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Admission Date: [**2162-10-10**] Discharge Date: [**2162-10-14**] Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**First Name3 (LF) 2736**] Chief Complaint: fall Major Surgical or Invasive Procedure: Single lead [**First Name8 (NamePattern2) **] [**Hospital 923**] Medical Identity ADx SR 5180 History of Present Illness: Ms. [**Known lastname **] is a [**Age over 90 **] yo female h/o dementia, hypertension, osteoporosis who presented to [**Hospital1 43650**] s/p fall at [**Hospital3 **]. She was found down in bathroom with wet floor and did not recall what happened. She initially complained of left knee pain and was found to have left eye hematoma. She denied head injury/LOC and had normal head imaging in the ED. Additionally with unremarkable C/T/L spine, bilaterall knee xray, and CXR in ED. The patient was initially placed in observation and plan was to have PT and case managment see her and then send her back to assissted living. However, in the ED around 8 AM she became bradycarduc to 30s, asystolic, and pulseless. A few compressions were delivered and the patient had ROSC, no shock was delivered. After a 7 second pause she went back in to sinus rhythm. The patient was unable to describe how she felt, however was back to her baseline mental status within 1-2 minutes. She had no complaints or recollection of the event. She responded to questions and said she felt "lousy", but could not provide more details. Of note the patient visited [**Hospital1 18**] ED for mechanical fall on [**8-14**] and was also admitted for mechanical fall in [**2161-8-20**]. Most recent previous admission [**2162-6-20**] for E. Coli Septicemia likely secondary to Cholangitis c/b pancreatitis that resolved with antibiotics and conservative management. In the ED the patient received ASA 300mg PR and oxycodone. Prior to transfer to CCU the patient was hemodynamically stable with VS T 97.7, HR 68, BP 128/51, RR 20, 99% on RA. On arrival to the floor, patient reports that her bladder hurts since the foley was placed. She denies pain. She denies CP, SOB, palpitations, dizziness/lightheadedness. She reports that she is at the hosptial because she fell, but can not provide other details. REVIEW OF SYSTEMS: Postive for achy joints and frequency of urination. Negative for dysuria. 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 chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: - Dementia - Hypertension - Arthritis - Sjogrens - Cataracts - h/o Bleeding ulcer - Narrow complex tachycardia: [**1-29**], reverted to sinus, on toprol. - L2-L3 compression fractures - Anterior abdominal wall fat-containing hernia and right inguinal hernia - Osteoporosis - Spinal Stenosis Social History: Lives in [**Hospital3 **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] facility and ambulates with walker. All of her cooking and cleaning are done for her. She has help in shower three times per week. Previously interior decorator, has 3 children, widowed, family very involved. Patient states had a daughter in [**Name (NI) **] and a daughter in [**Name (NI) 6607**]. Reports that her grand-daughters visit her frequently. -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: Mother/Father with CAD. Physical Exam: Admission Exam: VS: T=98.1 BP=161/74 HR= 60 RR=18 O2 sat= 93-97% on RA GENERAL: WDWN [**Age over 90 **] y/o female in NAD. Oriented to person, place, and some time (knows month, but not year). Hard of hearing. Mood, affect appropriate. Pleasantly confused. HEENT: NC. Left eye with hematoma and bruising present. Sclera anicteric. PERRL, EOMI. sl dry mucous membranes. NECK: Supple with flat neck veins. CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best at Right upper sternal border and radiating to clavicles. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. +BS EXTREMITIES: No c/c/e. SKIN: Scattered bruises of UE bilaterally. 5-8 mm slightly raised round lesions scattered over upper LE bilaterally (posterior>anterior and L>R). PULSES: DP pulses 2+ bilaterally Discharge Exam: T 97.8, P 80, BP: 94-159/50-80, RR: 18, 94% on RA GENERAL: WDWN [**Age over 90 **] y/o female in NAD. Hard of hearing. Mood, affect appropriate. HEENT: NC. Left eye with hematoma and bruising present. Sclera anicteric. PERRL, EOMI. sl dry mucous membranes. NECK: Supple with flat neck veins. CARDIAC: RRR, normal S1, S2. 3/6 systolic murmur heard best at Right upper sternal border and radiating to clavicles. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. +BS EXTREMITIES: No c/c/e. SKIN: Scattered bruises of UE bilaterally. 5-8 mm slightly raised round lesions scattered over upper LE bilaterally (posterior>anterior and L>R). bruising over left knee. PULSES: DP pulses 2+ bilaterally Pertinent Results: Admission Labs: [**2162-10-10**] 02:30AM BLOOD WBC-9.7 RBC-5.00 Hgb-13.7 Hct-41.6 MCV-83 MCH-27.3 MCHC-32.8 RDW-16.6* Plt Ct-517* [**2162-10-10**] 02:30AM BLOOD Neuts-66.0 Lymphs-21.4 Monos-10.5 Eos-1.3 Baso-0.7 [**2162-10-10**] 02:30AM BLOOD PT-9.4 PTT-20.4* INR(PT)-0.9 [**2162-10-10**] 02:30AM BLOOD Glucose-107* UreaN-12 Creat-0.5 Na-127* K-7.8* Cl-94* HCO3-26 AnGap-15 (hemolyzed specimen) [**2162-10-10**] 04:41PM BLOOD CK(CPK)-209* [**2162-10-10**] 04:41PM BLOOD CK(CPK)-209* [**2162-10-10**] 08:55AM BLOOD cTropnT-<0.01 [**2162-10-10**] 04:41PM BLOOD CK-MB-7 cTropnT-<0.01 [**2162-10-10**] 01:00PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2 [**2162-10-10**] 04:21AM BLOOD Na-132* K-4.2 Discharge labs [**2162-10-14**] 05:47AM BLOOD WBC-9.6 RBC-4.45 Hgb-12.4 Hct-37.4 MCV-84 MCH-27.9 MCHC-33.2 RDW-17.0* Plt Ct-518* [**2162-10-14**] 05:47AM BLOOD UreaN-14 Creat-0.7 Na-131* K-4.4 Cl-94* HCO3-25 AnGap-16 [**2162-10-12**] 08:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1 Images: CT Head [**10-10**]: 1. No acute intracranial hemorrhage or fractures. 2. New opacification of the left mastoid air cells and middle ear cavity, please correlate with signs of infection. CT C-Spine [**10-10**]: No acute cervical spine fracture. Multilevel moderate-to-severe degenerative changes of the cervical spine, worse at C4-C5 level. CT L-Spine [**10-10**]: 1. No new lumbar spine fracture. Stable compression of L2 and L3 vertebral bodies. 2. Multilevel severe degenerative changes of the lumbar spine, worse at L3-L4 level with moderate spinal canal stenosis. CT T-Spine [**10-10**]: No acute thoracic spine fracture. Mild compression of the superior endplate of T3 vertebral body, is likely chronic. Bilateral Knee Xray [**10-10**]: 1. No acute fracture. 2. Bilateral tricompartmental osteoarthritis, severe on the left and mild on the right. CXR [**10-10**]: The cardiomediastinal and hilar contours are normal. The lung volumes are low, with crowding of the bronchovascular markings in the lung bases. Patchy right basilar opacity may reflect atelectasis, aspiration or focal/early pneumonia. CXR [**10-10**] (post chest compressions): Cardiomediastinal contours are normal in appearance. Lungs are clear except for a tiny calcified granuloma in the periphery of the right lower lobe. No rib fractures are identified, but portable chest radiographs are relatively insensitive for detecting rib fractures, especially those involving the anterior ribs. There is no visible pneumothorax or pleural effusion. Echo: [**2162-10-11**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. There is a mild resting left ventricular outflow tract obstruction. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild to moderate ([**12-21**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with small LV cavity size with hyperdynamic LV systolic function. Consequently there is a mild left ventricular outflow tract gradient during systole. The aortic valve is thickened but opens reasonably well - the high velocity is due to the LVOT gradient. Mild to moderate aortic regurgitation. Probable diastolic dysfunction. CXR [**10-13**] Single-lead pacemaker in standard position, terminating in the right ventricle. No acute cardiopulmonary disease. Brief Hospital Course: Ms. [**Known lastname **] is a [**Age over 90 **] y/o female with a history of dementia, hypertension, and previous h/o narrow complex tachycardia with no known other cardiac history that presented [**1-21**] to fall and was found to have a symptomatic 7 second asystolic pause in ED with ROSC after chest compressions, no shock delivered. Active issues: # RHYTHM: Patient with previous history of narrow complex tachycardia on metoprolol. Now with 7 second asystolic pause in ED. Patient with mulitple falls recently, unclear whether mechanical or secondary to bradycardia and conduction abnormality. Differential includes high vagal tone, sick sinus syndrome, junctional abnormality. Tropnoin negative x 2. Normal K+ and Mg2+. Metoprolol was held. Patient monitored on telemetry and XX. EP consulted and followed patient. A pacemaker was implanted on [**10-12**] out of concern for arrhythmia as a cause for recurrent falls. The patient will follow up with EP for pacemaker interrogation after discharge. She was started on diltiazem 45 mg po QID for control of rate and rhythm given family report of "fuzziness" and fatigue that they attributed to the beta-blocker. She will have one more day of levofloxacin after discharge for prophylaxis against infection. # s/p Fall: patient presented to ED secondary to fall. Patient with multiple falls recently. Cause unclear, likely multifactorial given dementia, patient uses walker, and now found to have symptomatic 7 second asystolic pause. Patient with negative head CT, C/T/L spine CT, bilateral knee xrays in ED. Falls sound mostly mechanical after talking with family. PT consulted and recommended rehab. # ? bladder pain and increased frequency of urination: UA with neg nitrite, neg leuks. Patient with mild leukocytosis, however after CPR preformed and likely stress reaction. Of not on last admission patient with asymptomatic bacturia. Urine culture sent in ED, grew proteus mirabilis sensitive to ciprofloxacin and levofloxacin. She received a dose of ciprofloxacin and was continued on levofloxacin for prophylaxis after pacemaker insertion. She completed a three day course for UTI on [**10-14**]. # Hypertension: patient with reported hypertension, labile on last admission. Home metoprolol held for bradycardia and asystole. BP monitored throughout stay and was stable on 45mg of diltiazem QID. Chronic issues: # Dementia: patient currently AAO x 3, however confused. Home donezepil continued. # Sjogren's: continued saline eye drops # Osteoporosis, compression fractures: continued calcium, vitamin D, and weekly alendronate. Home oxycodone continued prn for pain. Transitional: -will need pacemaker interrogated in [**12-21**] weeks -titrate diltiazem dose to target BP and HR, then change to long-acting formulation when on a stable dose Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Donepezil 10 mg PO HS 2. Omeprazole 20 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES HS:PRN dry eyes 6. Alendronate Sodium 70 mg PO QMON 7. Calcium Carbonate 600 mg PO DAILY 8. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain 9. Polyethylene Glycol 17 g PO TID 10. cranberry *NF* unknown Oral daily 11. Glucosamine Sulf-Chondroitin *NF* (glucosamine [**Doctor First Name **] 2KCl-chondroit) 500-400 mg Oral daily 2 tabs daily Discharge Medications: 1. Alendronate Sodium 70 mg PO QMON 2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES HS:PRN dry eyes 3. Calcium Carbonate 600 mg PO DAILY 4. Donepezil 10 mg PO HS 5. Omeprazole 20 mg PO DAILY 6. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain 7. Vitamin D 1000 UNIT PO DAILY 8. Glucosamine Sulf-Chondroitin *NF* (glucosamine [**Doctor First Name **] 2KCl-chondroit) 500-400 mg Oral daily 2 tabs daily 9. cranberry *NF* 0 unknown ORAL DAILY 10. Levofloxacin 500 mg PO Q24H Duration: 1 Days Last day [**10-15**] 11. Diltiazem 45 mg PO QID 12. Polyethylene Glycol 17 g PO DAILY Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Sinus arrest 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. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You fell at home and was brought to the hospital. All of the tests to look for serious injury were negative. You had a slow heart rate and needed a pacemaker. The pacemaker was placed on [**10-12**] and there were no complications. A urine sample showed that you had a urinary tract infection and you will be on an antibiotic for one week. No lifting more than 5 pounds with your left hand or lift your left arm over your head for 6 weeks. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2162-10-18**] at 11:00 AM With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: FRIDAY [**2163-4-22**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD [**Telephone/Fax (1) 253**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2107-1-17**] Discharge Date: [**2107-2-12**] Date of Birth: [**2042-4-4**] Sex: F Service: MEDICINE Allergies: Keflex / Penicillins / Erythromycin Base / Demerol / Ceclor Attending:[**First Name3 (LF) 2932**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None. History of Present Illness: 64 yo woman w/ h/o recurrent PEs s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, GIB while anticoagulated, COPD, who was discharged [**2107-1-12**] after being treated for new PE presented to the ED with SOB and productive cough. She was readmitted [**2107-1-17**] after she was found to have a multifocal pneumonia and was treated with Levo/Flagyl and Vanco. Cultures were positive for MRSA. Levo and Flagyl were continued for suspected aspiration PNA. The pt recovered quickly over since admission and she is now back on her home O2 requirement. She was getting bridged for her anticoagulation with Lovenox starting [**1-18**] in preparation for discharge. However, she developed severe abdominal pain and a palpable mass in her L abdomen. A CT was showed a new large hematoma in the muscles of the left anterior and lateral lower abdominal and pelvic wall, without any intraperitoneal or retroperitoneal extent, but with associated mass effect on the lower abdominal and pelvic bowel loops. Surgery was [**Month/Year (2) 4221**] and suggested no intervention, but monitoring for now. HCT dropped 6 points in this setting, but she remained hemodynamically stable with tachycardia which has been present throughout her hospital stay (95-115). She required a total of 5 units PRBC and 4 units FFP transfusions and was transferred to the MICU for further monitoring. Her hematocrit has since been stable with serial checks. . ROS: She has baseline left to mid chest pain with exertion that is not currently bothering her. She denies current chest pain, SOB, dysuria, increased urinary frequency. She has stable R knee pain. Past Medical History: 1. H/O Rheumatic Fever - age 8 -dx'ed last year with rheumatic heart disease per pt (states ED diagnosed this) and has had syndenham chorea 2. ?CHF per pt. although [**12-13**] Echo revealed low normal LVEF, mildly thickened aortic and mitral valves with mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. 3. Orthostatic hypotension 4. Chest pain - nearly monthly visits to ED with negative ischemic w/u in the past 5. Duodenal/gastric ulcer 6. Seven miscarriages 7. Ulcerative colitis 8. Diverticulosis-s/p colostomy and reversal colostomy-had Colonoscopy [**1-12**] showed only diverticuli without e/o active bleed 8. Panic attacks x 15 yrs 9. Depression - several SA in past 10. Schizoaffective disorder 11. h/o polysubstance abuse 12. Iron deficiency anemia (baseline unclear-high 20's to 30's) 13. COPD 14. PE [**7-13**], c/b GIB while on anticoagulation, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter. New PE on [**2107-1-2**], again on anticoagulation Social History: Lives in lodge house. She has a homemaker help with her cleaning. She gets meals on wheels. She has very limited funds. Smoked 2 PPD X 40 yrs, quit smoking 4 months ago. Former drinker, reports drinking two 6 packs per day for 2 yrs; quit 27 yrs ago. Denies h/o illicits and IVDA. H/O domestic violence. Family History: Daughter -40 - colitis. Had 6 siblings. One sister died, 35, ovarian CA. Brother, died at 48, stroke. Sister, died at 64 from infection. Father died at 65 of MI. Mom was "psychotic", died of stroke at 93 Physical Exam: VS: 97.6 HR 114, Bp 118/74 RR 20-30 Sats 98% 2L. Gen: NAD, pleasant HEENT: PEERLA, MMM. Neck: supple, no LAD Lungs: moderate air movement, decreased breath sounds at bases CV: RRR, S1S2 present, distant heart sounds, no murmurs Abd: +BS, S/ND, + umbilical hernia, ulcer mid abdomen-reportedly chronic, unchanged, mildy errythematous base. no secretions. Tenderness in L abdomen, palpable mass over unclear extension, no guarding, no rebound Back: no CVA tenderness. Ext: 2+ on RLE, 1+ edema LLE/ no c/c/ 1+ DP Neuro: A&Ox3, CN II-XII intact. moving all extremities. Pertinent Results: ADMISSION LABS: [**2107-1-16**] 08:40PM PT-87.9* PTT-41.3* INR(PT)-11.8* [**2107-1-16**] 08:40PM WBC-16.2*# RBC-3.63* HGB-11.6* HCT-33.5* MCV-93 MCH-32.1* MCHC-34.7 RDW-14.0 [**2107-1-16**] 08:40PM NEUTS-90.5* BANDS-0 LYMPHS-4.7* MONOS-2.4 EOS-2.0 BASOS-0.5 [**2107-1-16**] 08:40PM GLUCOSE-127* UREA N-16 CREAT-1.0 SODIUM-136 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [**2107-1-16**] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2107-1-17**] 12:47AM LACTATE-1.3 [**2107-1-22**] 03:07AM BLOOD WBC-7.5 RBC-2.85*# Hgb-8.6*# Hct-25.6* MCV-90 MCH-30.3 MCHC-33.6 RDW-14.4 Plt Ct-243 [**2107-1-22**] 03:07AM BLOOD PT-22.4* PTT-31.1 INR(PT)-2.2* [**2107-1-22**] 03:07AM BLOOD Glucose-105 UreaN-11 Creat-0.6 Na-141 K-4.0 Cl-102 HCO3-35* AnGap-8 [**2107-1-22**] 03:07AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1 [**2107-1-23**] 04:34PM BLOOD PEP-HYPOGAMMAG IgG-535* IgA-254 IgM-109 . CTA chest: 1. Interval development of patchy areas of consolidation with mucous plugging, particularly in the right lower lobe, right upper and mid lobes suggest a new infectious process or aspiration. 2. Resolution of the previously identified pulmonary embolism. 3. Extensive centrilobular and paraseptal emphysematous change. 4. Fluid-attenuating structure adjacent to the right T11-12 neural foramen is also unchanged and could be a perineural cyst. . CT abdomen/pelvis: 1. New large hematoma in the muscles of the left anterior and lateral lower abdominal and pelvic wall, without any intraperitoneal or retroperitoneal extent, but with associated mass effect on the lower abdominal and pelvic bowel loops. 2. Unchanged infectious or inflammatory opacities in the right middle and lower lobes. . [**2107-2-1**] IR Embolization: 1. Right inferior epigastric arteriogram demonstrates no extravasation of contrast and successful embolization with Gelfoam until stagnation of flow. 2. The right internal mammary artery demonstrated no areas of active extravasation of contrast. . [**2107-2-3**] CXR: There is an irregular opacity in the right lower lobe concerning for pneumonia. There are no pleural effusions. There is no pneumothorax. The left subclavian catheter tip overlies the mid SVC. Heart size normal. Mediastinal and hilar contours are normal. IMPRESSION: Opacity in the right lower lobe concerning for pneumonia. . [**2107-2-8**] LENIS: Extensive occlusive thrombus is demonstrated from the common femoral vein at the takeoff of the greater saphenous vein extending distally to the popliteal veins bilaterally. No color flow, compressibility, or waveforms are demonstrated within these areas of thrombus. IMPRESSION: Extensive, completely occlusive, bilateral deep venous thrombi extending from the common femoral veins to the popliteal veins. . [**2107-2-9**] ECG: Sinus tachycardia, Normal ECG except for rate Brief Hospital Course: 64F w/ h/o recurrent PE s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, GIB on anticoagulation, COPD, recently admitted for new PE, readmitted for multifocal PNA, who developed a large abdominal wall hematoma in the context of enoxaparin injections. # Multifocal Pneumonia: She was admitted with multifocal pneumonia. She was started on levofloxacin and vancomycin. She completed a 7 day course of levofloxacin. MRSA was found to grow in her sputum so she was continued on a 14 day course of vancomycin. She originally presented with elevated WBC count and left shift which quickly resolved with the initiation of antibiotics. Her productive cough improved as well and she remained on her baseline home O2 of 2L. Approximately 4 days after completion of her 14 day course of Vancomycin, the patient developed worsening cough, SOB, and upper respiratory symptoms. A repeat CXR showed evidence of a new consolidation in the RLL. The patient was started back on Levofloxacin/Flagyl. Vancomycin was added to her regimen when blood cultures showed 2/4 bottles with GPC in clusters and chains. Additionally, her sputum culture grew out GNRs. Levofloxacin was discontinued and Meropenem was started for concern for Pseudomonas given the patient's long hospital course. Her O2 sat remained stable 93-100% on 2L nasal cannula (which is her baseline). She was given mucomyst inhaled nebulizers to assist in breaking up thick sputum. Her GNRs in the sputum grew out E. coli. Because of the sensitivity profile of the E. coli and the patient's allergy to penicillin and cephalosporins, the patient was continued on Meropenem. Her GPCs were found to grow out Coag negative Staph. Surveillance cultures had no further growth and the coag negative staph was thought to likely be a contaminant. Her Vancomycin was discontinued. She will continue a 14 day course of Meropenem and she was discharged with a PICC to complete this course. . # Pulmonary embolism/DVTs: She has had multiple PEs and has had one even since the placement of a TrapEase IVC filter. CT during recent previous hospitalization revealed appropriate location of filter and CTA on this admission showed improvement of clot. Admission labwork revealed an INR of 7.9. Coumadin was thus held and reversed with FFP and vitamin K given her history of GIB on anticoagulation. In the interim, therapeutic lovenox injections were initiated, but within days of starting, she developed a large abdominal wall hematoma near to lovenox injection site. Once her hematocrit stabilized, she was started on a heparin gtt with coumadin overlap. While [**Last Name (NamePattern4) 9533**] her Coumadin with an INR 1.2, she was found to have a large Hct drop and a CT scan of the abdomen showed a new rectus hematoma. She was subsequently transferred to the MICU for closer monitoring. It was decided after her second hematoma while on anticoagulation, the risks of anticoagulation outweigh the benefits at this time and she was not anticoagulated. In terms of her hypercoagulable workup, it has been negative thus far for hyperhomocysteinemia, Factor V Leiden and antiphospholipid antibody. Malignancy workup included a colonoscopy and EGD as well as CEA, all of which were within normal limits. SPEP revealed hypogammaglobulinemia, but was otherwise unremarkable. During her hospital course, she also began to complain of worsening lower extremity pain. LENIs were obtained which showed evidence of extensive, completely occlusive, bilateral deep venous thrombi extending from the common femoral veins to the popliteal veins. Radiology felt that these clots were most likely acute to subacute in nature. In this setting, hematology/oncology saw the patient again to consider the risks vs benefits of anticoagulation. Antithrombin III, prothrombin mutation, Lupus anticoagulation and [**Location (un) 1169**] Venom Viper were sent to reevaluate the reason for her hypercoagulability. The hematology/oncology team still felt that the risks of coagulation outweigh the potential benefits given that the patient has had multiple bleeding episodes in the setting of anticoagulation. # Abdominal wall hematoma: As mentioned above, she developed a large left-sided abdominal wall hematoma from a Lovenox injection site that caused a significant hct drop (originally 28.1-->19.4). Despite the drop, she remained hemodynamically stable (has sinus tachycardia at baseline prior to bleed). She received 3 units prbcs, 4 units FFP. Her hematocrit then stabilized and once stable, she was restarted on heparin gtt. Coumadin was re-initiated and heparin gtt was continued while awaiting her INR to become therapeutic. While [**Location (un) 9533**] her Coumadin with an INR 1.2, she was found to have another Hct drop (25.9-> 22.2) and a CT scan of the abdomen showed a new right-sided rectus hematoma. She was subsequently transferred to the MICU for closer monitoring. She was given 1 unit FFP and 9 units PRBCs between [**Date range (1) 39125**] until her hematocrit became stable and she bumped appropriately to transfusion. It was decided after her second hematoma while on anticoagulation, the risks of anticoagulation outweigh the benefits at this time and she was not anticoagulated. She has complained of [**6-16**] abdominal pain with movement and has maintained stable hematocrits. Her pain is most likely [**3-11**] to the large rectus hematoma that will resolve over time. Her Hct remained stable after her anticoagulation was discontinued. # Thoracic mass: CT chest and abdomen revealed a stable thoracic mass (stable x 3years) and thought potentially consistent with neural cyst. It was not further evaluated by MRI given its long term stability and also she has metal hardware in place s/p elbow surgery and facial plates. It should be followed up with imaging to ensure it remains unchanged in the future. # ? Zoster: Patient reports having a history of "herpes" on her right buttock. During her stay, she developed a tingling, itchiness and multiple small erythematous skin lesions on her right buttock over the S2, S3 dermatomal distribution. There were no vesicles appreciated. She was treated with acyclovir. # Candidal vaginitis: Treated with fluconazole x 2 with resolution of symptoms. # H/o GI bleeding during recent admission: Recent colonoscopy showed diverticulosis with no active signs of bleeding. She had no blood in her stools during this admission even while anticoagulated. Her stools were guiac-ed multiple times and were found to be guiac negative. # Constipation: She is constipated at baseline and requires daily scheduled bowel regimen to maintian regularity. # Hyperlipidemia: Continued on lipitor. # Depression/SAD: Continued on Prozac, risperdone, wellbutrin, and klonopin. # Ulcerative Colitis: Remains in remission. She was continued on mesalamine. # Orthostatic hypotension: She remained asymptomatic even while ambulating with physical therapy. She was continued on midodrine. Medications on Admission: 1. Fluoxetine 30 mg daily 2. Risperidone 3 mg PO HS 3. Bupropion SR 150 mg [**Hospital1 **] 5. Nicotine 7 mg/24 hr Patch 6. Hexavitamin daily 7. ascorbic acid 500 tab 1 [**Hospital1 **] 8. Calcium Carbonate 500 tab [**Hospital1 **] 9. Ferrous gluconate 325 PO daily 10. Atorvastatin 20 mg daily 11. Fluticasone Salmeterol 250/50 [**Hospital1 **] 12. Midodrine 5 mg tab 1 TID 13. Tiotropium bromide capsule one cap /day 14. Mesalamine 1200 TID 15. Pantoprazole 40/ day 16. Albuterol nebs prn (tid generally) 17. docusate sodium 18. Warfarin 5 mg/day 19. Ipratropium nebs prn (tid generally) 20. clonazepam 1mg po tid Discharge Medications: 1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please do not take this with levofloxacin. 13. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) as needed. Disp:*100 Lozenge(s)* Refills:*0* 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-8**] Sprays Nasal QID (4 times a day). Disp:*QS bottle* Refills:*2* 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 18. Saline Flush 0.9 % Syringe Sig: Three (3) ml Injection twice a day for 20 doses: prior to each vanco dose. Disp:*20 syringe* Refills:*0* 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 21. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 26. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 27. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 28. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 29. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 30. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: for PICC line. 31. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1) Pulmonary Embolism with history of DVT and IVC filter placement in [**2106-7-8**] 2) Community Acquired Pneumonia 3) History of GI Bleed (extensive) in [**2106-7-8**] when anticoagulated 4) Abdominal wall hematoma, with acute blood loss anemia requiring 10 units PRBCs when anticoagulated for current pulmonary embolism 5) Noscomial Pneumonia with GNR in sputum, 6) Coagulopathy 7) Noscomial UTI with E. coli - quinolone resistant 8) Vagnitis, attributed to broad spectrum antibiotic usage 9) otitis externa 10) tachycardia 11) diarrhea 12) incidentally noted left renal cyst/mass NOS 13) Coagulase negative staphylococcal bacteremia 14) Rectus sheath hematoma in setting of anticoagulation . Secondary: 1) chronic orthostatic hypotension 2) recurrent otitis externa 3) ulcerative colitis in remission 4) chronic obstructive pulmonary disease 5) depression 6) h/o schizoaffective disorder Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed, please keep all follow-up appointments. Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **], or return to the Emergency Department if you experience fevers, chills, worsening shortness of breath, dizziness, lightheadedness, worsened chest pain, nausea, vomiting, diarrhea, blood in your stools or any symptoms that concern you. . Please take all of your medications as prescribed and follow up with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below. Followup Instructions: You need to set up a followup appointment to see Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **] in [**2-8**] weeks. Please call ([**Telephone/Fax (1) 39126**] to set up this appointment. . You had the following appointment scheduled prior to your hospitalization: Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2107-1-28**] 1:00 ***Follow up CT scan or ultrasound of left kidney is recommended as well as Urologic follow up due to incidentally noted left renal cyst/mass that may be malignant.******* [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2107-2-12**]

