, HR 58, BP 180/69, RR 16, SPO2 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ERRL EOMs intact b/l Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: ___ throughout all 4 extremities Sensation: complete absence of light touch sensation in left L1 dermatome and possibly extending in to L2 dermatome, but can feel cold sensation in these dermatomes although reduced compared to right side. Intact proprioception in toes. Rectal exam normal sphincter control On discharge: AAO x 3, strength full in lower extremities. Right hip numbness and tingling through to labia majoria (right side only). Sensation intact otherwise. Pertinent Results: ___ MRI L spine 1. L4-5 degenerative disc disease and facet arthropathy resulting in grade 1 anterolisthesis, moderate to severe spinal canal stenosis, and mild bilateral neural foraminal stenosis. 2. Multilevel degenerative facet arthropathy. 3. No retroperitoneal hematoma. ___ CT abdomen and pelvis with contrast 1. No evidence for an intra-abdominal mass causing compression of peripheral nerves 2. Incidental findings include an angiomyolipoma of the lower pole of the left kidney and a subcentimeter hypodense lesion in the liver that is too small to characterize but likely represents a cyst or hemangioma. ___ 08:45PM BLOOD WBC-6.8 RBC-4.68 Hgb-13.5 Hct-40.9 MCV-87 MCH-28.8 MCHC-33.0 RDW-14.5 RDWSD-45.9 Plt ___ ___ 08:45PM BLOOD Neuts-64.7 ___ Monos-8.2 Eos-0.7* Baso-0.6 Im ___ AbsNeut-4.41 AbsLymp-1.74 AbsMono-0.56 AbsEos-0.05 AbsBaso-0.04 ___ 08:45PM BLOOD ___ PTT-31.7 ___ ___ 08:45PM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-142 K-4.5 Cl-106 HCO3-28 AnGap-13 Medications on Admission: Acyclovir dose uncertain Amlodipine 2.5 q am, 5mg q ___ Atenolol 25mg BID Atorvastatin 80mg daily Estradiol 0.5mg BID Lasix 20mg QOD PRN Lidoderm patch prn Lisinopril 40mg BID Aspirin 81mg daily Discharge Medications: 1. Amlodipine 2.5 mg PO QAM 2. Amlodipine 5 mg PO HS 3. Aspirin 81 mg PO DAILY Hx of Stroke 4. Atenolol 25 mg PO BID 5. Atorvastatin 80 mg PO QPM 6. Diclofenac Sodium ___ 50 mg PO BID Pain 7. Estradiol 0.5 mg PO BID 8. Tizanidine 4 mg PO BID 9. Lisinopril 40 mg PO BID 10. Lidocaine 5% Patch 2 PTCH TD QAM 11. Outpatient Physical Therapy Dx: L4-5 herniated nucleus pulposes Discharge Disposition: Home Discharge Diagnosis: L4-5 herniated nucleus pulposes Right hip pain, numbness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST INDICATION: *** CODE CORD *** History: ___ with LBP and R groin numbness IV contrast to be given at radiologist discretion as clinically needed // eval for cauda equina. PLEASE INCLUDE T11 AND T12. Please include eval for retroperitoneal hematoma at these levels. eval for cauda equina TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. COMPARISON: No prior examinations of the lumbar spine are available. FINDINGS: There is very mild grade 1 anterolisthesis at L4-5. Alignment is otherwise preserved. Marrow signal is within normal limits. There is desiccation of the intervertebral discs with moderate disc height loss at L4-5. The distal thoracic spinal cord is normal in course, caliber, and signal. The conus is normal in appearance and position, terminating at L1-2. T11-12: There is no disc herniation. There is no spinal canal or neural foraminal stenosis. T12-L1: There is no disc herniation or spinal canal stenosis. There is facet arthropathy but no neural foraminal stenosis. L1-2: There is no disc herniation or spinal canal stenosis. There is ligamentum flavum thickening and facet arthropathy but no neural foraminal stenosis. L2-3: There is a diffuse disc bulge, ligamentum flavum thickening, and facet arthropathy. There is no significant spinal canal or neural foraminal stenosis. L3-4: There is a mild diffuse disc bulge, ligamentum flavum thickening, and facet arthropathy. There is mild spinal canal stenosis. There is no significant neural foraminal stenosis. L4-5: There is grade 1 anterolisthesis disc uncovering, a diffuse disc bulge with a central protrusion, ligamentum flavum thickening with cystic changes (image 9, series 3), and facet arthropathy. There is moderate to severe spinal canal stenosis and mild bilateral neural foraminal stenosis. L5-S1: There is a broad-based disc protrusion and facet arthropathy. There is no significant spinal canal or neural foraminal stenosis. The paravertebral soft tissues are normal. There is no retroperitoneal hematoma. There is a probable cyst in the left kidney. IMPRESSION: 1. L4-5 degenerative disc disease and facet arthropathy resulting in grade 1 anterolisthesis, moderate to severe spinal canal stenosis, and mild bilateral neural foraminal stenosis. 2. Multilevel degenerative facet arthropathy. 3. No retroperitoneal hematoma. Radiology Report INDICATION: ___ year old woman with numbness in right L1 distribution, back pain, and L4-5 disc herniation. // Please perform with and without contrast. Concern for intra-abdominal process compressing peripheral nerves. TECHNIQUE: MDCT images were obtained from the lung bases to the lesser trochanters after administration of oral and intravenous contrast. Coronal and sagittal reformations were prepared. DLP: 835 mGy per cm COMPARISON: None FINDINGS: CT ABDOMEN: The lung bases are clear. The visualized portions of the heart pericardium are normal. The liver enhances homogeneously and there is a subcentimeter hypodense lesion in the dome of the liver on series 5, ___ 12. This is too small to characterize but statistically most likely represents a cyst or hemangioma. . 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 there is a 1.5 cm low-density lesion in the lower pole of the left kidney measuring -70 ___ consistent with an angiomyolipoma. . The stomach and small bowel are unremarkable. There is no portacaval, mesenteric and retroperitoneal lymphadenopathy. There is no free air or free fluid. CT PELVIS: The appendix is normal. The colon, rectum, urinary bladder are normal. There is no pelvic lymphadenopathy or free fluid. OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for malignancy. IMPRESSION: 1. No evidence for an intra-abdominal mass causing compression of peripheral nerves 2. Incidental findings include an angiomyolipoma of the lower pole of the left kidney and a subcentimeter hypodense lesion in the liver that is too small to characterize but likely represents a cyst or hemangioma. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Back pain, R Inguinal pain, RLQ abdominal pain Diagnosed with SKIN SENSATION DISTURB temperature: 98.4 heartrate: 58.0 resprate: 16.0 o2sat: 99.0 sbp: 180.0 dbp: 69.0 level of pain: 6 level of acuity: 2.0

You were admitted to ___ Neurosurgery service for evaluation of your left hip pain/numbness. You underwent a MRI of your lumbar spine that showed you have a bulging disc at L4-5, but that did not explain your left hip symptoms. Neurology was consulted to further evaluate those symptoms. You are now being discharged with the following instructions: You may continue to take your home medications as you were prior to this hospitalization.