Admission Date: [**2193-4-11**] Discharge Date: [**2193-4-16**] Date of Birth: [**2121-3-15**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: Elective Admission for Mass resection Major Surgical or Invasive Procedure: [**4-11**]: Right craniotomy for mass resection History of Present Illness: Patient is a 72M known to the neurosurgery service for prior hospitalization for AVM hemorrhage. At that time, incidental mass was identified, and he now presents electively for resection of said mass. Past Medical History: IVH/AVM bleed [**10-3**] h/o Lt temporal AVM, HTN, depression , BPH, UTI, seizure, bladder stone s/p VP shunt, cyberknife (AVM [**11-3**]), cysts removal from skin, lithotripsy, extra-ventricular drain [**10-3**] Social History: resides at home with wife Family History: Non-contributory Physical Exam: On Discharge: The patient is oriented x 3. His pupils are 2mm bilaterally. EOMs intact. Face symmetric. Tongue midline. Left pronator drift. LUE is weak as well as his IP in the LLE. His right side is full strength. The dressing was removed and the staples are clean, dry, and intact. Pertinent Results: Labs on Admission: [**2193-4-11**] 02:46PM BLOOD WBC-18.4*# RBC-3.81* Hgb-11.0* Hct-32.7* MCV-86 MCH-28.8 MCHC-33.5 RDW-15.5 Plt Ct-517* [**2193-4-12**] 03:11AM BLOOD PT-12.8 PTT-24.1 INR(PT)-1.1 [**2193-4-11**] 02:46PM BLOOD Glucose-179* UreaN-11 Creat-0.7 Na-139 K-4.2 Cl-107 HCO3-24 AnGap-12 [**2193-4-11**] 02:46PM BLOOD Calcium-8.3* Phos-4.2 Mg-1.7 Imaging: MRI/A Head Neck [**4-13**]: TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired before gadolinium. T1 axial and MP- RAGE sagittal images were obtained following gadolinium. 3D time-of-flight MRA of the circle of [**Location (un) 431**] obtained. Gadolinium-enhanced MRA of the neck and fat-suppressed axial images of the neck were acquired. FINDINGS: BRAIN MRI: Comparison was made with the previous MRI of [**2193-4-11**]. Since the previous study, the patient has undergone resection of a large meningioma in the right frontal region. Extensive right-sided brain edema is again identified. There are blood products at the surgical site. Although no residual nodular enhancement is seen, there is enhancement seen along the sulci and meningeal enhancement identified in the region. These findings indicate both pachy and leptomeningeal enhancement. Mild slow diffusion in the surrounding area on diffusion images is indicative of postoperative change. There is blood in the left lateral ventricle. There is persistent mass effect on the right lateral ventricle. Changes of small vessel disease are seen. A left frontal drainage catheter is identified. Note is made of new areas of slow diffusion in the right medial thalamus. These findings are indicative of acute infarcts which are new since the previous study. Again noted is enhancing meningioma in the tuberculum sella region. Additionally, enhancement and flow void in the left medial temporal lobe region indicative of an aneurysm at the site of previously noted arteriovenous malformation. Post-craniectomy changes are seen in the right frontal region. Pneumocephalus identified. IMPRESSION: Previous MRI examination, the patient has undergone resection of a large frontal meningioma with blood products at the surgical site without residual nodular enhancement. Leptomeningeal and pachymeningeal enhancement is seen which appears postoperative. Acute right-sided thalamic infarcts are seen which are new since the previous study. Other findings are stable as described above. MRA OF THE NECK: The neck MRA demonstrates normal flow in the carotid and vertebral arteries. The fat-suppressed images demonstrate subtle increased soft tissues adjacent to the proximal right common carotid artery as seen on the CTA. This could be related to small amount of blood in the surrounding soft tissues from recent attempted central venous line placement. There is no definite dissection seen. IMPRESSION: Normal MRA of the neck. MRA OF THE HEAD: The head MRA demonstrates no evidence of vascular occlusion or stenosis. The previously seen aneurysm in relation with the left posterior cerebral artery is not apparent on the MRA. The left medial temporal lobe arteriovenous malformation is also not clearly visualized. IMPRESSION: No vascular occlusion or stenosis seen on the MRA of the head. Postoperative changes are noted following removal of frontal lobe tumor. Acute right thalamic infarcts are identified. MRA of the neck is normal without dissection. MRA of the head demonstrates no stenosis or occlusion. Brief Hospital Course: Patient was electively admitted on [**4-11**] to undergo resection of his brain mass. Post-operatively, he was transferred to the ICU for continuous monitoring. During his perioperative course, central line placement was complicated by access to the carotid artery. Post-op, vascular surgery was consulted, duplex studies performed, and determined to be without injury to the carotid artery. MRI/A was also done to further confirm this as well as evaluate surgical resection. The vascular surgery team agreed that there was no carotid artery dissection and no intervention needed on their part. The patient was extubated in the ICU and was then transferred to the floor. He did well over the weekend. The patient was able to eat without difficulty. PT and OT evaluated him and recommended rehab placement. On [**4-16**] the patient was noted to have bloody urine in the foley. A urinalysis revealed a UTI. He was started on a 14-day course of cipro. The patient was sent to rehab on [**4-16**]. Medications on Admission: APAP, Celexa 20mg', Compazine 20mg prn, Flomax 0.4mg', Folic Acid 1mg', Keppra 500mg", lactulose prn,Ativan 1mg prn, Metoprolol 50mg"', [**Name (NI) 10687**], MOM, Ritalin 20mg', Seroquel 25mg"', Trazadone 50mg hs Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. [**Name (NI) 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right Frontal Meningioma Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office [**4-26**] at 10:00 am for removal of your staples and a wound check [**Telephone/Fax (1) 1669**]. ??????You need to have an appointment in the Brain [**Hospital 341**] Clinic. They will call you with an appointment. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain as this was done during your acute hospitalization. Completed by:[**2193-4-16**]

Admission Date: [**2146-11-17**] Discharge Date: [**2146-11-25**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 65376**] is an 83 yo RHM who was in his USOH until this afternoon when he had the sudden-onset of left-sided weakness that led to him falling to the ground. He managed to have a couple of bystanders help him get back on his motor scooter and drive himself home. He went into his apartment and tried to go to the bathroom. He then fell off the toilet and found that he could not get up from the toilet and he called a neighbor. [**Name (NI) **] denies head trauma, HA, N/V, vertigo. An ambulance brought him to [**Hospital3 1443**] Hospital where a head CT revealed a right thalamocapsular hemorrhage and he was transferred to [**Hospital1 18**] for further management. His sister reported recent weight loss. No f/c/s/n/v/d, no changes in voice, difficulty swallowing, hearing, dizziness, vertigo, diplopia, blurry vision, headache, or head trauma. Past Medical History: Inguinal hernia ORIF of hip fx History of MVA where he was dragged by a car about 70 years ago Social History: Lives alone, previously able to care for himself. Unmarried. Has intermittent contact with two sisters and daughter. Denies smoking, drugs, or EtOH use. Family History: No neurological disease. No CA. Mother with diabetes died from CHF as complication of parathyroid abnormality. Father died at 87 in accident. Brother recently admitted to [**Hospital1 18**] for traumatic intracranial bleed. Physical Exam: PE: Gen, very thin HEENT AT/NC, MMM no lesions, no bruits Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits Chest Clear, with slightly decreased BS at right base CVS RRR w/o MGR ABD soft, NTND, + BS, large left sided inguinal hernia. EXT no C/C/E. no petechiae, no asterixis, rash over penis, and much of lower extremities. Severe nail disease. Neuro MS: AA&Ox3, appropriately interactive, normal affect, normal fund of knowledge [**Doctor Last Name 1841**] with errors, simple calculations intact, fluent without paraphrasic errors. Prosody slow flat. Naming, [**Location (un) 1131**], intact. 0/3 at 5 minutes,[**3-3**] with prompting No L/R confusion. Normal graphesthesia. Able to mimic brushing teeth with either hand. CN: I--not tested; II,III-PERRLA, VFF by confrontation, optic discs sharp with normal vasculature; III,IV,VI-EOMI w/o nystagmus, no ptosis; V--sensation intact to LT/PP, masseters strong symmetrically; VII-Left facial weakness with sparing of forehead; VIII-hears finger rub bilaterally; IX,X--voice normal, palate elevates symmetrically, uvula midline, gag intact; [**Doctor First Name 81**]--SCM/trapezii [**5-5**]; XII--tongue protrudes midline, slight apraxia Motor: Normal bulk and tone. No rigidity, no tremor, no bradykinesia Strength: Left sided hemiplegia. Coord: FFM slow on LEFT but accurate. Refl: [**Hospital1 **] Tri Brachio Pat [**Doctor First Name **] Toe R 2 2 2 2 2 down L 2 2 2 2 2 down [**Last Name (un) **]: LT, PP, temperature, vibration, and position sense intact. No evidence of extinction. Pertinent Results: [**2146-11-25**] 11:25AM BLOOD WBC-9.3 RBC-3.86* Hgb-12.5* Hct-36.0* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.6 Plt Ct-180# [**2146-11-24**] 05:15AM BLOOD WBC-6.8 RBC-3.73* Hgb-11.9* Hct-34.9* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.5 Plt Ct-115* [**2146-11-23**] 05:50AM BLOOD WBC-6.9 RBC-3.79* Hgb-12.3* Hct-35.3* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.7 Plt Ct-85* [**2146-11-22**] 10:40AM BLOOD WBC-11.2* RBC-3.98* Hgb-12.7* Hct-35.8* MCV-90 MCH-31.9 MCHC-35.5* RDW-14.0 Plt Ct-77* [**2146-11-22**] 05:15AM BLOOD WBC-14.5* RBC-3.79*# Hgb-12.0*# Hct-34.3*# MCV-91 MCH-31.6 MCHC-34.9 RDW-14.2 Plt Ct-67* [**2146-11-21**] 01:57AM BLOOD WBC-15.4* RBC-2.91* Hgb-9.4* Hct-26.5* MCV-91 MCH-32.3* MCHC-35.5* RDW-13.9 Plt Ct-65* [**2146-11-20**] 03:00AM BLOOD WBC-19.6* RBC-2.98* Hgb-9.8* Hct-28.1* MCV-94 MCH-32.8* MCHC-34.8 RDW-13.4 Plt Ct-70* [**2146-11-19**] 02:30AM BLOOD WBC-25.1*# RBC-3.44* Hgb-11.2* Hct-32.3* MCV-94 MCH-32.6* MCHC-34.7 RDW-13.4 Plt Ct-106* [**2146-11-18**] 04:58AM BLOOD WBC-5.7 RBC-3.66* Hgb-12.4* Hct-34.2* MCV-93 MCH-33.9* MCHC-36.3* RDW-12.9 Plt Ct-118* [**2146-11-17**] 07:30PM BLOOD WBC-6.7 RBC-3.78* Hgb-12.4* Hct-34.0* MCV-90 MCH-32.7* MCHC-36.4* RDW-13.1 Plt Ct-117* [**2146-11-25**] 11:25AM BLOOD Plt Ct-180# [**2146-11-25**] 11:25AM BLOOD Glucose-110* UreaN-23* Creat-0.7 Na-138 K-4.6 Cl-104 HCO3-27 AnGap-12 [**2146-11-24**] 05:15AM BLOOD Glucose-111* UreaN-32* Creat-1.1 Na-139 K-4.4 Cl-106 HCO3-26 AnGap-11 [**2146-11-23**] 05:50AM BLOOD Amylase-53 [**2146-11-22**] 10:40AM BLOOD ALT-102* AST-52* Amylase-56 TotBili-0.6 [**2146-11-19**] 02:30AM BLOOD CK(CPK)-1600* [**2146-11-21**] 01:57AM BLOOD CK(CPK)-120 [**2146-11-25**] 11:25AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 [**2146-11-18**] 04:58AM BLOOD VitB12-786 [**2146-11-18**] 04:58AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2146-11-18**] 04:58AM BLOOD Triglyc-40 HDL-98 CHOL/HD-2.1 LDLcalc-98 [**2146-11-22**] 10:40AM BLOOD Ammonia-20 [**2146-11-18**] 04:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Barbitr-NEG Tricycl-NEG Urine Culture KLEBSIELLA PNEUMONIAE | ENTEROBACTERIACEAE | | KLEBSIELLA PNEUMONIAE | | | AMPICILLIN/SULBACTAM-- 4 S 4 S <=2 S CEFAZOLIN------------- <=4 S <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S <=1 S CEFUROXIME------------ 2 S 2 S <=1 S GENTAMICIN------------ <=1 S <=1 S <=1 S IMIPENEM-------------- <=1 S 2 S <=1 S LEVOFLOXACIN----------<=0.25 S <=0.25 S <=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S =>512 R <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S Blood culture [**11-18**] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Repeat Urine culture <10,000 colonies Repeat Blood cultures negative for three days. Head CT [**11-17**]:Right basal ganglia 21 x 10 mm intraparenchymal hemorrhage with mild surrounding edema. No prior studies were available for comparison. Head CT [**11-18**]: stable hemorrhage MRI/MRA: MRI demonstrates the right thalamic hemorrhage, as visualized on the CT scan of [**2146-11-17**]. No additional areas of susceptibility artifact are detected. There are no signs of acute infarction. MRA demonstrates flow in the major branches of the circle of [**Location (un) 431**] and no abnormal vascularity. LEFT X-ray Knee and Hip: No fracture, dislocation, or evidence of hardware loosening. CXR:A feeding tube has been withdrawn slightly in the interval. Although the tip still terminates in the stomach, the most proximal portion of the radiodense tip is likely just above the GE junction level. Cardiac silhouette is stable in size and demonstrates left ventricular configuration. There has been interval marked improved aeration in the left retrocardiac region with only minimal residual atelectasis remaining. Bilateral pleural effusions are improved, resolved on the right and nearly resolved on the left. There are no new or worsening areas of opacification to suggest pneumonia. Echo/TTE:The left atrium is mildly dilated. A patent foramen ovale or small atrial septal defect could not be excluded by color Doppler study. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with probable distal septal hypokinesis. Overall left ventricular systolic function is borderline depressed. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. No cardiac source of embolus identifed. Brief Hospital Course: Neurology - Mr. [**Known lastname 65376**] was admitted to the ICU for monitoring once it was discovered that his left-sided was secondary to a right sided thalmocapsular hemorrhage. In the ICU, he remained hemodynamically stable however his neurological exam worsened from left sided hemiparesis to essentially, hemiplegia involving most of his left side, including face, arm, and leg. The differential included hypertensive hemorrhage, mass, aneurysm, or hemorrhagic conversion of an embolic. As the patient had little recorded or reportable medical history it is unclear that he had a history of HTN, but this was clearly the most likely diagnosis as no mass was observed and the MRA was negtive for vascular malformation. He was quite hypertensive at admission, with BPs 200/100s requiring IV hydralazine for control. The patient had a deterioration in his mental status after transfer out of the ICU. An encephalopathy work-up revealed bilateral pleural effusions thought to be secondary to possible aspiration pneumonia. His antibiotic regimen was changed to Levofloxacin and Metronidazole and he became alert and oriented within 24 hrs. He should complete another 6 days of Levofloxacin and Flagyl. Physical therapy has been involved with his care and he has been moved to and from his bed to a chair. HbA1C, Lipids were normal. His Trans-thoracic Echocardiogram revealed normal EF without vegetations. Respiratory - pt intermittently required oxygen by NC. He was diagnosed with bilateral pleural effusions and possible left sided pneumonia which on repeat CXR [**11-25**] showed interval resolution. He currently does not have an oxygen requirement. FEN/GI - the patient had difficulty swallowing and had been maintained with an NGT for adequate fluid and nutritional intake. Speech and swallow recommended: 1. Continue with NG tube feedings to maintain nutrition/hydration 2. PO diet consistency of nectar thick liquids and purees as a SNACK only 3. Basic aspiration precautions should be followed: a. Pt should be awake and alert while eating b. Pt should be seated upright in the bed during all meals. He will likely benefit from f/u with a nutrionist in Rehab. Pt. also with large left inguinal hernia. This is a [**Last Name 19390**] problem that has not presented acute issues for him. Renal/GU - Patient admitted with hyophosphatemia and hypomagnesemia which have responded well to both oral and IV supplementation. His recent Mg and Phos have normalized. He has [**Doctor First Name **] kept on Neuta Phos packets [**Hospital1 **]. Patient was evaluated by Urology service for difficulty with Foley catheter placement in the ICU. A catheter was placed by GU; they recommended a voiding trial and on [**11-25**] the catheter was pulled and the patient voided spontaneously. The patient has had microscopic hematuria and GU was made aware of this. Their recommendation was that this could be followed up as an outpatient. ID - The patient had Klebsiella pneumoniae urosepsis. He was initially placed on Gentamicin. He subsequently had a drop in his platelets. Because the bacteria was also sensitive to ceftriaxone he was switched as there was concern that the thrombocytopenia (low of 65) was secondary to gentamicin. Once the gent was discontinued, his platelets subsequently recovered to normal range. He has been treated with Levaquin IV and Flagyl for 2 days and should complete another 6 days of these two antibiotics for the Klebsiella and the pneumonia. HEME - Thrombocytopenia as mentioned above. Pt. had developed anemia and was tranfussed two units of PRBCs in the ICU. He has since had stable CBCs. His anemia was likely secondary to acute illness. He was placed on Heparin 5000 U SC for DVT prophylaxis. Musculoskeletal: Pt c/o pain in left knee. He underwent X-rays of both knee and left hip earlier in the hospitalization as he presented with a fall. These tests were negative for fracture or change in hardware (secondary to left hip ORIF in past). PODIATRY - the patient had severe nail fungus and Podiatry debrided the nails. He has been receiveing LacHydrin moisturizing cream to his feet for severe dryness. There has been much improvement during his hospital course. DISPO - Patient has no PCP and would definitely benefit from regular medical follow-up. A phone number for [**Hospital **] will be provided. The patient will have f/u appointments with Urology and Neurology/Stroke. Patient will require long-term assistance with ADLs and will benefit from inpatient rehabilitation. DIAGNOSIS: Right thalamocapsular hemorrhage likely secondary to hypertension Medications on Admission: None Discharge Medications: 1. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO BID (2 times a day). Disp:*60 Packet(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60. Disp:*60 Tablet(s)* Refills:*2* 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:*900 mg* Refills:*2* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:*18 Tablet(s)* Refills:*0* 5. Ammonium Lactate 12 % Lotion Sig: One (1) application Topical [**Hospital1 **] (2 times a day). Disp:*60 applications* Refills:*2* 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). Disp:*600 mL* Refills:*2* 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). Disp:*90 mL* Refills:*2* 8. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous once a day for 6 days. Disp:*6 units* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Right thalamocapsular hemorrhage Left hemiplegia HTN BPH Discharge Condition: Fair Discharge Instructions: Please take your medications If you experience new wekaness, trouble speaking or swallowing, chest pain, or palpitations, please inform a physician Followup Instructions: Neurology/Stroke - Please call [**Telephone/Fax (1) 3767**] to schedule an apopointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Urology f/u for BPH [**Telephone/Fax (1) 164**] for appt. Patient will require referral for a PCP as an [**Name9 (PRE) 15973**]. The number for Helath Care Assocaites is:

Admission Date: [**2143-8-23**] Discharge Date: [**2143-8-27**] Date of Birth: [**2077-7-13**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 66-year-old man with severe CAD, status post CABG in [**2135**] with recent PCI to the LMCA and SVG to the PDL in [**2143-7-14**]. He presented on [**2143-8-23**] for an elective intervention brachytherapy of the SVG to PL and native RCA. The patient reported that he had been feeling well without chest pain, shortness of breath, or dyspnea on exertion. He was noted to have an ejection fraction of greater than 60 percent in [**2143-7-14**]. The patient underwent a cardiac catheterization on the morning of arrival with PCI to the native RCA and 4 stents and brachytherapy to the vein graft. The patient tolerated the procedure well and approximately 6 hours later developed a chest pain noted as 4 out of 10 substernal radiating to his throat and back without shortness of breath, diaphoresis, nausea or vomiting. EKG at that time revealed ST elevation in II, III, and aVF. The patient was brought back to the catheterization laboratory at that time. They found that the SVG to PL have been thrombosed. The artery was opened in the catheterization laboratory, AngioJet had been unsuccessful and the graft was opened with Nipride with subsequent TIMI 3 flow. The patient had persistently occluded communication between the native RCA and the vein graft. Postprocedure, after the sheath pull, a hematoma developed and the patient had baseline low blood pressure of systolic in the 90s. PAST MEDICAL HISTORY: 1. Status post MI in [**2129**]. 2. PCI to the LAD in [**2130**]. 3. PCI to the RCA in [**2132**], complicated by a stent blocking the femoral artery. 4. Status post iliac repair. 5. Coronary artery bypass graft in [**2135**] including LIMA to the LAD, SVG to the D1, SVG to the RPL. 6. PCI to the LMCA in [**2143-7-14**], PCI to the SVG to the PVL. 7. Status post right knee arthroscopy. 8. History of hemorrhoids. 9. History of benign polyps. MEDICATIONS ON PRESENTATION: 1. Aspirin 325 mg a day. 2. Lopressor 12.5 mg b.i.d. 3. Zocor 60 mg a day. 4. Plavix 75 mg a day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Smokes 10 packs a week for the past 50 years, currently trying to quit. Social tobacco with no illicits. FAMILY HISTORY: A brother died of MI at age 60. Father had his first MI in his 50s. The patient is married with several children. He is currently between jobs. After the procedure, the patient was admitted to the CCU for monitoring. PHYSICAL EXAMINATION: His temperature was 98.2 degrees, blood pressure 99/48, respiratory rate 15, 100 percent saturation on room air, heart rate 57 to 66. In general, he is a well-appearing elderly male, alert and oriented with an appropriate affect. HEENT revealed no JVD. Supple neck. Chest revealed clear lungs, no rhonchi, no crackles. Cardiovascular normal S1, S2, no murmurs, rubs, or gallops, no S3 or S4. Abdomen is flat, soft, nontender, nondistended, with normoactive bowel sounds. Extremities are warm with capillary refill less than 3 seconds, 2 plus DP and PT and radial pulses, no edema, left groin with bruit. LABORATORY DATA: EKG on presentation had a sinus rate of 55, inferior T-wave inversions, ST elevation in V1 and V2. IMPRESSION: The patient is a 66-year-old male with a severe CAD, status post brachytherapy, SVG to the PDL with subsequent thrombosis, status post opening of the artery during repeat catheterization. HOSPITAL COURSE: The patient was now hemodynamically stable with resolution of his EKG changes and ST elevation and he was admitted to the CCU for monitoring. That evening, the patient complained of back pain on his left side, which he attributed to lying on his back. On exam, there was no palpable hematoma, no bruit auscultated and strong DP pulses with warm extremities. The CT of the pelvis and abdomen was negative for retroperitoneal bleed. It was determined that the patient's pain was due to back pain; however, the concern for his low blood pressure, lack of evidence for retroperitoneal bleed. The patient was bolused 250 cc of IV fluid and blood pressure increased to a range of 98 to 106/50s to 60s. The patient was also noted to have hematocrit of 29.5, he was transfused 1 unit. After his catheterization, the patient had prolonged groin bleeding requiring a clamp; as stated the ultrasound was noted a small hematoma without aneurysm and a CT was negative for retroperitoneal bleed. The patient had been having low blood pressure persistently. There was no evidence of a tamponade, no evidence for bleeding, no evidence for adrenal insufficiency and the patient responded well to small boluses of fluid. This was presumably all due to preload dependent. The patient had 3 beats of NSVT on telemetry and otherwise was feeling quite well; had no recurrence of chest pain. Given persistent hypotension, the patient remained in the intensive care unit for 24 more hours. He was given a cosyntropin stimulation test to rule out adrenal insufficiency. It was inconclusive. He was given hydrocortisone 100 mg for empiric treatment and there was no effect on blood pressure; therefore, it was determined that it was highly unlikely his low blood pressure was due to adrenal insufficiency and likely was extensive vagal phenomenon from pressure on the groin status post procedure. Given that the patient was doing well, he was transferred out to the floor on day 3. Blood pressure remained low at 90s/60s. The patient continued to receive boluses with mild effective increase; however, the patient had profoundly good urine output and urine lytes that supported the patient being euvolemic. The patient ambulated well, had no complaints. He was restarted back on his home medications including his blood pressure medications. For his coronary artery disease, which was extensive, the patient's CK has declined, he was maintained on aspirin, Plavix and Lipitor at 80. He was restarted on his Lopressor before going home and tolerated that well without any difficulty with hypotension. The patient was consulted extensively on smoking cessation. The patient had a repeat echocardiogram that revealed an EF 50 to 55 percent, mild inferior wall hypokinesis compared to the previous study and it was hoped that he would restart on Ace inhibitor and titrated up on that in time as his blood pressure tolerated as an outpatient. For anemia, the patient's hematocrit remained stable. It was determined that he has a small arterial bleed status post catheterization; received 1 unit of blood. No evidence of AV fistula. The patient was instructed to have his hematocrit followed up by his primary care doctor. The patient's hypotension was determined to be due to vagal phenomenon. The patient was near his baseline blood pressure. There was no evidence of adrenal insufficiency and the patient was asymptomatic. He was discharged with plans to have his blood pressure checked and to titrate up his medications as tolerated. DISCHARGE INSTRUCTIONS: The patient was discharged to home with instructions to take Plavix every day as ordered or stent would close. He was instructed to never smoke again. He was instructed regarding his new medications. FINAL DIAGNOSES: 1. Coronary artery disease. 2. Acute stent thrombosis, status post cardiac catheterization and stenting. 3. Anemia due to blood loss. 4. Groin hematoma. 5. Hypotension. 6. Hypokalemia. 7. Tobacco use. FOLLOW UP: The patient was instructed to followup with his cardiologist, Dr. [**Last Name (STitle) 837**], on [**2143-11-27**]. He was instructed to have another stress test according to Dr. [**Last Name (STitle) 837**] on [**2143-11-18**]. He was instructed to call his primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 838**] and be seen within 2 weeks of discharge. DISCHARGE CONDITION: Good. DISPOSITION: The patient was discharged to home. DISCHARGE MEDICATIONS: 1. Nitroglycerine to be used sublingually p.r.n. 2. Aspirin 325 mg daily. 3. Plavix 75 mg daily. 4. Metoprolol 25 mg total tablet to be taken, half tablet p.o. b.i.d. 5. Nicotine patch 14 mg over 24 hours to be used daily. 6. Lipitor 80 mg daily. 7. Bupropion 150 mg sustained release tablet instructed to take 1 daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 839**], [**MD Number(1) 840**] Dictated By:[**Last Name (NamePattern1) 841**] MEDQUIST36 D: [**2143-10-21**] 18:50:31 T: [**2143-10-22**] 08:03:37 Job#: [**Job Number 842**]

Admission Date: [**2136-10-23**] Discharge Date: [**2136-10-24**] Date of Birth: [**2056-7-14**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Found down Major Surgical or Invasive Procedure: None History of Present Illness: 80M p/w a large R IPH with intraventricular extension, midline shift, and hydrocephalus. The patient was found lying face up in his bathtub after having shaved. There was no water in the tub and the shower was not turned on. He was found by a neighbor. [**Name (NI) **] EMS, he was moaning and there was "tone in his left arm" which may have been consistent with posturing. He was taken to [**Hospital1 18**] [**Location (un) 620**] and head CT was performed, revealing a large intraparenchymal hemorrhage extending from the lower midbrain into the hypothalamus, thalamus and basal ganglia on the right, with significant mass effect, intraventricular extension with casting of the right ventricle and some blood product in the posterior [**Doctor Last Name 534**] of the left lateral ventricle. [**Hospital1 18**] Neurosurgery was called and on review of imaging and reported exam- Mannitol 100gm and Decadron 10mg x1 was recommended and given. He was transferred to [**Hospital1 18**] for a Neurosurgical evaluation. Dr [**Last Name (STitle) **] discussed and offered surgical intervention, but this was refused based on the family's knowledge of his wishes to not prolong life if incapacitated. He also had signed a DNR/DNI order. He was clear that he did not want to be dependent of disabled. The family asked to maintain his intubation while other family members arrive from inside and outside [**State 350**]. They offered that he is an organ donor. Past Medical History: - DIABETES TYPE II - HYPERLIPIDEMIA - GLAUCOMA - OSTEOARTHRITIS - CAROTID STENOSIS left 60-69%, rt 50 - VASOVAGAL SYNCOPE - BACK PAIN Family History: NC Physical Exam: No eye opening, pupils 2mm and minimally react. No corneal on left, minimal corneal on right. Extensor posture with LUE, RUE attempts to localize, BLE withdraw to noxious stim. No gag, not overbreathing the vent. Tone increased in left arm, normal bulk. Toes are downgoing bilaterally. Pertinent Results: FINDINGS: There is a large intraparenchymal basal ganglionic based hemorrhage. It is multilobulated in nature and at its greatest extent measures 6.5 x 5.3 cm. This is causing mass effect and shift of the normally midline structures of approximately 1.1 cm at the level of the hemorrhage. There is also intraventricular extension into the ipsilateral and contralateral lateral ventricles. There is effacement of the ipsilateral frontal [**Doctor Last Name 534**] of the lateral ventricle Brief Hospital Course: Pt was admitted to the neurosurgery service and the ICU. The organ bank was contact[**Name (NI) **]. [**Name2 (NI) **] was extubated on [**10-24**] without incident and a morphine drip was started and titrated to respiratory rate. He passed away on [**10-24**] at 12:55 p.m. The family declined a post morteum exam. Medications on Admission: None Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Intracranial hemorrhage Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2136-10-24**]

Admission Date: [**2185-11-11**] Discharge Date: [**2185-11-17**] Date of Birth: [**2110-10-25**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 75-year-old female with a history of Alzheimer's dementia, coronary artery disease status post coronary artery bypass graft in [**2174**] with a history of five myocardial infarctions, the last in [**2185-7-28**] as well as congestive heart failure with an ejection fraction of 30%, hypertension, dyslipidemia. On [**2185-11-11**], she experienced transient episodes of left arm weakness associated with slow speech. Her husband called the patient's doctor who recommended she present to the emergency room. On arrival her vital signs were stable. Labs were unremarkable. Cardiac enzymes were negative initially. She was admitted to the Neurology for work up of a question of TIA or stroke. She underwent MRI of the head upon admission that was negative for an acute process. While on the floor on [**2185-11-11**], she was noted to become tachycardic in a sinus rhythm to 150 and was noted to have rales on exam. She was given 40 mg of IV Lasix without significant response; she received a second dose of 40 mg IV Lasix and then a code was called when she subsequently was noted to drop her oxygen saturation to the mid 80s on 100% nonrebreather. She also became hypotensive with a systolic blood pressure in the 70s. She was intubated and briefly required Dopamine to maintain her blood pressures. She was then transferred to the Coronary Care Unit for further management of congestive heart failure. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2174**]. 2. Diabetes mellitus. 3. Dyslipidemia. 4. Congestive heart failure, ejection fraction 30%. 5. Alzheimer's dementia. Her primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1537**]. Her neurologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. MEDICATIONS AT HOME: 1. Lisinopril 50 mg p.o. q.d. 2. Imdur 60 mg p.o. q.d. 3. Prilosec 20 mg p.o. q.d. 4. Lasix 40 mg p.o. q.d. 5. Potassium chloride 10 mEq p.o. q.d. 6. Coreg 6.25 mg p.o. q. AM and 3.125 mg p.o. q. PM. 7. Colestid with breakfast and supper. 8. Aspirin 325 mg p.o. q.d. 9. Folate 1 mg p.o. b.i.d. 10. Lanoxin 0.125 mg p.o. q. Monday, Wednesday and Friday and 0.25 Tuesday, Thursday, Sunday. ALLERGIES: 1. Sulfa. 2. Iodine. SOCIAL HISTORY: She lives with her husband. She does not smoke or drink. PHYSICAL EXAMINATION: Upon admission to the Coronary Care Unit, she was intubated and sedated. She had pink, frothy sputum suctioned from her G tube. Her lungs had audible rales at the bases. She had a regular rate and rhythm audible upon precordial exam with no audible extra heart sounds. Her abdomen was benign with positive bowel sounds. She had no edema with 1+ distal pulses. She was responding to stimuli, but was sedated. LABORATORY: Upon admission to the Coronary Care Unit had a sodium 134, potassium 4.4, chloride 97, bicarbonate 25, BUN 20, creatinine 0.7, glucose 124, INR 1.1. White count 7, hematocrit 33, platelets 211. EKG normal sinus rhythm at 90 beats per minute with a left axis, left bundle branch block. There was no comparison available at the time. Chest x-ray with patchy vascular markings consistent with congestive heart failure. HOSPITAL COURSE: The initial impression on admission to the Coronary Care Unit was that the patient was a 75 year-old female with severe coronary artery disease who developed symptoms of left arm discomfort on the day prior to admission. It may or may not have represented anginal type symptoms. She was now admitted directly from the floor in apparently decompensated congestive heart failure in the setting of elevated systolic blood pressure (as high as 200). The patient was able to be weaned off of Dopamine expeditiously upon admission to the Coronary Care Unit. She was diuresed aggressively and successfully with IV Lasix. She had a PA catheter placed upon admission in order to guide her management with initial pulmonary artery pressures of 35/10 and pulmonary capillary wedge pressure of 10. Of note, this was following aggressive diuresis. The patient did well with subsequent titration up of after load reduction with Captopril and initiation of Isordil. She was able to be extubated successfully on [**2185-11-14**]. She underwent a transthoracic echocardiogram which revealed a severely depressed LV function with ejection fraction of 20 to 30% and akinesis of the inferior row posterior walls and moderate hypokinesis at the LV as well as 1+ AR and MR. The patient subsequently did well and at the time of this dictation on [**2185-11-17**], she is awaiting transfer to the General Medical Floor where she will await eventual disposition most likely to short term rehab. TRANSFER STATUS: Stable. DISCHARGE STATUS: Pending. MEDICATIONS AT TIME OF DISCHARGE FROM CORONARY CARE UNIT: [**Unit Number **]. Lasix 100 mg p.o. q.d. 2. Isordil 30 mg p.o. t.i.d. 3. Heparin 5000 units subcutaneous b.i.d. 4. Captopril 75 mg p.o. t.i.d. 5. Lopressor 12.5 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Regular insulin sliding scale. 9. Levaquin 250 mg p.o. q.d. to be discontinued on [**2185-11-22**]. 10. Flagyl 500 mg p.o. t.i.d., last dose to be given on [**2185-11-22**]. DISCHARGE DIAGNOSES AT THE TIME OF TRANSFER FROM THE CORONARY CARE UNIT: [**Unit Number **]. Decompensated congestive heart failure. 2. Hypertension. 3. Alzheimer's dementia. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Last Name (NamePattern1) 25313**] MEDQUIST36 D: [**2185-11-17**] 14:32 T: [**2185-11-17**] 14:45 JOB#: [**Job Number 106144**]

Admission Date: [**2195-10-9**] Discharge Date: [**2195-10-13**] Date of Birth: [**2131-8-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5129**] Chief Complaint: mental status changes, shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 64 yoM with history of dCHF, COPD on 2L home O2 (noncompliant), OSA with phtn, hypertension, recurrent GI bleeds in the setting of acquired [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease, and MGUS treated with chemo velcade and dexamethasone x4 weeks with ongoing treatment recently hospitalized for dyspnea on exertion and weakness, discharged [**10-8**] from [**Hospital1 18**]. . During the last hosptialization his dyspnea was thought to be multifactorial from diastolic CHF, COPD and pulmonary hypertension. He was treated with diuresis and nebulizers. His symptoms did not completely resolve. He presented on the day of admission to oncology clinic for chemotherapy, but prior to initiation he reported feeling winded with short ambulation, ambulatory O2 sat was 78%, returning to 94% at rest. Repeat ambulatory sats to 85%. He was referred to the ED. He did not get scheduled chemo. . In the ED, V/S were 97.2 66 99/85 18 100% 4L. He was noted to be slightly confused, with sats in the low 90s on 4L. ABG was 7.23/ 117 /90 /52. Crackles noted on exam. He was given Levofloxacin 500mg po, prednisone 60mg and Duoneb X 1. Labs were significant for CO2 of 5, BNP 2166 similar to recent admission. CXR could not rule out L basilar infiltrate. Before transfer, V/S 128/59, 77, 95% 2L. He was mentating appropriately. Repeat ABG 7.33/86/63/47. . On the floor: Pt is satting 95% on 2L, in no respiratory distress and feels very comfortable. Past Medical History: Recurrent GI bleeds [**2-25**] AVMs [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] Disease, acquired MGUS s/p bone biopsy with plasma cell dyscrasia without evidence of multiple myeloma Hypertension dCHF with pulmonary hypertension COPD on 2L NC at home, noncompliant OSA-untreated, non-compliant Secondary hyperparathyroidism Dyslipidemia h/o respiratory failure with hypercarbia associated with episode of pneumonia and diastolic failure Morbid obesity Ventral hernia repair [**2192**] Social History: Lives with 20 year-old son in [**Location (un) 686**]. Retired correctional officer since [**2188**]. Smoking: None currently. h/o 0.5ppd - 1ppd x 35 years. EtOH: None Illicits: Marijuana, occasional joint x15 years Family History: Father: prostate cancer at 48, diabetes, died of colon cancer at 78 Sister: stroke, [**Year (4 digits) 14165**] cell trait, kidney transplant, sarcoid Extensive family history of hypertension No FH of heart disease Physical Exam: Admission PEx: Vitals: T:98.9 BP:156/75 P:103 R:15 O2:95%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to assess, no LAD Lungs: Pt able to speak 5 words between breaths. Lungs with scattered expiratory wheezes, no evident rales or rhonchi, though breath sounds distant. Prolonged expiratory phase. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, pneumoboots in place . Pertinent Results: Labs on Admission: [**2195-10-9**] 09:30AM BLOOD WBC-4.4 RBC-4.03* Hgb-11.2* Hct-33.4* MCV-83 MCH-27.7 MCHC-33.5 RDW-16.6* Plt Ct-211 [**2195-10-9**] 09:30AM BLOOD PT-13.0 PTT-39.4* INR(PT)-1.1 [**2195-10-9**] 01:51PM BLOOD Neuts-78.8* Lymphs-13.0* Monos-5.9 Eos-1.8 Baso-0.4 [**2195-10-9**] 09:30AM BLOOD Gran Ct-3580 [**2195-10-9**] 09:30AM BLOOD Ret Aut-3.2 [**2195-10-8**] 05:40AM BLOOD Glucose-117* UreaN-26* Creat-1.2 Na-136 K-4.5 Cl-91* HCO3-41* AnGap-9 [**2195-10-9**] 09:30AM BLOOD ALT-17 AST-62* LD(LDH)-193 AlkPhos-53 TotBili-0.3 [**2195-10-9**] 01:51PM BLOOD proBNP-2166* [**2195-10-9**] 09:30AM BLOOD TotProt-7.3 Calcium-9.0 Phos-3.9 Mg-2.1 Iron-33* [**2195-10-9**] 09:30AM BLOOD calTIBC-407 Ferritn-58 TRF-313 [**2195-10-9**] 09:30AM BLOOD PEP-PND b2micro-3.9* [**2195-10-9**] 03:12PM BLOOD pO2-90 pCO2-117* pH-7.23* calTCO2-52* Base XS-15 [**2195-10-9**] 08:47PM BLOOD Type-ART pO2-63* pCO2-86* pH-7.33* calTCO2-47* Base XS-14 [**2195-10-10**] 11:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2195-10-10**] 11:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2195-10-10**] 11:20AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-2 [**2195-10-10**] 11:20AM URINE CastHy-1* [**2195-10-10**] 11:20AM URINE Mucous-RARE [**2195-10-10**] 11:20AM URINE Micro: MRSA pending Labs on Discharge: Brief Hospital Course: 64yo male with acquired [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]'s disease associated with MGUS, recurrent GI bleeds, diastolic HF, pulmonary HTN, severe COPD on 2L, and OSA (refuses to use BiPAP), p/w acute on chronic hypercarbic/hypoxemic resp failure likely [**2-25**] untreated severe OSA, PH, COPD exacerbation, and chronic CHF. He was initially admitted to the ICU, but was not intubated. #Acute on chronic respiratory failuredue to OSA and COPD: -initially felt to be likely [**2-25**] CHF and COPD exacerbation on underlying severe untreated OSA/OHS. There was no obvious pneumonia on CXR and pt remained afebrile w/o leukocytosis. His mental status/somnolence and hypercarbia improved after BiPAP set at 18/10 4L O2. Suggest he use BiPAP overnight and with naps. -He will need a retitration sleep study as an outpt to further optimize and should have close follow-up with his sleep/pulm doctor [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (we have emailed Dr. [**Last Name (STitle) **] re this issue). He was transferred to the medical floor where he did very well. He was sufficiently concerned and indicated that he would use BiPAP at home as instructed. #CKD - his creatinine did rise from 1.2 on admission to 1.7 with diuresis in the ICU. Looking back at his previous labs, his creatinine has fluctuated up in this range in the past (was 1.9 in [**2195-8-24**]), and no other cause for renal failure was identified. Potentially nephrotoxic meds were held, #MGUS: f/u on UPEP #HTN: continue home meds #Nutrition consult for obesity/dietary input. 64yo male with severe COPD on continuous home O2, OSA (in the past has refused to use BiPAP), acquired [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]'s disease associated with MGUS, recurrent GI bleeding, diastolic HF, pulmonary HTN, who presented with dyspnea likely from COPD exacerbation. . # Acute on chronic respiratory failure requiring ICU stay but not intubation - MICU team felt COPD exacerbation main component and started high dose steroids, Abx, nebulized bronchodilators - no evidence of bronchospasm on my exam - am tapering steroids rapidly -D/C levofloxacin - wean O2 to maintain sats 88-92%, down to home flow of 2L/min via NC. Check ambulatory sats - OSA likely large component - needs to wear BiPAP at night. He did last evening and sats dropped to 93% only (good) . # Acute kidney injury -admission creat = 1.0, has been gradually increasing - now 1.8. -FeNa yesterday = 0.95%, suggesting pre-renal azotemia but creatinine continues to increase despite IV hydration and holding ACE-I -no evidence of urinary retention (PVR < 350) -He was seen in consultation by Nephrology on [**2195-10-12**], and they agreed with trial of IV hydration and with holding the ace-inhibitor and the diuretic. His discharge serum creatinine was 1.7. # Acute on chronic diastolic heart failure -last echo in [**2195-6-24**] showed right heart failure (likely due to chronic lung disease and resulting pulmonary hypertension) but preserved LV function -no evidence of acute HF now - received torsemide inthe ICU with resulting decrease in BNP, but increase in creatinine - on the floor, we held off on further diuresis -there was no peripheral edema . # OSA: -has follow up with pulm after discharge and pt states now that he is inclined to use a nighttime BiPAP. . # Htn: Continue carvedilol. Lisinopril D/C'd in the setting of rising creatinine . # MGUS: Patient has been on bortezomib and velcade to treat MGUS-associated VWd and subsequent GIB. - updated Dr. [**Last Name (STitle) 3060**] that patient was rehospitalized. - will need to reschedule next treatment. - Beta-2 Microglobulin was elevated at 3.9 (0.8 - 2.2 mg/L) and the ABNORMAL BAND IN GAMMA REGION IDENTIFIED PREVIOUSLY AS MONOCLONAL IGG KAPPA NOW REPRESENTS ROUGHLY 6% (440 MG/DL) OF TOTAL PROTEIN -FREE KAPPA, SERUM 43.4 H 3.3-19.4 mg/L FREE LAMBDA, SERUM 19.1 5.7-26.3 mg/L FREE KAPPA/LAMBDA RATIO 2.27 H 0.26-1.65 -He is also followed by Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] . # [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]'s disease - asx, blood counts remained stable. - trended CBC # Code: Full (discussed with patient) #code status: full Medications on Admission: 1. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO twice a day. 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times a day: 2 puffs po four times a day as needed for shortness of breath use 15 minutes before activity. 8. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for sob/wheeze. 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Acute on chronic hypercarbic respiratory failure COPD Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with respiratory difficulty likely due to poor oxygenation from COPD and obstructive sleep apnea and pulmonary hypertension. There may also have been a component of heart failure as well. It is vitally important that you use the BiPAP machine whenever you are sleeping, as we discussed. Continue to use the oxygen by nasal cannula when you are awake, as you have been doing. Maintain a low salt diet and watch closely for evidence of heart failure (leg swelling, increasing weight, and/or increasing shortness of breath). Weigh yourself every morning, call your primary care doctor or your cardiologist if your weight goes up more than 3 lbs. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: [**Last Name (Prefixes) **] [**2195-10-16**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 7975**] INTERNAL MEDICINE When: SATURDAY [**2195-10-17**] at 11:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2195-10-19**] at 9:00 AM With: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2196-7-26**] Discharge Date: [**2196-7-29**] Date of Birth: [**2120-2-8**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Augmentin Attending:[**First Name3 (LF) 602**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: EGD History of Present Illness: Patient is severely demented at baseline and history was obtained via [**Hospital1 1501**] records. . This is a 76 y/o F with history of CHF, Afib on coumadin, HTN, dementia who prsented from her living facility after vomiting coffee grounds earlier today. Per records, patient was suffering from constipation. Bowel regimen was aggressively uptitrated and on day prior to admission, patient was given magnesium citrate. Patient began vomiting coffee grounds on several occasions. Unclear if patient had fevers or chills, or abdominal discomfort. . In ED patient's initially VS were 99.7 140 167/110 22 99%4LNC. Patient triggered for HR. Exam was unrevealing. Initial EKG demonostrated SVT. Patient was given a total of 12mg of adenosine which revealed atrial flutter. Patient was given a total of 40mg IV diltiazem and 1LNS. NGL was completed which showed 1L coffee grounds with clots. This apparently cleared with an additional 500cc NS. GI was consulted and planed to scope patient in AM. Patient was started protonix gtt. Lab findings were significant for a WBC of 18, Hct of 44.5 (both which were thought to be hemoconcentrated) and a Na of 129 with Cr of 1.2. INR was noted to be 3.3. Patient received a total of 10mg of vitamin K and 1 unit of FFP. Lastly pt spiked to 101; blood cultures were taken and pt was given ceftriaxone for ?UTI. Prior to transfer, vital signs were 125/62 144 (still in flutter) 98% RA. . In the MICU, patient was resting comfortable complaining of thirst. Past Medical History: s/p CVA HTN DM A flutter Neurogenic bladder Obesity Social History: Lives at [**Hospital3 2558**]. Per the patient, her son visits her frequently. Family History: Non-contributory Physical Exam: ADMISSION EXAM: Vitals: 124/88 144 94% RA General: alert, not oriented HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM: Vitals: 98.8 126/62 80 18 98% RA GEN: Alert and oriented to person, place, time but not to living situation HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Incontinent Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: coalesced diffuse erythematous blanching patch on upper back crossing midline. Scaly. Two 2 cm scaly plaques on bilateral knees. Excoriations on right lower leg. itchy coalesced diffusely erythematous blanching patch on L buttocks Neuro: Facial droop on right, 0/5 strength of LUE with atrophied left hand, and 3/5 strength of L gastroc and anterior tibial, all consistent with her baseline [**1-27**] distant MCA stroke. . Pertinent Results: Admission Labs: [**2196-7-26**] WBC-18.0*# RBC-5.70*# Hgb-14.9# Hct-44.5# MCV-78* MCH-26.1*# MCHC-33.5 RDW-17.0* Plt Ct-451* [**2196-7-26**] Neuts-84.9* Lymphs-10.2* Monos-4.3 Eos-0.4 Baso-0.3 [**2196-7-26**] PT-33.1* PTT-29.4 INR(PT)-3.3* [**2196-7-26**] Glucose-283* UreaN-25* Creat-1.2* Na-129* K-3.5 Cl-83* HCO3-30 AnGap-20 [**2196-7-27**] ALT-8 AST-11 LD(LDH)-147 AlkPhos-76 TotBili-0.6 [**2196-7-26**] Calcium-10.3 Phos-2.3* Mg-2.8* . DISHCARGE LABS: [**2196-7-29**] WBC-8.4 RBC-4.35 Hgb-11.6* Hct-35.2* MCV-81* MCH-26.7* MCHC-33.0 RDW-17.6* Plt Ct-254 [**2196-7-29**] Glucose-152* UreaN-10 Creat-0.8 Na-136 K-3.4 Cl-102 HCO3-21* AnGap-16 [**2196-7-29**] Calcium-8.8 Phos-1.2* Mg-2.0 . Micro: [**2196-7-27**] 1:44 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2196-7-28**]** MRSA SCREEN (Final [**2196-7-28**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. . Imaging: EGD: Esophagus: Mucosa: Grade D esophagitis with stigmata of recent bleeding was seen starting at 15 cm from the incisors to the GE junction, compatible with severe erosive esophagitis most likely from GERD. Stomach: Excavated Lesions Multiple superficial non-bleeding ulcers ranging in size from 1 cm to 1 cm were found in the fundus, stomach body, and antrum . Duodenum: Mucosa: Normal mucosa was noted. Impression: Grade D esophagitis in the From 15cm to the GE junction compatible with severe erosive esophagitis most likely from GERD Ulcers in the fundus, stomach body, and antrum Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: Follow up in Dr.[**Name (NI) 84029**] clinic in 4 weeks [**Telephone/Fax (1) 9891**] Start high dose ppi (protonix 40mg [**Hospital1 **] or equivalent) for 6 weeks Avoid Nsaids Continue management per inpatient GI consult team . . CT ABD/PELVIS ([**7-26**]): CT ABDOMEN WITH IV CONTRAST: There is dependent subsegmental atelectasis at the lung bases. The heart is enlarged without pericardial effusion. There is coronary artery and thoracic aortic atherosclerotic calcification. The liver, spleen, and bilateral adrenal glands are normal. The gallbladder is surgically absent. A poorly evaluated 13-mm hypodensity arising from the posterior aspect of the pancreatic body may be new from the prior study. There is fatty atrophy of the pancreas. The non-opacified stomach and intra-abdominal loops of small bowel are normal without evidence of obstruction. A nasogastric tube terminates in the gastric fundus. There is colonic diverticulosis without evidence of acute diverticulitis. There is mild bilateral hydronephrosis and hydroureter. Within the right kidney, there is a fat-fluid level in an anterior interpolar calyx (2A:35). In addition, a fat-fluid level is noted within the mid right ureter (2A:66). Multiple hypodensities in the bilateral kidneys are mostly new compared to [**2189**] and are too small to further characterize, but may represent cysts. There has been interval atrophy of both kidneys. In addition, cortical thinning in the upper pole of the right kidney suggests prior infection or ischemia. There is no free air or fluid in the abdomen. There are no mesenteric lymph nodes meeting CT criteria for pathologic enlargement. A left para-aortic lymph node measuring 16 mm is similar to the prior study (2A:42). There is atherosclerotic calcification of the abdominal aorta which is of normal caliber throughout. Vascular calcifications are also noted in the branch vessels. CT PELVIS WITH IV CONTRAST: There is a tiny fat-fluid level within the anterior portion of the bladder (2A:82). The distal ureters are dilated bilaterally, and scattered areas of mild urothelial enhancement are seen bilaterally. The urinary bladder is distended with irregular and lobulated appearance of the wall, with diverticula. Heterogeneity is noted in the region of the endometrium, possibly due to an underlying polyp or fibroid. Adnexa and sigmoid colon are normal. There is a large amount of stool within the rectum. There is no free fluid in the pelvis. No pelvic or inguinal lymphadenopathy meeting CT criteria for pathologic enlargement is noted. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified. There is multilevel degenerative change of the thoracolumbar spine. IMPRESSION: 1. No evidence of bowel obstruction. 2. Irregular lobulated appearance of the bladder wall with diverticula suggests neurogenic bladder and clinical correlation is recommended. Mild bilateral hydroureteronephrosis may be due to bladder distention. Mild urothelial enhancement could be seen with infection and correlation with urinalysis and urine culture recommended. 3. Chyluria, of unclear etiology. Correlation with urine studies and history of instrumentation or prior urologic procedures is recommended. 4. Renal scarring in the right kidney suggests sequela of prior infection or infarction. 5. 13-mm pancreatic body hypodensity for which MRI could be obtained for further evaluation as clinically indicated. 6. Heterogeneous endometrium, possibly due to polyp or a submucosal fibroid. Correlation with non-emergent pelvic ultrasound recommended if not previously performed. The study and the report were reviewed by the staff radiologist. . ECHO ([**2196-7-27**]): There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild to moderate ([**12-27**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Small LV cavity size with hyperdynamic LV systolic function. An abnormal LVOT flow contour is seen but an LVOT gradient is not present. Mild to moderate aortic regurgitation. . . CXR (PA/LAT): ([**7-27**]): FINDINGS: As compared to the previous radiograph, there is no relevant change. Lung volumes and moderate cardiomegaly with retrocardiac atelectasis, but no evidence of pulmonary edema or pneumonia. The presence of minimal pleural effusion on the left cannot be excluded. On the right, there is no pleural effusion. Brief Hospital Course: 76 y/o F with CHF, dementia, Afib on coumadin presenting with coffee ground emesis found be in aflutter with RVR. # GI Bleed: Patient was admitted to the MICU with coffee ground emesis that was confirmed with nasogastric lavage. Patient was tachycardic (see below), however BP was stable. Hct initially was 44. With hydration, her hct fell to 35 but then remained stable. Patient received 1 unit of FFP and vitamin K for supratherapeutic INR however did not receive any packed RBCs. EGD revealed multiple superficial non-bleeding ulcers in the fundus, stomach body, and antrum as well as severe esophagitis. She was started on pantoprazole 40mg [**Hospital1 **]. Patient remained hemodynamically stable and was subsequently transferred to the general medicine floors. Her hct remained stable around 35 with no further episodes of vomiting. She was able to tolerate PO intake. She was discharged to continue high dose PPI and to have follow up EGD in [**6-1**] weeks. . # Tachycardia: Patient initially presented in SVT and received 12mg of adenosine which revealed underlying afib/aflutter with RVR. HRs remained fluid unresponsive, however were treated with IV beta blockade. Upon restarted home dual nodal blockade, HRs became appropriate. However, pt displayed evidence of tachy-brady syndrome, with heart rates up to 150s and down to 60s, so her diltiazem was decreased to 60mg TID She remained hemodynamically stable. Her coumadin was initially held in the setting of an acute bleed. However, GI felt that her risk of stroke was greater than her risk of rebleeding, so her coumadin was resumed on discharge, to be bridged with lovenox. . # SIRS: Patient met SIRS criteria by heart rate and WBC count. She received empiric treatment with ceftriaxone x1 in the ED. However, since no clear source of infection was identified, antibiotics were discontinued. Her WBC decreased to 8.4 at time of discharge and pt was afebrile. Her UA was significant for large leukocytes, 101 WBC, few bacteria, however as she was asymptomatic and her urine culture showed only mixed bacterial flora, she was not treated. . # [**Last Name (un) **]: Patient presented with elevated creatinine and hyponatremia, both which improved with gentle fluid resuscitation. . CHRONIC ISSUES: . CHF: Pt was dehydrated on presentation. She received gentle hydration and remained euvolemic during her hospital course. . DM: Metformin was held during hospitalization. Her BG was managed with sliding scale insulin. She was resumed on metformin upon discharge. . Pain management: Pt was managed on lidocaine patch only during hospitalization. She had no complaints of lower back pain. She may be able to dc percocet and continue only on lidocaine patch to decrease her constipation. . TRANSITIONAL ISSUES: Pt is DNR/DNI. She has a follow up EGD and GI appointment scheduled for 4 weeks from discharge. She also had several findings on CT that may deserve follow-up as an outpatient as described in her CT findings. As constipation seems to be an issue for her, she may benefit from pain control with lidocaine patch only, as she reported her pain was well controlled on that regimen while she was hospitalized. She was restarted on coumadin given that the benefit of stroke reduction seemed to outweight the risk of re-bleeding, per GI. She is being bridged with lovenox. We were unable to contact the son during her hospitalization, however the final decision to continue anticoagulation should be addressed with him. Medications on Admission: - Ventolin HFA 90mcg 2 puffs IN q6h prn - Ipratropium/Albuterol 3cc via Neb QID prn wheezing - Acetaminophen 1000mg PO Q4h prn - Magnesium Citrate 1 bottle PO - Diltiazem 90mg PO TID - Bisacodyl 5mg PO QHS - Milk of Magnesia 400mg/5mL PO 30cc QHS - Lidoderm patch - Percocet 5/325mg 1 tab PO TID - Coumadin - Bupropion XL 150mg Daily - Metformin 500mg Daily - Docusate 100mg [**Hospital1 **] - Metoprolol tartrate 50mg [**Hospital1 **] Discharge Medications: 1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Adhesive Patch, Medicated(s) 2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 6. warfarin 4 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous [**Hospital1 **] (2 times a day): Can be stopped once INR theraputic for 24-48 hours. 9. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO twice a day as needed for constipation. 11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: Upper GI bleed Secondary diagnosis: atrial flutter Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms [**Known lastname 4318**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital because you had bloody vomit. You had an upper endoscopy that showed that you have severe acid reflux with ulcers in your esophagus and stomach. Because of this, you were started on a new medication to control your stomach acid. You should take this medicine twice a day indefinitely. You will also need to follow up with the Gastrointestinal doctors because they [**Name5 (PTitle) 9004**] to repeat an endoscopy in [**3-30**] weeks. Your heart rate was also very fast when you came to the hospital. We gave you medication to slow your heart rate down, and then restarted your home dose of metoprolol and diltiazem. Please make the following changes to your medications: 1. start taking pantoprazole 40 mg by mouth twice a day 2. your back pain was well controlled with a lidocaine patch while you were in the hospital. Since this worked for you here, you may want to consider stopping percocet (it can make constipation worse) and using a lidocaine patch instead. 3. take lovenox Followup Instructions: Department: WEST PROCEDURAL CENTER When: THURSDAY [**2196-8-25**] at 8:00 AM With: WPC ROOM THREE [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: GI-WEST PROCEDURAL CENTER When: THURSDAY [**2196-8-25**] at 8:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2196-8-31**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Please call patient registration at ([**Telephone/Fax (1) 99686**] prior to appointment. Completed by:[**2196-7-30**]

Admission Date: [**2174-10-13**] Discharge Date: [**2174-11-2**] Date of Birth: [**2121-11-5**] Sex: F Service: SURGERY Allergies: Lisinopril/Hydrochlorothiazide Attending:[**First Name3 (LF) 6346**] Chief Complaint: bright red blood per rectum transfer from outside hospital Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions and right colectomy with ileocolostomy History of Present Illness: 52 F Jehovah's witness w/ pmhx of HTN who presents with 1 day hx of BRBPR rectum, occured last night 4 episodes of dark red blood mixed with loose stools, no clots at that time, denies maroon stools, or dark tarry stools, 1st episode. with associated lightheadness, weakness later in the evening w/ no LOC, or falls, also with some nausea, but no vomitting, no abdominal pain. . Presented to OSH where HCT was noted to be 30 stable VS 164/85 104 16 98RA, and then tx'd to [**Hospital1 18**] ED as pt jehovah's witness. . In ED VS 98 88 142/70 16 99RA, received 1L NS, BRB in rectal vault, GI was consulted and recommended bowel prep and colonoscopy. Here, denies weakness, no cp/sob/palpitations, dysuria Past Medical History: Diverticulosis - cscope 2 yrs ago Lap CCY [**9-2**] Csection x3 HTN Social History: No smoking, scoial drinker adminstrative assistant Family History: No colon ca/ibd, NC Physical Exam: 98.8 99 118/88 16 100RA GEN: NAD, pleasant, speaking in full sentences HEENT: PERRL, EOMI, OP Clear, MMM, JVD nondistended, anicteric CV: tachycardic no mrg CHEST: CTA b/l no mrg ABD: Soft, +BS, NT/ND, midline cscetion scar EXT: No c/c/ce Neuro: AAOx3, no focal deficits Pertinent Results: OSH HCT 31.9 . EKG-NSR 90bpm, NA, NI, q wave in III, No STT changes [**2174-10-14**] 06:31AM BLOOD WBC-2.9* RBC-1.52*# Hgb-4.8*# Hct-13.7*# MCV-90 MCH-31.3 MCHC-34.7 RDW-14.0 Plt Ct-168 [**2174-10-19**] 10:20AM BLOOD WBC-4.9 RBC-0.94* Hgb-2.8* Hct-8.8* MCV-94 MCH-29.4 MCHC-31.3 RDW-15.3 Plt Ct-293 [**2174-11-2**] 12:10PM BLOOD WBC-5.7 RBC-2.58*# Hgb-6.5* Hct-23.9*# MCV-92 MCH-25.1* MCHC-27.2* RDW-21.7* Plt Ct-708* [**10-14**] Tagged RBC Scan - Moderately brisk intermittent bleeding originating from the ascending colon. [**10-28**] CT - ?cortical infarct or pyelonephritis, small simple left pleural effusion with adjacent atelectasis Brief Hospital Course: Patient was admitted on [**10-13**] from OSH with lower GI bleed since patient was a Jehovah's witness and continued to have bloody bowel movements. Patient was admitted to the medical ICU and underwent a tagged RBC scan which suggested that the bleeding eminated from the ascending colon. Angiography was then performed which did not visualize the source of bleeding. The patient continued to have BRBPR and the general surgery service was consulted. Upon consultation the patient was found to have a hematocrit of 13.7 and an emergent colectomy was offered to resolve the active bleeding. The patient refused blood products citing her religious perference and all the patient was aware of all risks of the procedure and consented. The patient went to the OR on [**10-14**] and underwent a right hemicolectomy with ileocolostomy. The procedure was without complications and the patient was transfered to the TSICU in critical condition. Patient remained on the ventilator for several days, and was started on erythropoetin and IV Iron to maximize her RBC production capability. She was started on parenteral nutritional prior to return of bowel function. She was successfully extubated on pod# 10 and transfered to the floor once her hematocrit stabilized. Once the patient was transferred to the floor her hematocrit slowly increased each day and upon discharge was 23. GI Bleed - The patient continued to have guiac positive stool while in the ICU however these were felt to be the result of retained blood in the colon. After the patient was transferred to the floor patient had no episodes of BRBPR and no evidence of GI bleeding. Heme - Upon discharge the patients hematocrit was 23.9 which was significantly higher than her post op Hct of 8. The patient was started on 20K Units of EPO and will continue therapy for 1 week as well as Iron supplementation for 1 month. Pulm - Post operatively the patient developed a left lower lobe pneumonia which was treated with a one week course of cipro. Upon discharge the patient was afrebrile with a normal WBC. GI - The patient was started on parenteral nutrition while in the unit however was advanced to a regular diet after admission to the floor. Patient was discharged able to tolerate a regular diet. CV - Patient continued to be tachycardic throughout her hospital course as a result of her anemia. She was also hypertensive on several occassions which was treated with IV then PO Lopressor. Upon discharge the patient remained tachycardic and continued to have episodic hypertension which we will have her PCP follow up on. GU - While in the ICU the patient developed an enterococcal urinary tract infection which was treated appropriately with antibiotics Dispo - Patient will be discharged to short term rehab and will follow up with Dr. [**First Name (STitle) 2819**] in approximately 1-2 weeks Medications on Admission: Diovan 160mg Daily HCTZ 25mg Daily ASA 81mg daily MVI Discharge Medications: 1. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday) for 1 weeks. Disp:*3 injection* Refills:*0* 2. NuvaRing Vaginal 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HOURS A DAY (). Disp:*20 Adhesive Patch, Medicated(s)* Refills:*1* 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain only. Disp:*20 Tablet(s)* Refills:*0* 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Lower GI bleeding Hemorrhagic Shock Acute Blood loss anemia Urinary tract infection Left Lower Lobe pneumonia Post op fluid overload Discharge Condition: Good, patient is afebrile with stable vital signs, tolerating regular diet, ambulating and is without bloody bowel movements. Discharge Instructions: Please [**Name8 (MD) 138**] MD or go to ER if you experience Temp>101.5, severe chest pain, shortness of breath, bloody stools, severe abdominal pain, severe nausea/vomiting or inability to tolerate food. The steri strips covering your incision will fall off on their own. You may shower, however keep your incision clean and dry. Followup Instructions: Please call Dr.[**Name (NI) 11471**] office to schedule a follow up appointment in approximately 1-2 weeks.

Admission Date: [**2115-9-20**] Discharge Date: [**2115-10-16**] Service: OBSTETRICS/GYNECOLOGY Allergies: Ultram / Ether Attending:[**First Name3 (LF) 7141**] Chief Complaint: abdominal pain, transfer from OSH for further care Major Surgical or Invasive Procedure: PICC line placement CT guided abdominal Biopsy Exploratory laparotomy Resection of pelvic mass lymph node dissection Small bowel resection and anastomosis Cystectomy Ileo-conduit placement Omentopexy Sigmoidoscopy 11 units blood transfusion and 1 unit FFP transfusion ICU admission x 2 for hypotension and hemolytic transfusion reaction. History of Present Illness: HPI: Ms [**Known lastname **] presents with her daughter with 3 month history of worsening nausea, weight loss and decreased appetite. She was initially evaluated and admitted to [**Hospital 1474**] hospital [**Date range (1) 39208**] after she fell on her back after slipping on a wet surface. On arrival, she was also found to have nausea and abdominal pain at which time a pelvic mass was discovered on exam. She underwent CT evaluation and received IVF and pain meds. Her abdominal and back pain improved with vicodin and darvocet. Following her discharge on [**9-13**], she was informed by her PCP Dr [**Last Name (STitle) 3314**] that this was likely an ovarian malignancy but that she should undergo colonoscopic evaluation. She started the prep with Golytely but felt so awful during this, that she declined to actually undergo colonoscopy. . Patient came to [**Hospital1 18**] for further care. Continues to experience abdominal pain, confirmed to have a large pelvic mass, 16cm, and small lesions in liver (cannot characterize) and uncinate process. Pathology consistent with either GYN primary (ovarian) vs Renal. . Per Med consult, she has a history of angina (but has not had to use NTG for the past few months). She is able to do all ADLs and walk around a mall without CP or SOB. Denied any recent RVR episodes or CHF hospitalizations (maintained on 40mg [**Hospital1 **] of lasix). Previous cardiac catheterization >2 yrs ago, but no interventions were done. No Hx of MI. No DM. . Per family, prior to admission had lost some weight w/ decreased energy. Also, no bowel movement in 10 days. Otherwise ROS neg. Past Medical History: CHF (EF 55% on echo several years ago) Mitral regurgitation Afib on pacemaker osteoporosis hypothyroid PSH: TAH-BSO (40 years ago for unclear reasons and daughters were not entirely sure whether both ovaries were removed at the time), pacemaker placement in [**2112**] Social History: Remote smoking hx. no etoh. Lives independent and driving previously. Several children live nearby. Family History: No hx of colon, breast, ovarian CA Mother had hodgkin's disease Father had oral cancer with mets. Physical Exam: At time of admission: 98.2 75 120/61 16 95%RA Lying in bed, appears mildly uncomfortable Gen: A&O x 3. Gait not inspected. Answers questions appropriately. HEENT: no thrush, no [**Doctor First Name **] Breasts: no [**Doctor First Name **], no masses, no nipple discharge or inversion LUNGS: CTAB CVS: RRR, no murmurs Back: tenderness elicited at the level of lumber spine along bony processes. No bruising seen. ABD: moderately distended, tympanic to percussion in RUQ/LUQ, dull to percussion in RLQ/LLq. Firm, non-mobile mass in lower quadrants tender to palpation but no rebound or guarding. +BS. RECTAL: deferred (guaiac neg per ED resident) BIMANUAL: deferred (pt uncomfortable at the time) LE: 1+ pitting edema up to mid-calf in LLE. No palpable cord or tenderness. Ecchymosis along medial aspect of right knee and shin mildly tender to palpation. [**4-27**] motor strength with hip and knee flexion/extension. No limited ROM of kness bilaterally. No effusion or swelling of knees bilaterally. Pertinent Results: STUDIES: PATHOLOGY: Procedure date Tissue received Report Date Diagnosed by [**2115-10-2**] [**2115-10-2**] [**2115-10-10**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/lo?????? Previous biopsies: [**-6/3848**] ABDOMEN BX. DIAGNOSIS: Pelvic mass resection: I. Pelvic mass (A-E): Epithelioid malignant mesothelioma (see note). II. Lymph node, left external iliac (F-H): No malignancy identified (0/2) nodes. III. Segment of bladder dome (I and Z): Malignant mesothelioma involving bladder wall and undermining the mucosa. The tumor does not appear to arise from bladder mucosa and no in-situ carcinoma is seen. IV. Peritoneal tumor (J): Malignant mesothelioma in adipose tissue. V. Bladder, vagina, and pelvic mass (K-R, X-Y): Malignant mesothelioma extending into vagina and bladder walls. The tumor does not appear to arise from the vaginal or bladder mucosa and no precursor lesion is seen. VI. Segment of small bowel (S-T): Malignant mesothelioma involving serosa of small intestine of bowel. The tumor does not arise from the bowel mucosa and no precursor lesion is seen. VII. Omentum (U-W): Malignant mesothelioma. [**10-11**] CXR: REASON FOR EXAM: Assess for pleural effusions and pulmonary edema. Patient S/P surgery. Comparison is made with prior studies including most recent one dated [**2115-10-10**]. Cardiomediastinal contour is unchanged. Right transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. There is no CHF. There is minimal vascular engorgement which is stable. Blunting of the left lateral costophrenic angle with adjacent lung opacity is unchanged, due to small pleural effusion with adjacent atelectasis. [**10-10**]: LENIs FINDINGS: Grayscale and color Doppler imaging of the common femoral, superficial femoral, and popliteal veins were performed bilaterally. Normal compressibility, flow, waveform, and augmentation is demonstrated. No intraluminal thrombus is identified. IMPRESSION: No evidence of DVT. [**10-8**] LENIs RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins were performed. Normal compressibility, augmentation, flow, and waveforms were demonstrated. There is no evidence of intraluminal thrombus. . CT [**2115-10-9**] IMPRESSION: 1. New small bilateral pleural effusion with associated atelectasis (left greater than right). 2. Small amount of ascites which has slightly increased in size since the prior study. 3. Pelvic loculated fluid collection that may represent an organizing postoperative fluid collection/ hematoma. Alternatively, less likely, this may reflect residual tumor.There is a 3.7 x 4.2 cm cystic collection in the left aspect of the pelvis (series 2, image 6 and 7). This collection has a faint peripheral hyperdense rim that may reflect an organizing postoperative fluid/hematoma. Although no frank pocket of gas are seen within the fluid collection, a superimposed infection cannot be excluded. Alternatively, this may be related to residual tumor. 4. No evidence of colitis, free air, pneumatosis or bowel obstruction. CT Scan Pelvis [**2115-9-19**] IMPRESSION: 1. Large heterogeneous, lobulated pelvic mass seen, most likely of gynecological origin. Patient recalls history of TAH/BSO, however, prior records not available at time of dictation. Less likely considerations include lymphoma (although very unlikely given no lymphadenopathy identified elsewhere), or bladder origin. 2. Marked extrinsic compression of sigmoid colon, without evidence of obstruction. 3. Right sided hydronephrosis and proximal hydroureter. 4. Small hypoattenuating lesions seen within the liver. Metastases cannot be excluded. 6. Compression fracture of L1, of [**Last Name (un) 5487**] chronicity. 7. Poorly defined low attenuation lesion in uncinate process of pancreas, incompletely evaluated on this study. Primary versus secondary neoplasm suspected. Brief Hospital Course: #Pelvic Mass: On [**2115-9-19**] the patient was admitted to [**Hospital 61**] to be evaluated by surgical and gynecological services. Abdominal CT scan showed - 15.9 x 14.2 x 15.9 cm mass , incompletely encasing sigmoid colon. Small amount of oral contrast seen passing through sigmoid colon. Mild dilation of colon proximal to mass. Given the involvement of the sigmoid colon, the patient was admitted to the General Surgery team for possible surgical resection. On [**9-24**], a CT guided biopsy was performed which showed features suggestive of an unusual ovarian adenocarcinoma. The staining pattern suggests clear cell carcinoma of the ovary, or possibly metastatic endometrial carcinoma. Adrenal, renal or colonic origin are unlikely. Mesothelioma is unlikely, but cannot be entirely excluded based on the available information. Given the pathology findings, the patient was transferred to the GYN ONC service for further management. The patient underwent exploratory laparotomy, pelvic mass resection and cystectomy with ileoconduit placement by Drs [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**] on [**10-2**]. Please see operative note for details. The patient was admitted to the ICU postoperatively given 2 minutes of hypotension during surgery. #Nutrition/GI: Preoperatively, a PICC line was placed for TPN given minimal PO intake. Postoperatively, the patient's TPN was restarted. TPN was restarted following surgery. Nutrition consult following. The patient passed flatus and bowel movement postoperatively; her diet was advanced to regular. TPN continued until time of discharge due to limited PO intake. The patient refused TPN at time of discharge. The patient underwent a sigmoidoscopy which revealed normal 15cm but unable to advance scope due to insufficient bowel cleansing. #ID: The patient was started on Flagyl/Keflex postoperatively for empiric treatment given extent of surgery. -Pseudomonas infection: Postoperatively, her WBC was noted to double from 12 to 25. Peak WBC 39 while in the ICU. Blood cultures, JP fluid cultures, urine culture from ileo-conduit and wound culture were obtained. Pan-sensitive pseudomonas returned in urine, wound and JP drainage. An ID consult recommended IV and PO vancomycin and Zosyn. A CT scan was performed which demonstrated a post operative fluid collection vs hemotoma vs. organizing infection. An interventional radiology consult stated that the fluid was not-amenable to drainage. As the patient's WBC improved with IV antibiotic treatment and the patient remained afebrile, further surgical management was not pursued. Her antibiotics were narrowed to Zosyn IV. The patient was to receive PICC line IV treatments for total 14 days following discharge. Her WBC was normal at time of discharge. A repeat urine culture pending at time of discharge; but no bacteria present on urinalysis. #Respiratory: The patient was extubated on postoperative 2. The patient remained on room air. A CT scan on [**9-27**] was performed to evaluate for pulmonary metastasis; this workup was negative. The patient experienced acute dyspnea on postoperative day 9 during a blood transfusion. She received 2 doses of albuterol nebulizers; she desaturated to 89% room air. She needed minimal oxygen support upon her readmission to the ICU. She was discharged on room air. #Heme: The patient's HCT was followed closely. The patient received 9 units of blood during surgery and her initial postoperative stay to keep her HCT above 25. On postoperative day 9, the patient's hematocrit was noted to be slowly dropping from 28 -> 26 -> 23. It was unclear the cause of the hematocrit drop: slow bleeding from operative site vs hematoma. The patient was transfused [**12-25**] unit of blood before hemolytic reaction occurred (see below). This blood transfusion was discontinued immediately. During her 2nd ICU stay, the patient received 2 additional pRBC units that were screened by the Blood Bank after consultation with the transfusion fellow. Her postoperative HCT remained stable daily after the hemolytic reaction (bewlow) at 29-30. -Hemolytic Reaction: The patient experienced an acute hemolytic reaction manifested by acute onset of dyspnea on postoperative day 9. This unit of blood was discontinued immediately. She received 2 doses of Albuterol nebulizer treatment. She received 25 mg Benadryl, 40 mg Lasix IV and 20 mg proton pump inhibitor. Due to the patient's acute pulmonary distress and elevated respiratory rate to 40, a code Blue was called to facilitate any need for possible intubation. No intubation or cardiac resuscitation was needed. A transfusion fellow consult was called stat. A repeat type and screen found a JKA antibody in the patient's blood. The patient was transferred to the ICU for further monitoring. #Cardiac: The patient was noted to be in atrial fibrillation prior to surgery. The patient was rate controlled prior to surgery with Metoprolol and Diltiazem in the 80s-90s. She was followed on telemetry. A medicine consult was called preoperatively for assessment of her cardiac function. Prior cardiac evaluation was obtained from her PCP documenting an ejection fracture of 55% on recent Echo and 65% on recent stress test. Following surgery, postoperative cardiac enzymes were negative x 3. -Hypotension: Occurred intraoperatively for which the patient was placed on 2 pressors which were weaned off in the ICU. The patient maintained a MAP of 65 per A-line. All pressors were discontinued by time of ICU discharge and Metoprolol was restarted. -Atrial Fibrillation: The patient was maintained on telemetry and rate controlled with Metoprolol in the 80s-90s. She was restarted on her Coumadin when tolerating adequate PO on postoperative day 11. . # Pain: Patient had high level of post-operative pain treated with morphine PCA which was transitioned to PO due to patient somnolence. Patient able to wean off pain medications and as of [**10-9**] required minimal PO medications. . # Coagulopathy: INR elevated following surgery to 1.6 attributed to multiple transfusions intraoperatively. The patient responded well to one unit of FFP with INR 1.2. INR trended to 1.0 spontaneously prior to discharge. INR followed daily following restart of Coumadin. INR 1.1 at time of discharge. VNA to follow INR daily upon discharge. . # Hypothyroidism: levothyroxine continued . # Prophylaxis: PPI, sc heparin, aspiration precautions, pneumoboots when patient accepted. . # Code: Full, confirmed w/ HCP #Dispo: Patient discharged on [**10-16**] with VNA services, ostomy care, and follow up with Urology, INR checks to be followed by PCP, [**Name10 (NameIs) 39209**] and Thoracic oncology. Medications on Admission: coumadin 2-5mg cardizem 240 atenolol 25 synthroid 150mcg furosemide 40 qd Discharge Medications: 1. Simvastatin 40 mg Tablet [**Name10 (NameIs) **]: One (1) Tablet PO DAILY (Daily). Disp:*50 Tablet(s)* Refills:*2* 2. Latanoprost 0.005 % Drops [**Name10 (NameIs) **]: One (1) Drop Ophthalmic HS (at bedtime). Disp:*qs bottles* Refills:*2* 3. Docusate Sodium 100 mg Capsule [**Name10 (NameIs) **]: One (1) Capsule PO BID (2 times a day) as needed. Disp:*60 Capsule(s)* Refills:*2* 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 5. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Salmeterol 50 mcg/Dose Disk with Device [**Last Name (STitle) **]: One (1) Disk with Device Inhalation Q12H (every 12 hours). Disp:*60 Disk with Device(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY 10AM (). Disp:*50 Tablet(s)* Refills:*2* 9. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO TID (3 times a day) for 5 days. Disp:*75 ML(s)* Refills:*0* 10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) for 5 days. Disp:*qs piggyback* Refills:*0* 11. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 12. Levofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Xanax 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*0* 14. Codeine Sulfate 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 15. Levothyroxine 150 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 16. picc line care [**Last Name (STitle) **]: One (1) once a day: PICC line care [**First Name8 (NamePattern2) **] [**Last Name (un) 6438**] protocol . Disp:*1 1* Refills:*2* Discharge Disposition: Home With Service Facility: Partners [**Name (NI) **] [**Name2 (NI) **] Discharge Diagnosis: Primary Diagnosis: -Peritoneal mesothelioma -L1 compression fracture -Acute hemolytic reaction -Pseudomonas infection Secondary Diagnoses: -Afib with pacemaker -CHF -COPD -Osteoporosis -Hypothyroid Discharge Condition: Tolerating some regular diet, afebrile, normal white blood cell count, ambulating. Pain controlled. Voiding through ileo-conduit. Discharge Instructions: Call Dr. [**First Name (STitle) 1022**] if: shortness of breath, fever > 100.4, abdominal pain not relieved by medicine, chest pain, redness around incision that is expanding, drainage from incision, diarrhea, decreased urine output at your ostomy or concerns about your ostomy. No driving after surgery. Please have your daughters/son drive you. No heavy lifting for 6 weeks. No tub baths; you may shower. Do not scrub your incision. Let the water run down over the incision. You may take Codeine for pain as prescribed You may take a stool softener to keep bowels regular. -Please take Levoquin 500 mg daily (1 tablet). -Please continue: -Coumadin 2.5 mg daily. Your Coumadin dosing will be checked by the visiting nurse and your dose may be adjusted. Dr. [**Last Name (STitle) 3314**] will follow the dosing. -Levothyroxine 150 mcg -Latanoprost eye drops -Metoprolol 25 mg three times a day -Nystatin swish/swallow three times a day x 3 days -Zosyn (IV antibiotic) 5 days three times a day -Salmeterol inhaler twice a day -Zocor 1 tablet daily for high cholesterol -Xanax 1 tablet at night to help sleep Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2115-10-24**] 10:45am [**Location (un) **] [**Hospital Ward Name 23**] Center Thoracic Oncology [**10-29**] 3pm Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Location (un) **] [**Hospital Ward Name 23**] Building [**0-0-**] Dr. [**Last Name (STitle) 365**], Urology [**11-6**] at 12 noon [**Hospital1 9384**] (across from [**Hospital3 1810**] next to [**Company 38877**]) [**Location (un) 448**] ([**Telephone/Fax (1) 6441**]

Admission Date: [**2170-6-1**] Discharge Date: [**2170-6-11**] Date of Birth: [**2090-4-15**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Sulfa (Sulfonamide Antibiotics) / Tegretol / Statins-Hmg-Coa Reductase Inhibitors / Morphine / Plavix / Codeine / Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: exertional chest pain Major Surgical or Invasive Procedure: [**2170-6-1**] Cardiac catheterization [**2170-6-6**] Coronary artery bypass graft x4 (saphenous vein graft > left anterior descending, saphenous vein graft > obtuse marginal 1 > obtuse marginal 2, saphenous vein graft > posterior descending artery) History of Present Illness: 80 year old female with a history of HTN, hyperlipidemia, prior tobacco abuse, s/p left [**Last Name (LF) **], [**First Name3 (LF) **], and PVD, with a 2 month history of exertional chest tightness and upper chest discomfort that she describes as "pins and needles", along with mild shortness of breath, which is relieved by rest. This usually occurs with climbing a flight of stairs and occurred once while walking 50 yards following her thallium. She was referred for catheterization. Cardiac surgery consulted for revascularization. Past Medical History: Hypertension Hyperlipidemia Prior tobacco abuse PVD Gout Spinal Stenosis S/p right amaurosis fugax/[**First Name3 (LF) **] [**2167**] Arhtritis History of C-Diff [**2167**] Scarlet fever PNA Kidney stone s/p Back surgery s/p Right [**Year (4 digits) **] [**2167**] s/p Bilateral Cataract surgery Social History: partial with a few native lower teeth Lives with:her son live with her in [**Name (NI) 620**] Heights Occupation:retired Tobacco:smoked 1 pack per week for 30 years and quit in [**2147**] ETOH:denies Family History: non contributory Physical Exam: Pulse:59 Resp:18 O2 sat:100/RA B/P Right:135/87 Left: 140/94 Height:5'5" Weight:135 lbs General:NAD, alert, cooperative Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] I-II/VI systolic Murmur best heard at 2nd RICS Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right:+1 Left:+1 PT [**Name (NI) 167**]: +1 Left:+1 Radial Right: +2 Left:0 Carotid Bruit Right:+ brunit Left:+ bruit Pertinent Results: [**2170-6-1**] 02:40PM BLOOD WBC-6.1 RBC-3.36* Hgb-9.9* Hct-28.6* MCV-85 MCH-29.5 MCHC-34.6 RDW-15.2 Plt Ct-278 [**2170-6-1**] 02:40PM BLOOD Plt Ct-278 [**2170-6-1**] 02:40PM BLOOD PT-14.0* INR(PT)-1.2* [**2170-6-6**] 12:41PM BLOOD Fibrino-247 [**2170-6-1**] 02:40PM BLOOD Glucose-173* UreaN-8 Creat-0.6 Na-137 K-2.8* Cl-103 HCO3-26 AnGap-11 [**2170-6-1**] 02:40PM BLOOD ALT-12 AST-17 Amylase-64 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2170-6-6**] 06:17PM BLOOD cTropnT-1.00* [**2170-6-7**] 01:45AM BLOOD cTropnT-0.47* [**2170-6-2**] 06:15AM BLOOD Albumin-3.9 Mg-2.1 Cholest-211* [**2170-6-1**] 02:40PM BLOOD %HbA1c-5.3 eAG-105 [**2170-6-2**] 06:15AM BLOOD Triglyc-165* HDL-45 CHOL/HD-4.7 LDLcalc-133* Chest CT FINDINGS: Multiple bilateral solid and ground-glass pulmonary nodules are new or increased from prior examination, measuring up to 5 mm. Biapical and peripheral pleuro-parenchymal scarring persist, with associated ground-glass opacities, suggestive of interstitial lung disease. There is no focal consolidation. The central airways are patent to the subsegmental levels. Evaluation of intrathoracic vasculature is suboptimal without intravenous contrast, but there has been interval progression of diffuse atherosclerotic calcifications. At the origin of the right brachiocephalic artery, a 1.5-cm segment of severe stenosis now demonstrates near-complete luminal occlusion. Moderate orificial stenosis of the left common carotid artery also appears more prominent. In the proximal left subclavian artery, a 1.4 cm segment of moderate stenosis now demonstrates near-complete luminal occlusion. Extensive calcifications are also noted involving the aortic arch and root, three coronary arteries, and posterior descending artery. Thoracic aorta is normal in caliber, measuring 3.3 cm at the level of the main pulmonary artery, 2.7 cm at the arch, and 2.5 cm in the descending portion. Central pulmonary arteries are unremarkable. The heart is normal in size, without pericardial effusion. Prominent left axillary lymph node measures 9 mm, with fatty hilum. Intrathoracic lymph nodes are stable, measuring up to 5 mm in the superior paratracheal region, 7 mm in the precarinal region, and 7 mm in the subcarinal region. Note is made of mild pectus excavatum. Examination is not tailored for subdiaphragmatic evaluation, but reveals dense calcification of the abdominal aorta with severe celiac artery stenosis. Bilateral non-obstructing renal stones are present. Calcifications in the region of the porta hepatis are likely vascular. The bones are diffusely mottled and sclerotic, with mild multilevel degenerative changes. IMPRESSION: 1. Progression of severe atherosclerosis. 2. Interstitial lung disease, with multiple new pulmonary nodules measuring up to 5 mm. Recommend followup CT in [**6-10**] months, depending on patient's risk factors. 3. Bilateral non-obstructing renal stones. Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.4 m/s Left Atrium - Peak Pulm Vein D: 0.2 m/s Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 3.8 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Stroke Volume: 71 ml/beat Left Ventricle - Cardiac Output: 4.25 L/min Left Ventricle - Cardiac Index: 2.53 >= 2.0 L/min/M2 Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm Hg Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 15 Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.5 cm <= 3.0 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 2 mm Hg Aortic Valve - LVOT VTI: 25 Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: *2.3 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 0.8 m/sec Mitral Valve - Mean Gradient: 1 mm Hg Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: *257 ms 140-250 ms Findings LEFT ATRIUM: Normal LA size. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild to moderate ([**12-31**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. Conclusions The left atrium is normal in size. The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-31**]+) mitral regurgitation is seen. There is no pericardial effusion. Post Bypass: Patient is Apaced and intermittently AV paced, on phenylepherine infusion at 0.5 mcg/kg/min. Preserved biventricular function, LVEF >55%, no wall motion abnormalities. Mrremains mild to moderate. Aortic contours intact. Remaining exam is unchanged. Cardiac output 5.0 LPM at HR 80. All findings discussed with surgeons at the time of the exam. Brief Hospital Course: Ms.[**Known lastname 83206**] presented for cardiac catheterization which revealed significant coronary artery disease. Cardiac surgery was consulted and she underwent preoperative evaluation which included CT scan of chest that recommends follow up CT scan in 6 months to evaluate pulmonary nodules. On [**6-6**] she was brought to the operating room for coronary artery bypass graft surgery, see operative report for further details. That evening she was weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one she was weaned off phenylephrine and started on lasix for diuresis. That evening she was started on betablockers/ statin/aspirin and diuresis. Chest tubes and epicardial wires were removed per protocol. She continued to progress and was transferred to the step down unit for further monitoring. Physical therapy worked with her on strength and mobility. By post-operative day #5 she was ready for discharge to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] rehab. All follow-up appointments were advised. Medications on Admission: LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 (One) Tablet(s) by mouth daily METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg Tablet Extended Release 24 hr - 0.5 (One half) Tablet(s) by mouth daily NITROGLYCERIN [NITROSTAT] - (Prescribed by Other Provider) - 0.4 mg Tablet, Sublingual - [**1-1**] Tablet(s) sublingually q 5 minutes as needed Medications - OTC ASPIRIN - (OTC) - 325 mg Tablet - 1 (One) Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Tablet - 1 (One) Tablet(s) by mouth daily IBUPROFEN [ADVIL] - (OTC) - 200 mg Tablet - 1 (One) Tablet(s) by mouth as needed for back pain IBUPROFEN-DIPHENHYDRAMINE [ADVIL PM] - (Prescribed by Other Provider) - 200 mg-38 mg Tablet - 2 (Two) Tablet(s) by mouth daily at HS MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] - (Prescribed by Other Provider) - 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet - 1 (One) Tablet(s) by mouth daily NIACIN - (OTC) - 500 mg Tablet - 1 (One) Tablet(s) by mouth daily POTASSIUM GLUCONATE - (OTC) - Dosage uncertain Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. niacin 250 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 9. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension Hyperlipidemia Peripheral vascular disease Gout Spinal Stenosis Arhtritis Kidney stone Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: 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 [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on [**7-5**] at 1:00pm Cardiologist: Dr [**Last Name (STitle) 8579**] on [**7-10**] at 10:45am Pulmonary nodules on preoperative CT scan - recommended Chest CT in 6 months Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) 58623**] in [**4-3**] weeks [**Telephone/Fax (1) 58624**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2170-6-11**]

Admission Date: [**2155-7-22**] Discharge Date: [**2155-7-26**] Service: CHIEF COMPLAINT: Chest pain and shortness of breath requiring BiPAP. HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old gentleman with a past medical history significant for coronary artery disease with unrevascularized three-vessel disease and ischemic cardiomyopathy with an ejection fraction of 20% with also a history of VTs and sinus node dysfunction and status post VT ablation and pacer ICD placement, peripheral vascular disease, hypertension, and hypercholesterolemia, who was admitted with acute onset of substernal chest pain for one hour while at rest. The patient reported associated symptoms of diaphoresis and shortness of breath. The patient took six sublingual nitroglycerins without relief and he was given Lasix 80 mg IV en route to the Emergency Department. The patient refused aspirin. In the emergency room his heart rate was 96, blood pressure 194/88 and his oxygen saturation was 86% on a face mask, which improved to 95% on BiPAP. Chest x-ray was consistent with congestive heart failure and the EKG was uninterpretable due to pacer. He was given aspirin, nitroglycerin and was transferred to the coronary care unit where aggressive diuresis was initiated for his congestive heart failure. During his diuresis, he developed some abdominal pains and laboratory studies showed an elevated amylase and lipase. The patient is a poor historian, but reported vague abdominal pain approximately two weeks ago when he went for a pacer check with Dr. [**Last Name (STitle) **]. The patient in the coronary care unit was given some gentle hydration in response to his acute pancreatitis, and the patient was transferred to the floor where his pancreatic enzymes were trending down, however he developed a leukocytosis and a temperature to 101.1. On the floor he was taking clear liquids without abdominal pain. He denied any back or epigastric pain, but again the patient is a very poor historian. PAST MEDICAL HISTORY: 1. Coronary artery disease, three-vessel disease in [**2150-3-8**]. He had a catheterization that showed 30% stenosis of his LM and 30% of his PLAD and 30% of his D1. 2. Peripheral vascular disease, status post a right iliofemoral bypass in [**10-9**] and status post percutaneous transluminal coronary angioplasty of his left iliac in [**7-9**]. 3. Ischemic congestive heart failure with an ejection fraction of 20%. 4. History of VT sinus node dysfunction, status post ablation and pacer placement in [**2149**]. 5. Chronic obstructive pulmonary disease. 6. Chronic renal insufficiency with a baseline creatinine of 2.1 to 3.6. 7. Hypertension. 8. Hypercholesterolemia. 9. History of penile implant. ALLERGIES: The patient states by report that he has no known drug allergies, however review of computerized medical records reports that he has an allergy to ACE inhibitors. SOCIAL HISTORY: He is a previous smoker, 120-pack-year history, quit 10 years ago, denies alcohol use, lives in [**Location 11206**], MA with his wife. FAMILY HISTORY: His father died secondary to leukemia and his mother died of liver disease; no further information was provided. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg p.o. q.d. 2. Lasix 80 mg p.o. q.d. 3. Isordil 30 mg p.o. q. day. 4. Plavix 75 mg p.o. q. day. 5. Hydralazine 25 mg p.o. q. day. 6. Aspirin once a day. PHYSICAL EXAMINATION: Vital signs on transfer to the floor from the coronary care unit were temperature 101.2, blood pressure 103/58, pulse 61, respiratory rate 28, and he was saturating 95% on two liters. In general he was a confused gentleman sitting in his chair in no apparent distress. HEENT examination showed left pterygium, pupils minimally reactive bilaterally. His oropharynx was clear. His mucous membranes were dry. His neck was supple without jugular venous distension. His chest had bilateral crackles one-half way up the lung fields. His cardiac examination revealed a 2/6 systolic murmur best heard at the right upper sternal border greater than the left upper sternal border. Abdominal examination revealed positive bowel sounds, nontender with palpation, and no tenderness in the epigastrium and right upper quadrant with palpation. Extremities revealed no edema. Neurologically, cranial nerves II-XII were grossly intact. He had [**4-12**] right lower extremity strength, otherwise 5/5 strength in all extremities and his right lower extremity was cooler than his left lower extremity. LABORATORY DATA: On admission his white count was 17, hematocrit 41, platelet count 781. Differential showed a white blood cell count with 63.5 neutrophils, 26 lymphocytes, 7 monocytes, 3 eosinophils, 1 basophil. Sodium 139, potassium 4.5, chloride 103, bicarbonate 24, BUN 38, creatinine 3.0, glucose 155. He had a calcium of 9.1, a magnesium of 2.2 and a phosphorous of 4.5. He had an INR of 1.1, a PTT of 24.0. Laboratory studies on admission to the floor showed a white count elevated to 21.3, hematocrit 36.6, sodium 139, potassium 4.2, chloride 100, bicarbonate 26, BUN 48, creatinine 3.2 and a glucose of 123. He had a phosphorous of 4.0 and a magnesium of 2.1. He had an ALT of 18, an AST of 24 and alkaline phosphatase of 84. His amylase, three values, from 442 to 911 to 424; lipase 882 to 946 to 166. His total bilirubin was 1.0. He had cardiac enzymes drawn, a set of three, showing troponins 0.01, 0.04 and 0.03. The patient also had an MCV of 63, a TIBC of 442, which was elevated, and a ferritin of 11, which is increased. HOSPITAL COURSE: 1. Pancreatitis: The patient had experienced initial symptoms of abdominal pain while in the coronary care unit during aggressive diuresis. An ultrasound of the liver and gallbladder showed a gallbladder with stones and sludge. There was no acute cholecystitis. There was a nondilated biliary tree. He had an atrophic left kidney and there was a limited view of the pancreas. To obtain better imaging, we obtained an abdominal and pelvis CT without contrast concerning his chronic renal insufficiency that showed inflammation of his pancreas. The patient was tolerating clears and then a full diet while on the floor without abdominal pain. The patient's pain control was purely on a p.r.n. basis. There were no standing medications provided. We believe that his pancreatitis was secondary to transient passage of gallstones. GI consult was not appropriate at this time because the onset of his pain had been for more than 24 hours, thus sphincterotomy was not indicated. 2. Congestive heart failure: The patient was weaned off oxygen and on the day before discharge he had an O2 saturation of 93% on room air. The patient's lung examination improved with diminished crackles in both lungs. The patient was kept off his diuretics while in the hospital secondary to his chronic renal insufficiency, but more importantly, secondary to his acute pancreatitis and his fluid balance. The patient will be discharged on a smaller dose of Lasix. He originally came in on 80 p.o. q. day and will be discharged on 40 p.o. q. day with follow up with his primary care physician in regards to adjustment of his Lasix dosage. 3. Leukocytosis: The patient experienced an increase in his white count from 17.0 to 21.3 with a bandemia once he was transferred to the floor with neutrophils to 88. The patient did have a left shift in a differential blood count that was received while the patient was on the floor, with 88 neutrophils. We believe his leukocytosis is related to a urinary tract infection. Urine cultures are pending, however two urinalyses were consistent with a urinary tract infection with elevated white blood cells and bacteria. The patient in response to this was treated with levofloxacin 250 mg p.o. q. 48 hours for a total of seven days. This is the renal dosing for levofloxacin. He will be discharged on this medication to complete his course of therapy. 4. Chronic obstructive pulmonary disease: The patient was given metered dose inhalers p.r.n. for his chronic renal insufficiency. His creatinine was at the higher end of his baseline and for his coronary artery disease we obtained pressure control with hydralazine and rate control with amiodarone. 5. Anemia: The patient has a microcytic anemia that is consistent with iron deficiency anemia. He was started on ferrous sulfate 325 mg while in the hospital and a hemoglobin electrophoresis was sent out for analysis of possible thalassemia. CONDITION ON DISCHARGE: Fair. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Pancreatitis. 3. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Amiodarone 200 mg p.o. q. day. 3. Hydralazine 10 mg p.o. q. 6 hours. 4. Iron 325 mg p.o. q. day. 5. Levofloxacin 250 mg p.o. q. 48 hours for a total of seven day. 6. Clopidogrel 75 mg p.o. q. day. 7. Protonix 40 mg p.o. q. day. 8. Isosorbide dinitrate 30 mg p.o. q. day. FOLLOW-UP PLANS: He is to call his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6680**] for follow up in the next two weeks. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-953 Dictated By:[**Last Name (NamePattern1) 11207**] MEDQUIST36 D: [**2155-7-25**] 17:53 T: [**2155-7-29**] 15:09 JOB#: [**Job Number 11208**]

Admission Date: [**2159-5-24**] Discharge Date: [**2159-6-11**] Date of Birth: [**2106-10-6**] Sex: M Service: MEDICINE Allergies: Penicillins / Lovastatin Attending:[**First Name3 (LF) 7651**] Chief Complaint: STEMI, motorcycle accident Major Surgical or Invasive Procedure: Cardiac catheterization IABP placement Mechanical ventilation Central venous line placement History of Present Illness: 52yo male presented to [**Hospital 19135**] Hospital s/p motorcycle vs car collision. The pt was traveling at a high rate of speed, swerved and fell. + LOC. He and his motorcycle were found in the middle [**Male First Name (un) **] of the road. He was wearing a helmet. At [**Hospital1 **], he was alert and oriented x 2. Multiple facial lacerations were noted and a tetanus shot was given. Vitals upon presentation to [**Hospital1 **] were BP 174/101, HR 80, RR 20, 100% on RA. Pelvis, chest, and C-spine [**Last Name (un) 22942**] were unremarkable. He was transfered to [**Hospital1 18**] for further care. Prior to transfer an ECG had been obtained which showed inferior ST elevations. He was taken to the cath lab. He was intubated using laryngoscopy due to airway swelling. Cath showed thrombotic mid-distal RCA lesion which was stented with BMS x 2. He was then transfered to the CCU. U tox came back + for cocaine. Plastic surgery evaluated and sutured facial lacs. Trauma surgery is folllowing the patient along with CCU team. . Unable to obtain ROS [**12-19**] mental status. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ED here, initial vitals were 179/100, HR 84, RR 19, 100% O2 sat. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: family denies -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: GERD, multiple orthopedic procedures (back, shoulder, knee) Social History: Tobacco history: former smoker, quit 2 months ago Family denies EtOH and ilicit drug use, say he's been clean for 22 years. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death per pt's daughter Physical Exam: VS: T=99.3 BP=103/65 HR=102 RR= 16 O2 sat= 100% GENERAL: sedated, intubated HEENT: Periorbital ecchymosis and swetting. Lips edematous. Right forehead facial lact covered with dry gauze THYROID: no goitre, no signs hyperthyroidism CARDIAC: RR, normal S1, S2. Soft systolic murmur. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No tenderness. + BS EXTREMITIES: No edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. GAIT: unable to assess MUSCLE: tone appears normal Pertinent Results: Admission Labs: [**2159-5-24**] 11:00AM BLOOD WBC-15.9* RBC-5.24 Hgb-15.2 Hct-43.0 MCV-82 MCH-28.9 MCHC-35.3* RDW-14.1 Plt Ct-214 [**2159-5-24**] 11:00AM BLOOD PT-11.8 PTT-20.0* INR(PT)-0.9 [**2159-5-24**] 11:00AM BLOOD Fibrino-288.4 [**2159-5-24**] 03:00PM BLOOD Glucose-190* UreaN-16 Creat-0.8 Na-135 K-4.5 Cl-103 HCO3-24 AnGap-13 [**2159-5-24**] 11:00AM BLOOD CK(CPK)-667* [**2159-5-24**] 11:00AM BLOOD Lipase-20 [**2159-5-24**] 11:00AM BLOOD cTropnT-<0.01 [**2159-5-24**] 03:00PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 [**2159-5-24**] 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2159-5-24**] 11:17AM BLOOD Glucose-170* Lactate-1.6 Na-141 K-5.1 Cl-103 calHCO3-23 [**2159-5-24**] 11:17AM BLOOD freeCa-1.03* Cardiac Enzymes: [**2159-5-24**] 11:00AM BLOOD CK(CPK)-667* [**2159-5-24**] 04:48PM BLOOD CK(CPK)-1662* [**2159-5-24**] 10:43PM BLOOD CK(CPK)-1887* [**2159-5-25**] 04:10AM BLOOD CK(CPK)-2627* [**2159-5-25**] 10:00AM BLOOD CK(CPK)-4153* [**2159-5-26**] 03:59AM BLOOD CK(CPK)-4480* [**2159-5-26**] 02:47PM BLOOD CK(CPK)-3689* [**2159-5-24**] 11:00AM BLOOD cTropnT-<0.01 [**2159-5-24**] 04:48PM BLOOD CK-MB-137* MB Indx-8.2* [**2159-5-24**] 10:43PM BLOOD CK-MB-163* MB Indx-8.6* cTropnT-1.50* [**2159-5-25**] 04:10AM BLOOD CK-MB-259* MB Indx-9.9* [**2159-5-25**] 10:00AM BLOOD CK-MB-438* MB Indx-10.5* [**2159-5-25**] 08:27PM BLOOD CK-MB-422* cTropnT-6.60* Other Notable Labs: [**2159-6-7**]: HbA1c 6/0 [**2159-6-7**]: ALT 35, AST 44, AlkPhos 55, TBili 0.7, Albumin 2.9 [**2159-5-29**]: TSH 3.0, T4 5.1, Free T4 0.88 Discharge Labs [**2159-6-11**]: WBC 6.7, HCT 36.1, Plt 428 Na 141, K 4.7, Cl 107, HCO3 26, BUN 15, Cr 0.9, Glucose 110 Ca 8.4, Mag 2.1, Phos 4.3 PT 14.4, PTT 26.3, INR 1.2 Admission ECG [**2159-5-24**]: Sinus rhythm. Compared to the previous tracing of [**2153-3-20**] there is ST segment elevation in the inferolateral leads and ST segment depression in the anteroseptal leads suggesting acute myocardial infarction of the inferolateral territory. Repeat ECG [**2159-5-24**]: Acute inferior myocardial infarction. Probably mid-right coronary lesion with ST segment depression in lead aVL and aVR being negative. ST segment elevation in lead III greater than in lead II. A-V dissociation is not present. There is some irregularity to the rhythm suggesting capture beats. This may be interference dissociation with a junctional rhythm that is rapid. Since the previous tracing of [**2159-5-24**] junctional rhythm is present with interference dissociation. Admission CXR [**2159-5-24**]: Low inspiratory lung volumes, but otherwise no acute cardiopulmonary process. Cardiac Cath [**2159-5-24**]: 1. Selective coronary angiography in this right dominant system demonstrated one vessel disease. The LMCA had no angiographically apparent disease. The LAD had no angiographically apparent disease. The Cx had no angiographically apparent disease. The RCA had a proximal 50% stenosis as well as a distal 70% stenosis that was thrombotic and ulcerated. The distal RCA stenosis was located proximal to the PL/PDA bifurcation. 2. Successful PTCA and stenting of distal RCA with a 4.5x28mm Vision BMS postdilated to 5.0mm. 3. Successful PCI of proximal PL with 5.0x18 Ultra stent. 4. Airway compromise from trauma requiring fiberoptic intubation by anesthesia staff. 5. Unsuccessful PTCA of distal PL cutoff with 2.5mm balloon. 6. Successful rescue PTCA of PDA origin with 2.0x15mm Apex balloon. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. STEMI 3. Successful PCI distal RCA. 3. Successful PCI proximal PL. 4. Unsuccessful PTCA of distal PL cutoff. 5. Successful rescue PTCA of PDA origin. 6. Successful fiberoptic intubation by anesthesia staff for airway protection. CT Head w/o Contrast [**2159-5-24**]: No acute intracranial abnormality CT C-spine w/o Contrast [**2159-5-24**]: No evidence of acute fracture or malalignment of the cervical spine. CT Sinus/Mandidble/Maxillofacial Non-Contrast [**2159-5-24**]: Multiple facial fractures are seen involving the bilateral nasal bones, bilateral maxillary sinuses (anterior, lateral, posterior and medial walls), the right palatine process of the maxilla and palatine bone, bilateral pterygoid plates, bilateral frontal processes of the maxillae, right lateral orbital wall and right orbital floor. The globes appear intact. No extraocular muscle herniation is seen. The bilateral lamina papyracea are intact. Blood is seen throughout the bilateral maxillary sinuses, ethmoid air cells, sphenoid sinuses and frontal sinuses. Soft tissue swelling and hematoma is seen in the frontal scalp along with subcutaneous emphysema extending to the right periorbital region and along the right cheek. Subcutaneous emphysema extends to the masticator space bilaterally, right greater than left. The globes appear intact. No mandibular fracture is seen. IMPRESSION: Multiple bilateral facial fractures with involvement of the right lateral orbital wall and floor as described above. The globes appear intact and no evidence of ocular muscle entrapment is seen. CT Abdomen and Pelvis with Contrast [**2159-5-24**]: 1. No acute traumatic injuries seen within the torso. 2. Left adrenal nodule, which does not meet criteria for an adrenal adenoma on this exam. Further evaluation with dedicated CT or MRI of the adrenal glands is recommended. 3. Mild dependent atelectasis in both lungs. TTE [**2159-5-25**]: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferior, inferolateral and inferoseptal akinesis. The remaining segments contract normally (LVEF = 30%). Right ventricular chamber size is normal with moderate global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional biventricular systolic dysfunction, c/w RCA-territory infarction and RV infarction. Mild mitral regurgitation. Mild pulmonary hypertension. Cardiac Cath [**2159-5-25**]: 1. Selective coronary angiography of this right dominant system revealed one vessel coronary artery disease. The RCA was 100% occluded proximal to the prior stent. The LCA was not engaged. 2. Limited resting hemodyanmics revealed severe hypotension with a central pressure of 86/53 mmHg on high dose dopamine. 3. Successful placement of 40cc IABP for hemodyanamic support. FINAL DIAGNOSIS: 1. One vessel coronary artery disease with occluded RCA due to stent thrombosis. 2. Severe hypotension on high dose dopamine. 3. Successful placement of IABP for hemodynamic support. CT Head w/o Contrast [**2159-5-29**]: 1. New small right parafalcine subdural hematoma. 2. New scalp collections, left greater than right, likely evolving hematomas. Overlying fascial enhancement is likely inflammatory, but please correlate clinically to exclude the possibility of superimposed infection. CT Sinus with Contrast [**2159-5-29**]: 1. Extensive facial fractures as described above, overall unchanged in appearance since [**2159-5-24**]. 2. Interval increase in opacification of the paranasal sinuses, in part due to blood. This is a common finding in intubated patients. However, acute sinusitis cannot be excluded, if it is suspected on clinical grounds. CT Chest/Abdomen/Pelvis with Contrast [**2159-5-29**]: 1. No acute intra-abdominal pathology or source of infection identified. 2. Interval development of small pericardial effusion and moderate bilateral pleural effusions with fissural component on the left. Compressive atelectasis of left greater than right lower lobes. 3. Fatty deposition in the liver. 4. Interval development of trace amount of free fluid within the abdomen and pelvic cavities, as well as interval increase in subcutaneous edema likely reflect a slightly fluid overloaded status. TTE [**2159-6-2**]: Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) secondary to extensive inferior and posterior akinesis with focal dyskinesis of the midventricular segment of the inferior free wall. The right ventricular cavity is dilated with depressed free wall contractility. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2159-6-1**], focal dyskinesis of the inferior free wall is now present. TTE [**2159-6-4**]: 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 severe regional left ventricular systolic dysfunction with infer-septal, inferioa, and infero-lateral hypokinesis to akinesis. The apex appears hypokinetic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2159-6-2**], no change. IMPRESSION: No VSD or pseudoaneurysm seen. CT Head w/o Contrast [**2159-6-6**]: 1. No acute intracranial hemorrhage. Previously seen tiny right parafalcine subdural hematoma has since resolved. 2. Multiple facial fractures as before, incompletely assessed on this study. No new fracture is identified. 3. Resolution of small bilateral scalp hematomas. ECG [**2159-6-10**]: Supraventricular tachycardia with a ventricular premature beat. Inferior ST segment elevation with Q waves and T wave inversions suggesting an myocardial infarction, could be recent/acute. T wave inversion in leads I, aVL and V5-V6 also suggest ischemia. Clinical correlation is suggested. Low QRS voltage in the limb leads. Brief Hospital Course: 52yo male admitted after motorcycle accident and found to have inferior STEMI, who underwent emergent cardiac cath with BMS to distal RCA. #) STEMI - Patient brought to CCU s/p emergent cardiac cath for inferior STEMI, which revealed a proximal 50% stenosis of the RCA as well as a distal 70% stenosis that was thrombotic and ulcerated. Patient had BMS placed in distal RCA. There was evidence of right ventricular ischemia/infarction. Of note, patient had no previously known h/o CAD, but his urine tox screen was positive for cocaine on presentation. The patient later denied any recent cocaine use. A TTE obtained the next day revealed moderate regional biventricular systolic dysfunction, c/w RCA-territory infarction and RV infarction, mild mitral regurgitation, and mild pulmonary hypertension. The patient developed ventricular bradycardia and hypotension, and Swan that was placed showed elevated pressures in RA, RV, LA/WP indicating biventricular failure. Repeat cath the following day showed thrombosis of RCA stent, and a decision was made to medically manage the patient as at this point microvascular perfusion was severely impaired by distal embolization and clot formation. Post cath he was gravely ill with acute systolic CHF and right ventricular failure. He had an IABP placed for support, which was gradually weaned and pulled. His cardiac enzymes peaked on [**2159-5-26**]: CK 4480, MB: 300, Trop: 6.21. The patient was aggressively diuresed after developing significant pulmonary edema, and his fluid balance was closely monitored given his pre-load dependence in setting of RV infarct. He had several repeat TTEs during the admission, and most recent echo was on [**2159-6-4**]. Echo showed severe regional left ventricular systolic dysfunction with infer-septal, inferioa, and infero-lateral hypokinesis to akinesis, a hypokinetic apex, mildly dilated RV, mild global free wall hypokinesis, mod-severe MR, and a small to moderate pericardial effusion without evidence of tamponade. #) Supraventricular tachycardia/atrial fibrillation - On night of initial presentation, s/p PCI, rhythm went from sinus tachycardia to atrial tachycardia with ventricular bradycardia; BP 60-70/40s. Arrhythmia thought to be secondary to AV nodal infarct (RCA branch) causing some degree of heartblock. Per EP, patient appeared to have 2:1 conduction at higher HRs with good conduction at lower HRs (~50), and pacemaker was not indicated at the time. On [**2159-5-28**] patient had several episodes of sustained monomorphic V tach, lasting up to 2 min at a time with increasing frequency. Per EP recs, patient started on amiodarone bolus and drip. He continued to have several runs of non-sustained V-tach, and was started on metoprolol tartrate for additional rate control. The amiodarone was later stopped, but the patient was continued on metoprolol. He began having several episodes of a fib/flutter on [**2159-6-7**], without hemodynamic compromise, and his rhythm would spontaneously convert back to normal sinus rhythm. He had an episode of symptomatic bradycardia on [**2159-6-10**], with ECG/telemetry showing retrograde p waves and junctional rhythm, rate 50/min. The patient was subjectively SOB but not hypoxic, and episode was brief. No further episodes of symptomatic bradycardia, but patient should be closely monitored. Of note, patient had episode of a fib/flutter on [**2159-6-10**] for which he received 2.5mg metoprolol IV, with resultant drop in BP and requiring 250cc bolus NS. His CHADS score is 1 and he will receive aspirin for thromboembolic prophylaxis. #) Systolic heart failure: Patient has left ventricular dysfunction likely seconary to his STEMI with an ejection fraction of 30%. His heart failure regimen includes metoprolol, lisinopril, and spironolactone. He was initially managed with lasix but was autodiuresing well, so his lasix was held on [**2159-6-10**]. This will need to be restarted as an outpatient to prevent volume overload. #) Hypotension - On night of presentation s/p cath, patient developed atrial tachycardia with ventricular bradycardia and BP 60-70/40s. He was started on Dopamine for pressure support, and would require ongoing support with several pressors to keep MAP at goal of >65. He was eventually weaned off pressors, however his SBPs generally remained in the 80s-90s. He had some degree of orthostatic hypotension, and his anti-hypertensive and diuretic regimen were adjusted accordingly. Of note, patient's SBP persistently in 80s-90s in days prior to discharge. Patient asymptomatic with SBP in 80s. #) Respiratory Status - Patient sustained multiple facial fractures in the MVA, and required intubation for significant airway swelling. During his CCU course, he was gradually weaned off ventilator support, and he was successfully extubated on [**2159-6-3**]. #) Sinusitis/Fever - During early hospital course, patient was persistently febrile and diaphoretic. In setting of multiple facial fractures, he was started on broad spectrum antibiotic coverage. Per ID, patient was on regimen of vancomycin, aztreonam, cipro, and metronidazole (given penicillin allergy). No clear source of infection was initially identified, although it was felt that patient may have develoepd sinusitis in setting of facial trauma. CT sinus revealed opacification of sinuses, however ENT consult did not feel there was any pus, abscess or fluid collection ammenable to drainage. The patient's antibiotic regimen was tailored back to metronidazole and levofloxacin, for a 14-day course. He had a PICC placed on [**2159-6-4**]. The patient was also placed on standing Tylenol during the time of his persistent fevers. Prior to discharge, the patient was off all antibiotics and remained afebrile. He had 1/4 bottles on blood culture positive for coag negative staph, which was felt to be a contaminant. Repeat blood cultures were negative. #) Facial fractures - Multiple facial fractures noted on CT, including the bilateral nasal bones, bilateral maxillary sinuses (anterior, lateral, posterior and medial walls), the right palatine process of the maxilla and palatine bone, bilateral pterygoid plates, bilateral frontal processes of the maxillae, right lateral orbital wall and right orbital floor. Blood was present in the bilateral maxillary sinuses, ethmoid air cells, sphenoid sinuses and frontal sinuses. The globes appeared intact with no evidence of ocular muscle entrapment. He was seen by trauma surgery, plastic surgery, and ophthomology. Plastic surgery irrigated and sutured facial lacerations in CCU, and ophtho was consulted for periorbital swelling and orbital fx on CT. They did not feel there was evidence of entrapment or intraoccular involvement. #) Asymmetric Pupils - Left pupil noted to be 1-2mm more constricted than the right, and neurology was consulted. Both left and right pupil would constrict to light. Immediate CT scan could not be obtained secondary to patient's hemodynamic instability, but CT head once patient medically stable revealed only a small subdural hematoma. Ophthomology was [**Name (NI) 653**], and felt it was highly unlikely any intraocular pathology was contributing to his asymmetric pupils. #) Delirium/Agitation - Patient developed agitation and delirium later in his hospital course, thought to be ICU-related delirium. He was seen by psychiatry, and started on a regimen of olanazpine and mirtazapine. He also responsed well to additional olanzapine prn agitation. He had some difficulty sleeping, and seemed to respond well to trazadone prn insomnia. Patient will have neuropsych testing in outpatient setting. #) Hyperglycemia - The patient had no previous diagnosis of diabetes, but was persistently hyperglycemic during CCU course, requiring glargine and an insulin sliding scale. HbA1c was 6.0. He did not tolerate metformin, and was briefly started on glyburide. However he had some lower blood sugars in the 60s on glyburide, and this medication was stopped. He will need close monitoring of his blood sugar levels following discharge. #) FEN - The patient was started on tube feeds via OG tube while he was intubated. His diet was advanced following his extubation, and he was tolerating a cardiac healthy regular diet at time of discharge. Medications on Admission: Glucosamine HCl 1500mg w/MSM 1500ug B-50 - high energy complex Prilosec 20mg daily Omega 3 fish oil Vitamin E 400 IU Potassium gluconate 550mg MVI daily Simvastatin 20mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**11-18**] PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 9. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for Dyspepsia. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for Dyspepsia. 16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 17. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2) Drop Ophthalmic QID (4 times a day) as needed for dry eyes. 18. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic HS (at bedtime) as needed for dry eyes. 19. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 56223**] Discharge Diagnosis: Acute ST-elevation myocardial infarction Acute systolic heart failure Status post motorcycle accident Facial fractures Gastroesophageal reflux disease Discharge Condition: Good. Able to ambulate with walker. Mental status alert and oriented to person, place, and time Discharge Instructions: You were admitted because you had a heart attack and motorcycle accident. You required cardiac catheterization, mechanical ventilation, and initiation of heart medications to reduce your risk of having future heart attacks. You were also found to have heart failure. Please take all of your medications as prescribed. Please attend all of your follow-up appointments. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Eat a heart-healthy and low sodium diet. This is important because of your heart failure. Followup Instructions: Cardiology: [**Hospital1 18**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD E/SH-446C [**2159-6-29**] 10:40 AM ([**Telephone/Fax (1) 2037**] Neuropsychology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PHD Date/Time:[**2159-6-12**] 9:00 [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] Phone:[**Telephone/Fax (1) 1690**] Ophthalmology: Plesae call [**Telephone/Fax (1) 24169**] to schedule an appointment at [**Hospital1 18**] or follow-up with your local opthalmologist

Admission Date: [**2180-11-12**] Discharge Date: [**2180-11-15**] Date of Birth: [**2126-3-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Transferred from [**Hospital3 **] with GI bleed, and obstructive jaundice Major Surgical or Invasive Procedure: ERCP History of Present Illness: 54yo m w/hx metastatic [**Hospital3 499**] ca s/p colectomy, chemo/XRT, cholangitis s/p multiple stents, basal cell CA presented to [**Hospital3 **] [**2180-11-10**] after sudden onset maroon colored stool w/clots in ostomy bag. States ostomy bag filled with blood clots but there was no abdominal pain or cramping associated with output. Some lightheadedness, but pt feels that was more related to anxiety over the output vs. blood loss. Pt has been taking ibuprofen prn x2 weeks for low grade fevers. No shortness of breath, no chest pain, no nausea, vomiting. Has not noticed increasing jaundice. Was started on lasix several weeks ago for leg swelling. Abdomen has been distended but has been improving since starting Lasix. At OSH, pt had several episodes of 500-1000ml bloody stools w/clots out of stoma, SBP 90-120, HR 90's, Hct 23, INR 1.5. Given 7U PRBC and 1U FFP, vitamin K 10mg for one dose. Had gastroscopy [**11-11**] which showed no evidence of bleeding. Colonoscopy was also done on [**11-12**] that showed bleeding only near site of stoma, and some ? changes consistent with ischemic colitis at right transverse [**Month/Year (2) 499**]. His bilirubin has been slowly increasing to max of 22. No fevers documented butstarted on levofloxacin empirically. Today, has only had 150-200cc blood via ostomy bag. Transferred to [**Hospital1 18**] for further management. Upon transfer to [**Name (NI) 153**], pt denies any current complaints. Tolerating clears without any nausea, vomting or abdominal pain. Past Medical History: 1. Metastatic [**Name (NI) **] Cancer: Diagnosed in [**6-1**], treated with colectomy, with adjuvant chemo, XRT from [**Date range (1) 103587**]; second course of chemo ended [**3-1**]. Known meastatic disease. 2. Cholangitis: s/p ERCP, multiple biliary stents, last placed [**10-2**] ([**Doctor Last Name **]) 3. Basal Cell Skin Cancer: Benign. Present since pt in his 20's. Over 100 resections. Social History: Married, retired lawyer. Quit [**Name2 (NI) **] 15 years ago, with 30 years at 1 PPD prior. Prior heavy alchol use, roughly 10 beers/day. Family History: Father with [**Name2 (NI) 499**] cancer, died at 64. No CAD/CVA. Physical Exam: T 98, HR 88 (NSR), BP 103/57, RR 24, O2 99% RA Gen: jaundiced male in NAD, alert, awake and oriented x 3 [**Name2 (NI) 4459**]: MM slightly dry Lungs: R basilar crackles Heart: S1, S2, RRR, no murmurs, rubs, gallops heard Abdomen: distended, slightly firm, NT, NABS; ostomy bag in place with minimal pink-tinged liquid Extrem: 1+ bilat edema Skin: multiple basal cell carcinomas, upper back and R LE with lesions non-bleeding, covered by dressings Pertinent Results: Labs from OSH [**2180-11-10**]: WBC 15.7, Hgb 8.2, Hct 23.6 (b/l 27-34), Plt 352 Pt 14.4/PTT 30.9/INR 1.5 Na 132, K 3.6, Cl 97, CO2 23, BUN 15, Cr 1.3 (0.8), Gluc 121, Ca 8 Alb 1.8, TP 6.2, Tbili 17.0 (was 5 in [**10-2**]), dbili 10.1, APhos 769, ALT 100, AST 158 - Labs from OSH [**2180-11-12**]: WBC 14.1, Hct 32.1, INR 1.26 Na 135, K 3.8, Cl 101, CO2 24, BUN 16, Cr 1.3, Gluc 95 TBili 22, Dbili 14.4, Alk Phos 607, ALT 102, AST 190 - [**Hospital1 18**] labs: [**2180-11-12**] 04:34PM GLUCOSE-88 UREA N-21* CREAT-1.1 SODIUM-136 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-12 [**2180-11-12**] 04:34PM ALT(SGPT)-114* AST(SGOT)-216* LD(LDH)-184 ALK PHOS-736* [**2180-11-12**] 04:34PM ALBUMIN-2.7* CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-1.7 [**2180-11-12**] 04:34PM WBC-13.0* RBC-3.59* HGB-11.6* HCT-32.0* MCV-89 MCH-32.3* MCHC-36.2* RDW-16.2* [**2180-11-12**] 04:34PM NEUTS-88.3* LYMPHS-5.2* MONOS-4.5 EOS-1.5 BASOS-0.4 [**2180-11-12**] 04:34PM ANISOCYT-1+ POIKILOCY-1+ [**2180-11-12**] 04:34PM PLT COUNT-280 [**2180-11-12**] 04:34PM PT-13.4 PTT-25.2 INR(PT)-1.1 Brief Hospital Course: 54yo m w/metastatic colorectal cancer complicated by multiple episodes of ascending cholangitis secondary to tumor obstruction and is s/p several stents who presents with GI bleed and obstructive jaundice. 1. GI Bleed: Patient's HCT remained relatively stable throughout the hospital course, and he was seen by the GI team who decided not to pursue any invasive tests given that he recently had a coloscopy and gastroscopy both of which were negative. He was also seen by the stoma nurse who noted that he had some variceal veins at the edge of his stoma and that could be the cause of his bleed. Recommended some pressure applications during oozing. His HCT remained stable, and he was tolerating po well and so it was decided to hold off on any intervention 2. Obstructive Jaundice: Has had history of multiple cholangitis secondary to obstruction from his metastatic cancer. Patient presented jaundiced but did not have any fevers, and no leukocytosis. Decided to go ahead for ERCP and tolerated the procedure well. During the procedure, they performed a balloon sweep and found some hemobilia and pus in his ducts. It was re-canulated. His LFTs continued to slowly trend down after the procedure. Given the hemobilia, it was thought that his bleed could have been secondary to that. To complete a 7 day course of Levofloxacin. 3. Metastatic colorectal cancer: Known end stage disease and he is currently DNR/DNI. We had introduced the idea of the palliative team consult but patient was not interested but the wife was. Palliative team notified and discussed with wife as per her request. He also has some abdominal distension but we decided to hold off on the Lasix given his rise in Creatinine. 4. Acute Renal Failure: Patient's creatinine has been stable through most of his hospital course but on the day of discharge, it had bumped to 2.0. Unclear etiology but there was a call from the lab about ? anicteric sample. A repeat creatinine was checked and it was found to be 1.5. At that time, his PCP was notified and made aware, and we informed his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] that we were going to have [**Last Name (STitle) 269**] come out and draw his blood on Friday and fax him the results of his Creatinine. Case managers were also notified regarding [**Last Name (STitle) 269**] setup. His Lasix was held during discharge, and we dosed his antibiotics based on his renal clearance. 5. Code: DNR / DNI Medications on Admission: Levoflox 500 daily Ambien 5 qhs Was on lasix prior to admission at OSH Discharge Medications: 1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Primary: 1. Cholangitis 2. GI Bleed Secondary 1. Metastatic Colorectal Cancer Discharge Condition: Fair Discharge Instructions: Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**7-8**] days. Please complete your antibiotic course. Please have your blood drawn by [**Date Range 269**] services on Friday [**11-17**] and results sent to Dr. [**Last Name (STitle) **] Fax # [**Telephone/Fax (1) 103589**] Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2181-1-18**] 3:15

Admission Date: [**2154-2-13**] Discharge Date: [**2154-2-21**] Date of Birth: [**2080-1-25**] Sex: F Service: MEDICINE Allergies: Hayfever Attending:[**First Name3 (LF) 2290**] Chief Complaint: CC: SOB/cough Reason for MICU admission: hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 74 year-old female with hx of COPD on home oxygen, asthma, dCHF, diabetes, and remote history of colon cancer who presented to the ED with several days of worsening cough and dsypnea. The patient states she last felt completely well two weeks ago. Two days ago she began to have increasing cough, productive of mucous. Denies blood in the mucous. No fevers, but does admit to some chills at night. Does admit to left-sided rib pain with coughing, but no other chest pain. In terms of her COPD history, she has never required intubation and hasn't received steroids recently. She is on [**3-15**] L of oxygen at baseline. She did not have a flu shot this year. She did have one last year and a pneumovax last year. EMS was called and found her to be satting at 94% on NRB with coarse wheezing throughout her lung fields. She was given 2 albuterol nebs on her way to the ED. In the ED, inital VS: T 100.5 HR 116 BP 133/86 RR 28 Sat 92% on a NRB. CXR was unremakrable. EKG showed sinus tachycardia. On exam she had increased work of breathing. She was placed on a continuous neb x 1 hour, but when she was tried to be spaced out to combivent nebs/nasal cannula her oxygen sats dropped to the low 80's (82% on 5L NC) so she was placed back on a NRB. She was also given levofloxacin 750 mg IV, 2 gm IV magnesium, and 125 mg IV methyprednisolone. She also got 1 L NS. Per report her lung exam/tachypnea did improve with the nebs given in the ED. Currently she states her breathing is much improved from when she arrived in the ED. She still feels slightly short of breath at rest now. On review of systems she denies abdominal pain, vomiting, diarrhea, new myalgias or arthralgias. She does admit to a HA and slight nausea previously. Past Medical History: - COPD,emphysema-oxygen dependent, O2 2L-4L,former smoker (40yrs)Spirometry with only mild to moderate obstructive defect, FEV1 1.17 (68% predicted) but low DLCO at 38% predicted. - Asthma - OSA on home CPAP - Hypertension - Diastolic CHF and pulmonary hypertension. Last TTE [**12/2151**] with EF >55%, mild RV dilation with preserved function, estimated TR gradient 43-63. - Arrhythmia s/p ablation - DM II - History of rectal cancer s/p chemo, XRT, and s/p transanal excision - Hyperlipidemia - Depression - Anxiety - OA knee s/p Lt TKR and Rt TKR - h/o Shingles [**2151-1-30**] - s/p hysterectomy Social History: She lives with her daughter. [**Name (NI) **] daughter cooks for her and takes care of her. She walks with a cane. She is retired, but had worked in a laundry. Quit smoking 12 years ago. No alcohol or drug use. Family History: Denies a family history of lung disease. Physical Exam: Admission: GEN: Elderly female laying in bed with slightly increased work of breath. HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy RESP: Slight accessory muscle use and increased RR. Diffuse expiratory wheezing present throughout. CV: Regular and slightly tachycardic. No MRG. ABD: +BS, soft, NTND [**Name (NI) **]: no edema, 2+ DP and radial pulses, clubbing present SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength in her upper and lower extremities. Sensation to light touch intact throughout. DISCHARGE: VS: 97.7 132/65 80 24 92% 4L NC GEN: Elderly female reclining, with slightly increased work of breath but in no acute distress. HEENT: PERRL, EOMI, anicteric, MMM, OP without lesions, no supraclavicular or cervical lymphadenopathy RESP: Slight accessory muscle use and increased RR. Diffuse expiratory wheezing present throughout. CV: RRR. S1, loud S2. No murmurs, rubs, gallops. ABD: Protuberant, slightly distended. Midline scar below umbilicus. +BS, soft. Tenderness on deep palpation in LLQ. No massess. No rebound or gaurding. [**Name (NI) **]: WWP, no edema. Clubbing present. Radials, DPs 2+. SKIN: No rashes or abnormal lesions noted on limited skin exam. NEURO: AAOx3. PSYCH: Appropriate with normal affect. Pertinent Results: Admission labs: Na 132 K 4.2 Cl 95 Bicarb 27 BUN 18 Cr 0.8 Glu 242 trop <0.01 BNP 171 WBC 11.2 Hct 37.3 Plt 237 N 79% L 15% M 5.2% E 0.5% PT 14.3 PTT 24.5 INR 1.2 Lactate 2.5 Micro: BCx x 3 - pending EKG: sinus tachycardia. Imaging: CXR: Mild hyperinflation. No acute cardiopulmonary process. No change from previous CXR. TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2153-4-9**], no major change. Brief Hospital Course: TO FOLLOW UP: - prednisone taper - titration of insulin as prednisone weaned off Ms [**Known lastname **] is a 74 yo female with COPD on home oxygen, asthma, dCHF, and DM II who was admitted with cough, dsypnea, and persistent hypoxia consistent with a COPD exacerbation. She was difficult to wean from BIPAP and stayed in the MICU for 7 days while her respiratory function slowly recovered. PNA felt less likely to be contributing, but treated with 5 day course of levofloxacin. Additionally, has diastolic failure and was diursed in a effort to improve her respiratory status. # COPD Flare: Patient is oxygen dependent (2-4L) at baseline, but was persistently hypoxic to the low 80's in the ED on increased oxygen support even after several neb treatments and she was admitted to the MICU on BIPAP. She did not require intubation. Atypical or early PNA felt to be possible and she was treated with 5d of levofloxacin. COPD treated with high dose steroids, tapered to 50mg on discharge, tiotroprium, albuterol nebs, monteleukast, spiriva and fluticasone inh [**Hospital1 **]. She was in the MICU for 7 days with difficulty weaning from BIPAP but called out to floor on HD 7. Legionella negative. She will need her prednisone to be tapered at rehab as she improves. Would do slow taper given significant COPD. # Nausea/vomiting: The day the patient was called out to the MICU, she developed nausea/vomiting overnight on [**2-19**] and had an elevated white count to the 20's on am labs. This resolved with bowel movements and WBC count felt to be [**3-13**] steroids and they trended down to 16 on day of discharge. C. diff was not sent and she was not treated with antibiotics. # Hyponatremia: Na of 132 in the ED. Likely slightly dry on admission. Resolved with IVFs. Likely secondary to hypovolemic hyponatremia. # Diabetes Type II: Patient on metformin and glipizide as an outpatient. These were held while she was acutely ill. Sugars were high on the sliding scale so lantus qam was added and her sliding scale was uptitrated, it is attached to this summary. As she weans off steroids, will likely need insulin titrated. # Chronic dCHF/hypertension: Patient has an EF >55% on her last TTE in [**12-17**]. Normal BNP in the ED and no evidence of volume overload on exam or CXR. Mostly normotensive. She was continued on diltiazem and lisinopril was added back as her blood pressure have been stable. TTE reordered due to concern that her respiratory issues may be paritally cardiac which showed no change (EF > 55%). Hctz was added back on [**2-19**]. She is not on a BB as she has no systolic failure. # Hx of arrhythmia s/p ablation: She was continued on Diltiazem 180 mg po daily which was uptitrated to 260 mg daily. # Depression/anxiety: She was continued on Fluoxetine 40 mg po daily. # GERD: She was continued on Omeprazole 20 mg po daily. # Hyperlipidemia: She was continued on Simvastatin 40 mg po qhs # HCP: [**Name (NI) **] daughter, [**Name (NI) **] [**Name (NI) 22771**] cell [**Telephone/Fax (1) 93966**], home [**Telephone/Fax (1) 93964**] # Code: Full code, confirmed with the patient. Medications on Admission: (per OMR) Albuterol nebs prn Albuterol inhaler 90 mcg q6h prn Diltiazem 180 mg po daily Fluoxetine 40 mg po daily Advair 500 mcg-50mcg 1 puff [**Hospital1 **] Glipizide 5 mg po daily Hydrochlorothiazide 12.5 mg po daily Xopenex inhaler 45 mcg 2 pufss qid prn Lisinopril 20 mg po daily Lorazepam 0.5 mg po qhs prn Metformin 500 mg po bid Montelukast 10 mg po daily Omeprazole 20 mg po daily Simvastatin 40 mg po qhs Spiriva 18 mcg inh daily Calcium 500+D Colace Loratadine 10 mg po daily prn Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day): hold for loose stool. . 3. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**2-10**] nebs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: Two (2) puffs Inhalation [**Hospital1 **] (2 times a day). 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 20. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H (every 2 hours) as needed for constipation. 21. insulin glargine 100 unit/mL Cartridge Sig: Twelve (12) units Subcutaneous qam. 22. insulin lispro 100 unit/mL Cartridge Sig: per attached sliding scale Subcutaneous qachs. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital **] Center at [**Location (un) 86**] Discharge Diagnosis: COPD flare Constipation Diastolic Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Sating well on 4L NC, which is patient's baseline. Discharge Instructions: You were admitted to the intensive car unit for COPD worsening. You were treated with steroids and BIPAP and did well. We also gave you some medication to get rid of fluid from your lungs as it may have been contributing. You also had some abdominal pain that was likely from constipation and it resolved with a bowel movement. You will continue on prednisone for your COPD and it will be tapered down as you get better. It was a pleasure meeting you and participating in your care. Followup Instructions: Department: MEDICAL SPECIALATIES When: FRIDAY [**2154-3-1**] at 10:20 AM With: DR [**Last Name (STitle) 93967**]/DR [**First Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2154-3-18**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2193-5-3**] Discharge Date: [**2193-5-15**] Date of Birth: [**2145-4-30**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 898**] Chief Complaint: Seizure and fever Major Surgical or Invasive Procedure: Intubation Right internal jugular central venous line Arterial Line History of Present Illness: This is a 48 year old male with mental retardation, history of seizure disorder (unknown etiology, absence type, last [**12-6**]) who came to medical attention after having a generalized seizure at his group home. After his seizure he was taken to OSH, where VS 103.4, HR 119, BP 68/32 resolving to 102/67 without intervention, RR 24, O2 Sat 94% on 1.5 L nasal cannula. He was lethargic with diffuse "maculopapular blanching" rash. He was also noted to be in acute kidney injury with Cr 2.1 with a WBC count of 8.3 (with 20% bands). INR was 3.6 (pt on chronic warfarin for history of DVT *2) and UA, CXR, and CT head were without acute process. He received ceftriaxone 2gm, gentamicin 120mg, and fosphenytoin 1000 mg. As he had what appeared consistent with a drug rash and was recently started on treatment for cellulitis with TMP/Sulf he was also presumptively treated for anyphylactic shock with IM epineprhine, IVF, methylprednisolone, diphenhydramine, and famotidine. He was then started on dopamine gtt and transferred to [**Hospital1 18**] for further management. Upon arrival to [**Hospital1 18**], VS: T 98.9, P 112, BP 126/44, RR 21, O2 92% on 100% non-rebreather mask. He was quickly weaned off dopamine. At that point exam was notable for delirium/agitation, diffuse erythematous macular rash, edema, and oral mucosal irritation on the tongue and hard palate with conjunctival injection. He received 2-3L LR for hypotension with CVP in ~14-17 range. Because he was persistently agitated he received 2mg lorazepam and 2 mg haloperidol with resulting sedation then progressive hypoxia requiring intubation. REVIEW OF SYSTEMS: Unobtainable as patient initially unresponsive and then without enough mental status to report. His mother denied any changes in bowel or bladder habits, known fevers or chills prior to the day of presentation, complaints of chest pain, labored breathing, or other complaints. Past Medical History: -Seizure Disorder (last seizure [**12-6**]) -Deep Vein Thromboses *2 without history of pulmonary embolism -Lower extremity cellulitis (started on TMP-Sulfa [**Date range (1) 83313**]) -Mental Retardation -Obsessive Compulsive Disorder -Hypothyroidism -Urosepsis with hospitalization at [**Hospital3 **] in [**2191**]. Social History: He lives at a group home. No known smoking, alcohol, drugs. Family History: Non-contributory Physical Exam: Vitals: T 98.9, P 112, BP 126/44, RR 21, O2 Sat 92%NRB -> 88%RA. General: agitated, delerious, non-communicative. HEENT: oropharynx with dark, ?ulceration on hard palate, trauma over toungue. Neck: supple, no LAD Lungs: roncherous bilaterally (airway sounds) anteriorly. CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses. Skin: diffuse, confluent, erythematous macules over arms, legs, abdomen, lower extremities, sparing palms, and soles. +blanching. Pertinent Results: LABORATORY RESULTS =================== On Presentation: WBC-9.8 RBC-4.05* Hgb-11.8* Hct-36.3* MCV-90 RDW-14.3 Plt Ct-146* ---Neuts-93.0* Lymphs-4.1 Monos-2.6 Eos-0.3 Baso-0.1 PT-47.3* PTT-38.8* INR(PT)-5.3* Na 143, K 4.5, Cl 110*, HCO3 22, BUN 16, Cr 1.5*, Glu 196* ALT-34 AST-38 LD(LDH)-245 CK(CPK)-1116* AlkPhos-102 TotBili-0.5 Albumin-3.2* Calcium-6.9* Phos-3.7 Mg-1.2* UricAcd-9.0* Serum Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 Eos-NEGATIVE --Tox bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG On Discharge: WBC 5.2, Hb 11.1, Hct 32.5, Plt 459* PT 45.1, PTT 42, INR 4.8 na 144, K 3.7, Cl 108, HCO3 30, BUN 7, Cr 0.5, Glu 95 Ca 9.2, Mg 2.3, P 3.5 Other Studies: CEREBROSPINAL FLUID (CSF) WBC-13 RBC-373* Polys-7 Lymphs-57 Monos-0 Macroph-36 TotProt-97* Glucose-74 (HSV PCR Negative for HSV 1 and 2) MICROBIOLOGY ============= All cultures no growth to date OTHER RESULTS ============== ECG [**2193-5-3**]: Sinus tachycardia. RSR' pattern in lead V1. Reverse anterior R wave progression. Clinical correlation is suggested. Non-specific T wave changes. Chest Radiograph [**2193-5-3**]: FINDINGS: Lung volumes are low and there is elevation of the right hemidiaphragm. There are bilateral infiltrates throughout both lungs central greater than peripheral, it is difficult to assess the cardiac and mediastinal silhouettes secondary to the low lung volumes and overlying infiltrates. There is a left subclavian line with tip in the SVC. EEG [**2193-5-7**]: IMPRESSION: This is an abnormal portable EEG due to the slow and disorganized background. This abnormality is suggestive of a widespread encephalopathy of medication, metabolic disturbance, or infection etiology. Of note is the sinus tachycardia. There were no lateralized or epileptiform features seen. Chest Radiograph [**2193-5-10**]: IMPRESSION: AP chest compared to [**5-8**]: Consolidation in the perihilar right lung and infrahilar left lung has improved consistent with resolving pneumonia. There is no good evidence for edema. Heart size is top normal, mediastinal vasculature hard to assess, pulmonary vessels are minimally engorged. No pneumothorax or pleural effusion. Trasnthoracic Echocardiogram [**2193-5-14**]: Conclusions The left atrium is normal in size. The interatrial septum is not well visualized (suboptimal views). Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is borderline dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: 48 year old male with past medical history of mental retardation, seizure disorder and DVT* 2 who presented with a seizure and mental status changes and was found to have seizure. 1)Meningitis: The patient presented with a seizure, a fever to 103.4, and altered mental status. He was unable to answer questions about localizing symptoms. Meningitis was initially suspected due to skin rash, though this was more maculopapular than petechial in nature. On the first day of his hospitalization he received vancomycin/ceftriaxone/and acyclovir, which would be appropriate empiric treatment of a non-specified meningitis/encephalitis. Unfortunately, due to difficulties with obtaining an LP, this was not performed until hospital day three and showed pleiocytosis and increased protein but was ultimately culture negative. Ultimately, this was thought most consistent with partially treated bacterial meningitis. Therefore, the patient was treated with vancomycin/ceftriaxone with resolution of his fevers and improvement of his mental status to baseline without further seizures. Acyclovir was stopped when HSV PCR returned negative. The patient will ultimately need to complete fourteen days of antibiotic therapy for meningitis. 2) Seizure: The patient has a previous history of seizures and has been on phenytoin. His previous seizures have not been grand mal, but this appears to have been the type that occurred on the day of presentation. The likely precipitant of this seizure was the patient's infection and fever, though phenytoin level was also a bit low. Initially, he was maintained on IV phenytoin then fospheynytoin but then transitioned back to his outpatient PO regimen as mental status resolved. He never showed signs of further seizure activity and EEG obtained to rule out further seizure activity was not consistent with persistent epileptiform activity. 3) ? Allergic Reaction/Respiratory Failure: The patient had a presentation of rash, hypotension, and per report swelling of the throat and tongue. This could be consistent with acute allergic reaction and the TMP/Sulfa he had been given for cellulitis is certainly a potential causative [**Doctor Last Name 360**]. Still, it seems unlikely he would react suddenly and this remarkably to TMP/Sulfa after he had been receiving it for a full day. Nevertheless, he was treated appropriately for an anaphylactic reaction with epinephrine, histamine blocker, and steroids and recovered. 4) Respiratory failure: As stated before it is difficult to tell if the patient actually had anaphylactic shock leading to airway compromise and respiratory failure. Other possible etiologies would include pulmonary edema given need for vigorous fluid resuscitation soon after presentation and oversedation in the emergency departments. Ultimately, the patient was weaned off supplementary oxygen without event. 5) Altered mental status: Per the patient's mother at baseline he has the mental status of a small child with minimal verbal communication skills but he follows commands and interacts appropriately. The patient was initially extremely somonolent and then minimally responsive raising concern for non-convulsive status epilepticus. EEG was more consistent with encephalopathy, however, and the patient's mental status eventually resolved to baseline with treatment of his underlying condition and maximization of other variables. Likely this was due to toxic-metabolic delirium in the context of severe infection. 6) History of DVT: The patient has a history of two DVT's and thus is presumably on lifelong anticoagulation. His INR was initially supratherapeutic so further anticoagulation was held then he was transitioned to low molecular weight heparin for systemic anticoagulation while he was NPO. Once he was eating, warfarin was restarted and LMWH was stopped after 24 hours of therapeutic INR on coumadin. 7) Non sustained ventricular tachycardia: On the morning of [**2193-5-13**] the patient had two brief runs of NSVT that broke without further management. This was discussed with EP who thought barring signs of structural heart disease that this likely had no prognostic significance and was likely simply a response to acute illness. The patient had an echocardiogram that was within normal limits and he had no further episodes of VT. Of note this also happened while he was being phenytoin loaded, which may have contributed to arrythmia. 8) FEN: The patient initially required tube feeds due to altered mental status and lack of inclination to eat. He self discontinued his dobhoff unfortunately and due to a desire to spare another invasive process if possible he was observed and thankfully had cleared enough to tolerate PO in around forty eight hours. After that he tolerated a full diet with out incident. He tolerated a full diet prior to discharge. All vital signs were stable and he was afebrile>72 hours. The patient was full code. Medications on Admission: - atenolol 25mg po qdaily - neurontin 600mg po tid - risperdal 0.5mg po qdaily + qhs - ativan prn - dilantin 200mg po bid - levothyroxine 250 mcg po qdaily - warfarin 4.5 mg po qdaily - buspirone 30 mg po qdaily - ranitidine 150mg po qdaily - sertraline 250-mg po qdaily - clonidine 0.1mg po bid - tylenol - keopectate - peridex oral rinse - robitussin - mvi Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO twice a day: once daily and once QHS. 4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for anxiety. 5. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO twice a day. 6. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO once a day. 7. Buspirone 30 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sertraline 100 mg Tablet Sig: 2.5 Tablets PO once a day. 10. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: Two (2) gm Intravenous Q12H (every 12 hours) for 2 days: Continue two more days after discharge. through [**2193-5-17**]. 12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every eight (8) hours for 2 days: Continue for two more days after discharge. Through [**2193-5-17**]. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for temp>101 or pain. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please start on [**2193-5-16**]. Please note that the patient's previous home dose was 4.5 mg daily. His dose is decreased for INR [**1-1**] for prophylaxis of DVT. 18. Outpatient Lab Work coumadin PRN to goal INR is [**1-1**] Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Primary Diagnoses -Meningitis -Seizure disorder -History of DVT -Acute Kidney Injury Secondary Diagnoses: -Hypothyroidism Discharge Condition: Good, mentating at baseline, afebrile Discharge Instructions: You were admitted because you had an infection that precipitated a seizure. We treated you for this infection with antibiotics and you improved. Your medications have have been changed. You will have to continue your antibiotics for 2 more days after discharge (for a total of 14 days of therapy). Otherwise your medications have not been changed. Please see your doctor or come in to your local emergency department if you have fevers, chills, night sweats, chest pain, shortness of breath, inability to tolerate food or drink, or any other concerning changes in your health. Followup Instructions: You are being discharged to a facility to complete your recovery. After you are discharged you should schedule follow up appointments with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as well as your neurologist and other providers.

Admission Date: [**2126-3-22**] Discharge Date: [**2126-4-6**] Date of Birth: [**2065-5-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8404**] Chief Complaint: COPD; s/p fall Major Surgical or Invasive Procedure: EGD endotracheal intubation mechanical ventilation central intravenous line placement arterial line placement History of Present Illness: Mr [**Known lastname **] is a 60 M w/ end-stage COPD on home O2, CHF and 3 prior suicide attempts who presents to [**Hospital1 18**] ED s/p witnessed mechanical fall down one entire flight of stairs after tripping over his O2 tubing. Per wife and 14 year old son, he was found with empty bottles of anti-hypertensives and anti-epileptic medications including proprolol, gabapentin and mirtazipine that were prescribed to a friend. [**Name (NI) **] had been slurring his words and walking hunched over all day yesterday after having been out at night for 3 hours without telling his wife where he was going. Upon his return, he fell down the stairs after tripping over his O2 tubing. Per wife who subsequently called 911, he did not lose consciousness and was able to ask for a tissue prior to arrival of EMS. He presented to the ED A&Ox1-2 MAE and following commands. On initial trauma exam, there was no spinal tenderness and good rectal tone without gross blood. During his ED course, the pt rapidly deteriorated from a respiratory standpoint and required intubation to maintain SaO2 > 80s. Pt was a difficult intubation and aspirated thick olivey liquid in the field, for which he was treated with CTX/Flagyl. (He had a heavy dinner consisting of mashed potatoes, meatloaf, a scone and ice cream). . CT head/C-spine/torso shwoed injuries c/w C4 pedicle fx, T12/L1 compression fxs and T12 spinous process fractures. He also has R clavicular fx and R pareital subgaleal hematoma as well as multiple skin and soft tissue injuries Neurosurgery was consulted for evaluation of spinal injuries and recommended C-spine immobilization w/ logroll precautions in place, order for TLSO brace and MRI C& L-spine w/n 48h to assess ligamentous injury. . VS prior to xfer: Afebrile, 118 114/85 24 92% on 450/24/100/14peep . In [**Name (NI) 10115**] pt is intubated and sedated, not following commands as on propofol but [**Name8 (MD) **] RN was awake and answering questions appropriately before propofol bolus was given. Per patient's wife who is in the process of getting divorced from him, he has had multiple suicide attempts in the past and this was one of them. His 1st 2 prior attempts were narcotics overdoses and his 3rd was antifreeze ingestion. He apparantly has been having suicidal ideation since [**2124-10-3**] but exhibited markedly worsened depressive behaviour over the past few weeks when he lost his job and filed for bankruptcy. Per wife, they recently had a meting with their attorney to declare bankruptcy and sell their house. His wife then told him she wanted to get separated and they recently looked at rooms for him to move into. She believes this may have precipitated his recent suicide attempt. . All other ROS otherwise negative Past Medical History: -COPD -CHF -dementia -depression Social History: Used to work at the State House for the [**Location (un) **] of [**State 350**]. Now unemployed, sleeps [**1-19**] h/day. lives at home w/ wife [**Name (NI) **] to whom he has been married for the past 20 years, and rheir 14 y/o son [**Name (NI) 43984**]. Also has 2 children from previous marriage, ages 30 and 32, has 6 month old grand-daughter. +smoking history, heavy EtOH and prescription narcotic abuse in the past. Past suicide attempts. Family History: Non-contributory Physical Exam: ADMISSION EXAM: VS: afebrile, 107 110/78 24 94% on AC settings GEN: intubated, sedated, currently not following commands in the setting of having received propofol bolus HEENT: C-collar in place, pt has multiple scattered facial excoriations and ecchhymoses, pupils constricted but reactive b/l CV: tachycardic rate, no murmurs appreciated LUNGS: anteriorly ABD: +BS obese soft ND GU: multiple scattered violaceous scrotal petechiae EXT: L-olecranon process ecchymoses and skin breakdown with fresh blood, R-olecranon process ecchymoses SKIN: R-hip/buttocks area large ecchymoses w/ some skin breakdown NEURO: intubated, sedated, not following commands . DISCHARGE EXAM: patient was made Comfort Measures Only and expired Pertinent Results: ADMISSION LABS: [**2126-3-22**] 02:25AM BLOOD WBC-21.1* RBC-4.68 Hgb-15.5 Hct-46.6 MCV-100* MCH-33.0* MCHC-33.2 RDW-13.6 Plt Ct-226 [**2126-3-22**] 02:25AM BLOOD Neuts-57.9 Lymphs-37.5 Monos-3.1 Eos-0.7 Baso-0.8 [**2126-3-22**] 02:25AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0 [**2126-3-22**] 02:25AM BLOOD Glucose-138* UreaN-38* Creat-2.4* Na-142 K-4.5 Cl-97 HCO3-35* AnGap-15 [**2126-3-22**] 02:25AM BLOOD ALT-20 AST-32 AlkPhos-131* TotBili-0.2 [**2126-3-22**] 09:08AM BLOOD Albumin-4.2 Calcium-9.0 Phos-4.2 Mg-2.3 [**2126-3-22**] 09:53AM BLOOD Lactate-1.1 . DISCHARGE LABS: patient expired ................................................................ MICROBIOLOGY: c diff positive ................................................................ IMAGING: [**2126-3-22**] CXR: The lungs are low in volume and show bilateral interstitial opacities. The cardiac silhouette is enlarged. The mediastinal silhouette and hilar contours are normal. No pleural effusions are present. . [**2126-3-22**] CT Head w/o con: Right subgaleal vertex hematoma. No intracranial hemorrhage. . [**2126-3-22**] CT C-Spine w/o con: 1. Left left superior articular facet fracture at C4. 2. A small amount of air noted along the PLL at C5 is likely related to degenerative disc disease. There are disc osteophyte complexes at C4/5 and C6/7. 3. Retrolisthesis of C4 on C5. . [**2126-3-22**] CT Chest/Abd/Pelvis w/o con: 1. Compression fractures of the T12 and L1 vertebral bodies and fracture of the T12 spinous process as described above. 2. Fracture of the right distal clavicle (features are consistent with a chronic finding). 3. Ground-glass opacities in the right upper and middle lobes and atelectasis and consolidation in right lower lobe could represent sequelae of aspiration or pneumonia. However, given the history of trauma, pulmonary hemorrhage cannot be excluded. . [**2126-3-23**] TTE: The left ventricle is not well seen. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Very suboptimal image quality due to patient's body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. No significant valvular abnormality seen. . [**2126-3-23**] MRI Spine: 1. Mild to moderate compressions of the superior endplate of T12 and L1 without retropulsion or spinal stenosis. 2. Multilevel degenerative changes. Moderate spinal stenosis seen at L4-5 level and mild-to-moderate spinal stenosis seen at L3-4 level. Bilateral spondylolysis of L5 with grade 1 spondylolisthesis of L5 over S1 and foraminal narrowing. . [**2126-3-28**] RUE U/S: 1. Superficial thrombophlebitis involving the right cephalic vein. 2. No evidence of deep venous thrombosis within the right subclavian, axillary, or brachial veins. Brief Hospital Course: 60M w/ COPD, CHF, s/p mechanical fall down a flight of stairs w/ multiple spinous fx, subgaleal hematoma, and difficult intubation for respiratory failure c/b aspiration event. . # RESPIRATORY FAILURE/ASPIRATION: Patient haS primarily hypercarbic respiratory failure w/ primary respiratory acidosis as pH 7.22 PCO2 83 PO2 136 but this is also oxygenation failure as ABG was on 100% FiO2 so indicates high A-a gradient. Patient has end-stage COPD and likely has PCO2 in the 60s. Acute precipitant of respiratory failure is likely toxic ingestion superimposed on underlying severe lung disease. Upon DL for intubation, gross food particles evident in airway, thick olive paste secretions from NG. Marked leukocytosis at 27.3. He was started on ceftriaxone and flagyl for his presumed aspiration pneumonia. Sputum cultures grew out GPCs, so he was started on vancomycin and flagyl was discontinued. He eventually was switched to vancomycin and cefepime, he eventually concluded a 7 day course. Unfortunately, he developed ARDS and could not be successfully weaned down on any of his ventilator settings. A family meeting was held, and the decision was made to make the patient comfort measures only (he was originally DNR, but not DNI). He was terminally extubated and expired on [**2126-4-6**] at 4:15pm. The medical examiner accepted the case for review. . # FEVERS: His temperature started to spike on HD #2. His antiobiotics were broadened and he was repeatedly pan-cultured. With these, he was found to have c diff + stool. He was treated with oral vancomycin and iv flagyl. He continued to periodically spike fevers during the course of his stay, in spite of treatment with antibiotics. As above he was eventually made CMO and terminally extubated. . # SPINAL TRAUMA: T12 and L1 compression fractures with fracture of the T12 spinous process as well as Left pedicle fracture at C4 w/ retrolisthesis of C4 on C5. Neurosurgery evalutated the patient, but no surgical intervention. [**Location (un) 2848**] J collar applied and TLSO brace were applied whenever he was >30. . # ATRIAL FIBRILLATION: He has episodes of atrial fibrillation with RVR during his hospital stay which were generally well controlled with diltiazem. . # ATTEMPTED SUICIDE: Unclear what medications the patient took and if it clearly was a suicide attempt. U tox was negative. Patient does have history of multiple past suicide attempts and he has been increasingly depressed recently. Intent was to set him up with psychiatry, social work, however patient was made CMO and expired. . # HYPERKALEMIA: He was newly hyperkalemic upon presentation at 6.2, likely secondary to acute kidney injury. An EKG was done w/no evidence of cardiac dysfunction. This resolved with resuscitation. . The patient was maintained on a ppi for Gi prophylaxis, pneumoboots and subcutaneous heparin while he was in the hospital. He was given tube feedings for nutrition. Eventually, the decision was made by his health care proxy and his entire family after an extensive family meeting to make the patient comfort measures only. He was terminally extubated, made comfortable with scopolamine and fentanyl. He expired on [**2126-4-6**] at 4:15pm. The medical examiner was contact[**Name (NI) **] given that the death involved a trauma and a possible suicide attempt. The ME accepted the case for review. Medications on Admission: amlodipine 10mg daily lasix 40mg daily lexapro 20mg daily metoprolol 50mg daily lamotrigine 100mg [**Hospital1 **] ventolin inhaler symbicort inhaler spiriva inhaler Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: hypoxia, respiratory failure, chronic obstructive pulmonary disease, status post fall Discharge Condition: Expired Discharge Instructions: not applicable Followup Instructions: not applicable [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]

Admission Date: [**2111-3-15**] Discharge Date: [**2111-3-22**] Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female with a history of restrictive lung disease, diastolic congestive heart failure, atrial fibrillation, obstructive sleep apnea who developed upper respiratory symptoms two days prior to admission. Mildly productive cough. No fevers, chills. No pain. No shortness of breath. No nausea, vomiting. No dysuria. No pharyngitis. No stiff neck. No headache. Had apparently been lethargic for approximately three days. On day of admission patient's daughter spoke with her on the phone and noticed her to be extremely lethargic and falling asleep while on the phone speaking with her. Patient's daughter called 9-1-1 and emergency medical services found patient oriented times three with oxygen saturations of 50% on room air. In the Emergency Department patient's O2 sats were 84% on 6 liters nonrebreather mask. Chest x-ray revealed a right lower lobe infiltrate. Was given Albuterol nebulizers times two, Solu-Medrol 125 times one, Rocephin 1 gram intravenously times one, and Clindamycin 600 mg intravenously times one, and subsequently transferred to the Medical Intensive Care Unit for noninvasive ventilation. In the Medical Intensive Care Unit patient was placed on continuous positive air pressure for improved oxygenation and CO2 exchange. Was treated with Azithromycin and Ceftriaxone for the pneumonia. She was additionally given Albuterol and Atrovent inhalers to improve pulmonary function and given Lasix for diuresis as patient was mildly overloaded on chest x-ray. Code was discussed and was made "Do Not Resuscitate"/ "Do Not Intubate." It was subsequently called out to the floor. PAST MEDICAL HISTORY: 1. Restrictive lung disease. 2. Pulmonary function tests in [**12/2110**]: FVC of 0.75, 38% of predicted; FEV1 0.55, 46% of predicted; FEV1/FVC 73, 120% of predicted. 3. Congestive heart failure: Reported diastolic dysfunction. Echo [**4-/2109**]: Left atrium mildly dilated, some left ventricular hypertrophy, left ejection fraction more than 55%, right ventricle dilated, no signs of aortic stenosis, mild 1+ mitral regurgitation, moderate pulmonary hypertension, trace pericardial effusion. 4. Atrial fibrillation. 5. Hypertension. 6. Obstructive sleep apnea. 7. Lacunar infarcts. 8. Spinal stenosis. 9. Grave's disease. 10. Hypothyroidism. 11. Right breast cancer status post XRT. 12. Cerebrovascular accident in [**2101**] with left eye visual disturbance. 13. Left cataract surgery. 14. Total abdominal hysterectomy secondary to fibroids. 15. Cholecystectomy. 16. PFO. 17. Scoliosis. SOCIAL HISTORY: Patient is a widow, has two children, and lives with daughter. Denies alcohol. 100-pack-year history of tobacco. Worked as a bookkeeper in past. FAMILY HISTORY: Three siblings who died of heart attacks. Father died of CVA. Mother died in her 60s of hypertension and renal dysfunction. MEDICATIONS AT HOME: 1. Colace. 2. Coumadin 5 mg alternating with 7.5 mg by mouth every other day. 3. Salmeterol. 4. Diltiazem 30 mg by mouth twice per day. 5. Furosemide as needed. 6. Nifedipine 30 mg p.o. in the evening. 7. Folic acid 1 mg q. day. 8. Multivitamin one q. day. 9. Levothyroxine 100 mcg q. day. 10. Aspirin. 11. Isosorbide dinitrate 20 mg t.i.d. PHYSICAL EXAMINATION: Vital signs: Temperature 97.6, pulse of 76, blood pressure 136/54, respirations 21, satting 89% on 4 liters nasal cannula. General: Very irritable and difficult, elderly, disheveled female; not compliant with exam. EENT: Extraocular movements intact; pupils equal and reactive to light; dentures appreciated; mucous membranes moist. Jugular venous distention approximately 7 to 8 cm. Neck: Supple without masses or thyromegaly; no lymphadenopathy appreciated. Cardiovascular: Regular rate and rhythm; laterally displaced point of maximal impulse; prominent S1 greater than S2; no murmurs, rubs, or gallops. Pulmonary: Bibasilar crackles and wheezes diffusely throughout lung fields; breath sounds decreased at bases bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended; no hepatosplenomegaly, masses, or bruits. Extremities: No clubbing, cyanosis, or edema; 2+ dorsalis pedal and posterior tibial pulses bilaterally. Skin: Multiple skin tags and actinic keratoses on the back; no rashes or bruises. Neuro: Motor [**6-3**] in all extremities. Sensation generally intact to light touch. Reflexes, patellar, and brachioradialis 1+ bilaterally. Cranial nerves II-XII grossly intact. LABORATORY STUDIES ON ADMISSION: ABG 7.29/83/95 on CPAP. Chem-7: Sodium 141, potassium 4.1, chloride 105, bicarbonate 27, BUN 30, creatinine 0.9, glucose 152, white blood count of 8.3, hematocrit of 36, platelets of 152, INR 2.3, troponin of 0.07. Urinalysis within normal limits. A chest x-ray showed a right lower lobe infiltrate with cardiomegaly. Chest x-ray done on [**2111-3-15**] showed right lower lobe pneumonia, mild cardiac failure, left pleural effusion. Chest x-ray on [**2111-3-16**] showed slight improvement in right lower lobe consolidation, improving left retrocardiac opacity, and slight decrease in left pleural effusion. Chest x-ray on [**2111-3-17**] showed progression of right upper lobe opacity; stable right lower lobe and left lower lobe consolidation; improving left pleural effusion; persistent uppers on vascular redistribution. CONCISE SUMMARY OF HOSPITAL COURSE: 1. Hypercarbic respiratory failure: Ms. [**Known lastname 32729**] was admitted directly to the Medical Intensive Care Unit for management of her hypercarbic respiratory failure with noninvasive ventilation. She is a chronic CO2 retainer ranging from 50s to 110s on her CO2. Serial arterial blood gases were checked to monitor her progress. On her initial presentation her Chem-7 and ABG were consistent with her respiratory acidosis without metabolic compensation and with hypoxia. No anion gap. She was started on Solu-Medrol 100 mg t.i.d., then changed to Prednisone 60 mg q. day upon discharge to the floor. The patient was initially improving on BiPAP as noted on ABGs. However, she did not tolerate BIPAP and refused to continue with it. An agreement was made between patient and team to keep face mask and nasal cannula during the periods that she was off the BiPAP. She did so through the remainder of her MICU stay. She was started on antibiotics in the MICU for treatment of her pneumonia. They used Rocephin and Azithromycin to treat her community-acquired pneumonia. It is very likely that this development of pneumonia may have been the cause of her hypercarbic respiratory failure. In addition, patient was noted to be somewhat volume overloaded on subsequent exams in the MICU and was also noted to have some congestion on chest x-ray. She was started on Lasix 20 mg intravenously b.i.d. in the MICU to assist with diuresis and resolution of her pulmonary edema. Patient was then transferred to the floor and she continued to refuse the BiPAP and CPAP assistance. Patient additionally refused any other antibiotic medications on the last day of her MICU stay as she was called out to the floor. That was hospital day five. Team, nursing, and Attending had a meeting to the patient to address her refusal of oxygen and medication management. Patient was convinced to keep oxygen at 2 liters throughout the remainder of her stay and also agreed to continue taking her medications to improve her pneumonia. Repeat chest x-rays showed improvement of pneumonia and some of her pulmonary congestion. Whenever patient was off the oxygen patient would have episodes of agitation and confusion. Prior to her discharge patient's mentation sensorium was improved, pneumonia was under treatment, and volume overload was significantly improved. 2. Diastolic dysfunction: Patient was noted to be in pulmonary edema and was volume overloaded on exam with an elevated jugulovenous pressure on subsequent exams in the MICU. Patient was started on 20 mg intravenous Lasix b.i.d. until euvolemic. Euvolemia was assessed by measuring her JVP, serial weights, and monitoring daily input and output. Patient was euvolemic prior to discharge. 3. Right lower lobe pneumonia: Patient was treated for community-acquired pneumonia with Azithromycin and Rocephin. On hospital day five of admission patient refused two to three doses of her antibiotics likely secondary to confusion, agitation because patient had been off oxygen for quite some time. Meeting was held with patient, team, Attending, and nurse to convince her to comply with treatment goals. She agreed to continue taking her medications and keeping the oxygen on thanks to Dr.[**Name (NI) 9920**] persuasion. Pneumonia was under treatment prior to discharge. Repeat chest x-rays showed improvement in the pneumonia. 4. History of atrial fibrillation: Patient was continued on Diltiazem throughout the remainder of her hospital course. She was in normal sinus throughout hospital stay. The patient was continued on Coumadin with INR goal of 2 to 2.5. Patient was taken off Coumadin on hospital day three to hospital day five because was noted to have a supertherapeutic INR. Coumadin was reinstituted two days prior to discharge and was discharged on a therapeutic INR. 5. Obstructive sleep apnea: CPAP was attempted; however, patient refused to have it on. CPAP was not well tolerated by patient and did not have it on throughout the remainder of her hospital course. Agreed to have two liter nasal cannula on at all times. 6. Endocrine: Hypothyroidism: Patient was continued on her outpatient dose of Synthroid. Hyperglycemia: The patient was placed on regular insulin sliding scale during the time that she was on steroids. Steroids were stopped by patient on hospital day five, not allowing for a taper. Ultimately, her regular sliding scale was discontinued two days prior to discharge since good blood glucose levels were within normal range. 7. Code: Long discussion held with patient and daughter by Dr. [**Last Name (STitle) **]. Patient agreed to be "Do Not Resuscitate"/"Do Not Intubate" and being made comfortable when sick. However, she did not sign Comfort Measures Only form and was reluctant to discuss this further with [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**]. The discussion was to arranged with Dr. [**Last Name (STitle) **] on subsequent office visits. She is, however, DNR/DNI. 8. Acute renal failure: Patient was noted to be in acute renal failure during her MICU course. However, when discharged to the floor patient's renal failure had resolved. Her peak creatinine was 1.3 and her creatinine prior to discharge was 1.0. DISCHARGE CONDITION: Fair. DISPOSITION: To home with VNA services; discussions to be held on subsequent visits with Dr. [**Last Name (STitle) **] regarding Hospice care. DISCHARGE DIAGNOSES: 1. Hypercarbic respiratory failure. 2. Pneumonia. 3. Alkalemia. 4. Thrombocytopenia. 5. Hypertension. 6. Hypothyroidism. 7. Diastolic heart failure. 8. Obstructive sleep apnea. 9. Restrictive lung disease. 10. Acute renal failure. DISCHARGE MEDICATIONS: 1. Fluticasone. 2. Salmeterol 250 to 50 mcg, one puff b.i.d. 3. Diltiazem 30 mg tablets, one tablet p.o. b.i.d. 4. Furosemide 50 mg tablet, one tablet p.o. q. day. 5. Nifedipine 30 mg tablet, Sustained Release, one tablet p.o. q. h.s. 6. Aspirin 81 mg tablet, one tablet p.o. q.d. 7. Folic acid 1 mg tablet, one tablet p.o. q. day. 8. Synthroid 100 mcg tablet, one tablet, p.o. q. day. 9. Multivitamin, one capsule q. day. 10. Colace 100 mg, one capsule p.o. b.i.d. 11. Isosorbide dinitrate 10 mg, one tablet p.o. t.i.d. 12. Levofloxacin 250 mg tablets, one tablet p.o. q. 24 times five days. DISCHARGE INSTRUCTIONS: 1. Patient to follow up with Dr. [**Last Name (STitle) **] in one to two weeks. Patient will call to schedule an appointment ([**Telephone/Fax (1) 102295**]). 2. Patient to follow up at the Clinical Center Radiology to have her mammography done on [**2111-11-16**] at 10 a.m. She is to call [**Telephone/Fax (1) 327**]. [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**] Dictated By:[**Last Name (NamePattern1) 9622**] MEDQUIST36 D: [**2111-5-23**] 15:17 T: [**2111-5-23**] 21:36 JOB#: [**Job Number 102296**]

Admission Date: [**2162-3-29**] Discharge Date: [**2162-4-19**] Date of Birth: [**2075-12-17**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. Intubation and mechanical ventilation. 2. Placement of 2 pleurex catheters History of Present Illness: 86F history of DM2, HTN, HLD, cardiac problem, transferred from [**Name (NI) **]. Pt presented with one month of breathing difficulty, weight loss, cough, decreased apetite getting progressively worse over time. Family trie to bring pt in earlier but she refused to go to hospital. Last night pt became acute more SOB and family called ambulance and pt brought to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At [**Hospital1 **] found to have WBC 44, HR 170's in A fib, lactate=4; concern for possible malignant process and ? PE. Got dilt 30mg PO and 10mg IV for HR, which improved. Also got 4L IVF. LENI showed R DVT. Got head CT which showed nothing acute. Deferred CTA chest due to elevated Cr (Cr 1.8). Started on heparin gtt for DVT and concern for PE. Got azithro and ceftriaxone at [**Hospital1 **]. During transport pt developed worsened rales/crackles possibly secondary to 4 L IVF given. . In the [**Hospital1 18**] ED, initial VS were: 65, RR 32, 128/59, 97% 15L NRB. ECG showed AFib with RVR. Patient was started on a nitro gtt, heparin gtt, given vancomycin/zosyn, and placed on BiPAP for resp distress which didnt tolerate. Labs were notable for a lactate of 8.5, WBC count 49.3, INR 1.6 and Cr of 1.8. CXR: air fluid level abscess in lung. Patient was initially trialed on BiPAP, did not tolerate, and thus was intubated (straight forward intubation). Placed R IJ. CVP=13. Lactate rose to 10 and concern for gut ischemia. CTA chest and torso: No PE, revealed multiple abscess in L lung- Rim enhancing fluid collection. Multiple hypodensisities in kidney and liver suggestive of embolic infectious process. in ED given: Vanco, zosyn, flagyl. Thoracics consult: Poor surgical candidate. Recc drainage per IR right now. K=6-->insulin/D50, Kayexlate. Gave 1 UPRBC for elevated lactate. ED attempted to call family several times to give update, never got through. . On arrival to the MICU, pt is intubated, sedated, on Levo 0.2 and Dopamine 8. Had family meeting with son and 3 grandchildren. Family very tearful, as of now they request FULL code but will continue to discuss goals of care. They report this pt is usualy active at baseline, ambulatory, takes care of her great grandchildren. Past Medical History: Dm2 HTN HLD Cardiac process- seen at [**Hospital 1263**] hospital, family is not sure what process this is. Social History: Lives with son, normally active at baseline and babysits grandchildren. Ambulatory. Rarely admitted to the hospital. No history of smoking or drug use. Family History: no cancers. Physical Exam: Vitals:T 98.1, HR 83, BP 110/51, A fib, 98% on AC FiO2 40, TV 350, F 20, PEEP 5, MV 8.2. IVF in: 6L plus 1 PRBC. UO: 230 in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and 180 in [**Hospital1 18**] ED. General: sedated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: irregular rate, no mrg. Lungs: anterior breath sounds, no crackles, few ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated Pertinent Results: Cytology [**2162-3-29**] NEGATIVE FOR MALIGNANT CELLS. Acellular specimen with bacterial overgrowth; Correlate with microbiology report. ECG Study Date of [**2162-3-29**] 2:29:44 AM The rhythm is regular and most likely a junctional escape rhythm at 60 beats per minute without clear atrial activity. Delayed R wave transition. No previous tracing available for comparison. Possible prior anteroseptal myocardial infarction. CHEST (PORTABLE AP) Study Date of [**2162-3-29**] 2:45 AM FINDINGS: There is extensive opacification of the left hemithorax with an air-fluid level identified superiorly. These findings are representative of a large mass, possibly abscess in a fissure. Less likely would be a large hiatal hernia. There is rightward shift of normally midline structures. Otherwise, the right hemithorax appears clear. No acute fractures are identified. A dedicated chest CT is recommended for further evaluation Portable TTE (Complete) Done [**2162-3-29**] at 12:03:01 PM FINAL The left atrium is elongated. No thrombus/mass is seen in the body of the left atrium. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade CT ABD & PELVIS WITH CONTRAST Study Date of [**2162-3-29**] 3:05 AM IMPRESSION: 1. Multilobulated large left hemithorax pleural empyema with foci of gas noted. Given the foci of gas the differential includes recent instrumentation versus infection with a gas-forming organism versus a bronchopleural fistula. 2. Multiple hypodense areas are also visualized throughout bilateral nonenlarged kidneys. These findings may be representative of multiple cysts but a superinfectious process with multiple abscesses cannot be excluded. 3. Small subsegmental right upper lobe pulmonary emboli. 4. There is mild gallbladder wall edema and mottled apparance of the liver are likely due to congestive hepatopathy. 5. Endotracheal tube with the tip at the level of the carina. Retraction by 2cm is recommended. 6. Bilateral small pleural effusions. 7 . Severe cardiomegaly. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2162-3-29**] 3:05 AM IMPRESSION: 1. Multilobulated large left hemithorax pleural empyema with foci of gas noted. Given the foci of gas the differential includes recent instrumentation versus infection with a gas-forming organism versus a bronchopleural fistula. 2. Multiple hypodense areas are also visualized throughout bilateral nonenlarged kidneys. These findings may be representative of multiple cysts but a superinfectious process with multiple abscesses cannot be excluded. 3. Small subsegmental right upper lobe pulmonary emboli. 4. There is mild gallbladder wall edema and mottled apparance of the liver are likely due to congestive hepatopathy. 5. Endotracheal tube with the tip at the level of the carina. Retraction by 2cm is recommended. 6. Bilateral small pleural effusions. 7 . Severe cardiomegaly. Multiple CXR performed, representative reads shown. CHEST (PORTABLE AP) Study Date of [**2162-3-31**] 2:17 AM FINDINGS: The left pigtail catheter is unchanged in position. The right IJ and ET tubes terminate in the standard position. The NG tube terminates outside the field of view. Compared to [**3-30**], there are increasing bilateral pleural effusions, pulmonary vascular congestion, and parenchymal opacities suggesting developing pulmonary edema. Cardiomegaly is unchanged. Tere is no pneumothorax. Findings were discussed by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) **] by phone at 11:45 a.m. on [**2162-3-31**]. CT CHEST W/O CONTRAST Study Date of [**2162-3-31**] 9:08 AM IMPRESSION: Interval resolution of a dominant gas/fluid collection within the left hemithorax, and near-resolution of an adjacent medial collection. There remains a loculated posterior collection that does not appear tocommunicate with the catheter. 2. Adjacent severe left lower lobe atelectasis with a consolidative component. Slightly enlarged small right pleural effusion. Trace pericardial effusion. New moderate anasarca. Increased caliber of the main pulmonary artery likely reflects chronic pulmonary hypertension. . CT Torso [**4-4**] IMPRESSION: 1. Reaccumulation of left sided localized hydropneumothorax s/p pigtail catheter removal. 2. Bilateral peribronchial ground glass opacity and patchy opacities which are a non-specific finding. 3. Slight decrease in size of right pleural effusion. 4. Stable increased diameter of the main pulmonary artery likely due to pulmonary hypertension. 5. Persistent non-mobile 1.3cm filling defect within the left main bronchus which is suspicious for polyp, neoplasm or mucus plug. . CT Chest [**4-6**] IMPRESSION: 1. Mid-esophageal soft tissue mass severly narrows and may invade left main bronchus. 2. Interval placement of a second left lower lung drain with interval decrease in size of the air and fluid collection. Persistent left lower lung consolidation is either pneumonia or atelectasis. 3. Markedly enlarged right atrium. 4. Thinning of the renal cortices with hyperdensity which could represent retained contrast or nephrocalcinosis. . ECHO [**4-6**] The left atrium is elongated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. with borderline normal free wall function. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. An eccentric, posteriorly directed jet of mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. Compared with the prior study (images reviewed) of [**2162-3-29**], the degree of TR and pulmonary hypertension have increased. .. INDICATIONS: 86-year-old female with esophageal cancer, lung empyema and ischemic right foot. Bilateral lower extremity ABIs, Doppler waveforms, and PVRs were performed at rest. FINDINGS: RIGHT: The right ABI is 0.65 at DP. There is no signal present at PT. Doppler waveforms are biphasic to the level of the popliteal artery. Posterior tibial waveform is absent. The dorsalis pedis waveform is monophasic. PVRs are artifactually diminished proximally and aphasic at the metatarsal level suggesting severe tibial disease. The left ABI is 0.61 at DP. The PT waveform is absent. Left-sided Doppler waveforms are triphasic at the popliteal level and monophasic at the dorsalis pedis. PVRs show significant dropoff between calf and ankle and again between ankle and metatarsal level suggesting severe tibial occlusive disease. IMPRESSION: ABIs are likely falsely elevated. Based on Doppler waveforms and PVRs, there is severe tibial disease bilaterally. . COMPARISON: CT [**4-4**] and [**2162-4-6**]. TECHNIQUE: MDCT data were acquired through the chest without intravenous contrast. Images were displayed in multiple planes. FINDINGS: There are two pigtail catheters at the left lung base. A small-to-moderate effusion layers posteriorly. There is no large air-fluid collection in communication with the anterior or posterior drain. Moderate left basilar atelectasis and/or consolidation is unchanged. A moderate right effusion is slightly larger. No new consolidation, nodule, or pneumothorax is present. Since the prior exam, an esophageal catheter has been removed. The boundaries of a large mid esophageal mass are hard to delineate without contrast. The lesion measures approximately 1.9 x 3.4 cm (2:20). Since the preceding exam five days ago, the left main bronchus has become completely effaced (2:20) by a combination of mass effect from the thickened esophagus, and bronchial secretions. There are extensive secretions in the distal left lower lobe segmental bronchus at (2:25). A tracheo-esophageal connection is not directly visualized but would not be suprising given the appearence. The non-contrast appearance of the heart and great vessels shows cardiomegaly, massive right atrial enlargment, and minimal aortic arch calcification. The tip of a right subclavian line terminates in the low SVC. The thyroid has normal attenuation. No mesenteric, hilar or axillary adenopathy is present. There is residual renal excretion of contrast from [**3-29**]. There are peripheral hyperdense foci in the visualized portions of both kidneys. Previously, the cortices of both kidneys were uniformly hyperdense. Residual oral contrast is seen in nondistended loops of large bowel. BONES AND SOFT TISSUES: There are no concerning lytic or sclerotic lesions. Bilateral lower old rib fractures. There is diffuse soft tissue edema. IMPRESSION: 1. Large mid esophageal soft tissue mass with now complete opacification of the left main bronchus either by invasion, hemorrhage, and/or secretions. Persistent post-obstructive left lower lobe consolidation and bronchial secretions. 2. Improving small-to-moderate left pleural effusion. No large collection at the site of two pigtail catheters. 3. Increasing moderate right effusion. 4. Stable right atrial enlargement. Final Report CHEST RADIOGRAPH INDICATION: Query pneumothorax, 86-year-old woman with large esophageal neoplasm extending into the left mainstem. TECHNIQUE: Portable upright chest view was read in comparison with multiple prior radiographs with the most recent from [**2162-4-13**]. FINDINGS: Lower lung opacity due to a combination of effusion and atelectasis now involves the entire left hemithorax suggestive of an increased large left pleural effusion. Two pleural pigtail catheters in the left lower hemithorax are unchanged in position. Increase in the left pleural effusion. There has not been much change in the position of the mediastinum probably due to associated left lung volume loss. Moderate right pleural effusion and right basilar atelectasis is similar. Upper lung is clear. IMPRESSION: Left pleural effusion has progressed over last two days. Two left pleural pigtail catheters are in unchanged position and moderate right pleural effusion and bibasilar atelectasis is unchanged. The study and the report were reviewed by the staff radiologist. Microbiology: [**2162-4-15**] 8:12 pm URINE Source: Catheter. **FINAL REPORT [**2162-4-16**]** URINE CULTURE (Final [**2162-4-16**]): NO GROWTH. [**2162-4-5**] 6:36 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [**2162-4-5**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2162-4-8**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2162-4-11**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2162-4-6**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2162-3-29**] 4:40 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES Site: PLEURAL **FINAL REPORT [**2162-4-2**]** Fluid Culture in Bottles (Final [**2162-4-2**]): GRAM NEGATIVE ROD(S). REFER TO SPECIME # 343-4776A [**2162-3-29**]. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SENSITIVITIES PERFORMED ON CULTURE # 343-4776A [**2162-3-29**]. GRAM POSITIVE RODS. REFER TO SPECIMEN # 343-4776A [**2162-3-29**]. Anaerobic Bottle Gram Stain (Final [**2162-3-29**]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI IN PAIRS AND CHAINS. GRAM POSITIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27395**] ON [**2162-3-29**] @ 740 PM. Aerobic Bottle Gram Stain (Final [**2162-3-29**]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI IN PAIRS AND CHAINS. GRAM POSITIVE ROD(S). [**2162-3-29**] 3:30 am BLOOD CULTURE # 2. **FINAL REPORT [**2162-4-4**]** Blood Culture, Routine (Final [**2162-4-4**]): NO GROWTH. [**2162-4-16**] 04:08AM BLOOD WBC-11.3* RBC-3.46* Hgb-10.0* Hct-33.9* MCV-98 MCH-28.9 MCHC-29.6* RDW-22.8* Plt Ct-270 [**2162-4-15**] 03:04AM BLOOD WBC-11.2* RBC-3.57* Hgb-10.2* Hct-34.7* MCV-97 MCH-28.5 MCHC-29.3* RDW-22.6* Plt Ct-286 [**2162-4-14**] 05:06AM BLOOD WBC-8.9 RBC-3.28* Hgb-9.3* Hct-33.9* MCV-103* MCH-28.3 MCHC-27.3* RDW-23.0* Plt Ct-262 [**2162-4-12**] 03:03PM BLOOD WBC-10.5 RBC-3.60* Hgb-10.1* Hct-33.0* MCV-91 MCH-28.1 MCHC-30.7* RDW-22.6* Plt Ct-304 [**2162-4-12**] 06:00AM BLOOD WBC-10.4 RBC-3.71* Hgb-10.6* Hct-34.8* MCV-94 MCH-28.5 MCHC-30.4* RDW-23.1* Plt Ct-299 [**2162-4-10**] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292 [**2162-4-11**] 03:42AM BLOOD WBC-11.6* RBC-3.78* Hgb-10.4* Hct-34.4* MCV-91 MCH-27.4 MCHC-30.1* RDW-22.6* Plt Ct-305 [**2162-4-10**] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292 [**2162-4-9**] 02:57AM BLOOD WBC-14.2* RBC-3.62* Hgb-10.1* Hct-33.7* MCV-93 MCH-28.0 MCHC-30.1* RDW-23.5* Plt Ct-265 [**2162-4-8**] 03:48AM BLOOD WBC-20.4* RBC-3.62* Hgb-10.3* Hct-32.8* MCV-91 MCH-28.5 MCHC-31.4 RDW-22.2* Plt Ct-247 [**2162-4-7**] 02:27AM BLOOD WBC-22.8* RBC-3.41* Hgb-9.6* Hct-30.1* MCV-88 MCH-28.1 MCHC-31.8 RDW-19.8* Plt Ct-226 [**2162-4-6**] 02:20AM BLOOD WBC-23.5* RBC-3.86* Hgb-10.9* Hct-35.7* MCV-93 MCH-28.2 MCHC-30.5* RDW-19.6* Plt Ct-206 [**2162-4-5**] 01:57AM BLOOD WBC-20.3* RBC-3.76* Hgb-10.6* Hct-34.2* MCV-91 MCH-28.1 MCHC-30.9* RDW-19.2* Plt Ct-180 [**2162-4-4**] 03:04AM BLOOD WBC-22.3* RBC-3.85* Hgb-10.7* Hct-34.7* MCV-90 MCH-27.7 MCHC-30.7* RDW-18.6* Plt Ct-165 [**2162-4-3**] 02:56AM BLOOD WBC-27.4* RBC-3.94* Hgb-11.4* Hct-35.6* MCV-90 MCH-29.0 MCHC-32.1 RDW-17.7* Plt Ct-175 [**2162-4-2**] 03:22AM BLOOD WBC-24.2* RBC-4.21 Hgb-11.7* Hct-38.3 MCV-91 MCH-27.8 MCHC-30.5* RDW-17.4* Plt Ct-204 [**2162-4-1**] 03:34AM BLOOD WBC-24.2* RBC-3.99* Hgb-11.2* Hct-35.4* MCV-89 MCH-28.2 MCHC-31.8 RDW-17.6* Plt Ct-212 [**2162-3-31**] 01:10PM BLOOD WBC-27.0* RBC-4.15* Hgb-11.4* Hct-37.2 MCV-90 MCH-27.4 MCHC-30.6* RDW-16.8* Plt Ct-310 [**2162-3-31**] 04:24AM BLOOD WBC-24.9* RBC-3.96* Hgb-11.0* Hct-34.9* MCV-88 MCH-27.8 MCHC-31.6 RDW-17.2* Plt Ct-264 [**2162-3-30**] 11:17PM BLOOD WBC-23.3* RBC-3.85* Hgb-10.3* Hct-33.1* MCV-86 MCH-26.8* MCHC-31.2 RDW-16.3* Plt Ct-288 [**2162-3-30**] 07:07PM BLOOD WBC-28.8* RBC-3.31* Hgb-9.3* Hct-28.8* MCV-87 MCH-28.0 MCHC-32.3 RDW-16.0* Plt Ct-408 [**2162-3-29**] 11:58PM BLOOD WBC-36.1* RBC-4.10* Hgb-11.0* Hct-36.1 MCV-88 MCH-26.7* MCHC-30.3* RDW-15.9* Plt Ct-425 [**2162-3-29**] 01:37PM BLOOD WBC-48.5* RBC-3.99* Hgb-10.5* Hct-35.7* MCV-90 MCH-26.3* MCHC-29.3* RDW-15.4 Plt Ct-541* [**2162-3-29**] 10:41AM BLOOD WBC-46.5* RBC-3.79* Hgb-9.8* Hct-34.3* MCV-91 MCH-25.9* MCHC-28.6* RDW-15.0 Plt Ct-501* [**2162-3-29**] 08:20AM BLOOD WBC-44.7* RBC-3.74* Hgb-9.9* Hct-34.6* MCV-93 MCH-26.5* MCHC-28.7* RDW-15.0 Plt Ct-514* [**2162-3-29**] 02:45AM BLOOD WBC-49.3* RBC-3.71* Hgb-9.7* Hct-33.7* MCV-91 MCH-26.2* MCHC-28.8* RDW-15.2 Plt Ct-589* [**2162-3-29**] 02:45AM BLOOD Neuts-85* Bands-3 Lymphs-4* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2162-3-29**] 08:20AM BLOOD Neuts-95.9* Lymphs-2.5* Monos-1.2* Eos-0 Baso-0.4 [**2162-4-1**] 03:34AM BLOOD Neuts-90.9* Lymphs-8.1* Monos-0.5* Eos-0.2 Baso-0.2 [**2162-4-2**] 03:22AM BLOOD Neuts-93.0* Lymphs-5.2* Monos-1.0* Eos-0.2 Baso-0.6 [**2162-4-16**] 04:08AM BLOOD PT-15.7* PTT-103.7* INR(PT)-1.5* [**2162-4-15**] 03:04AM BLOOD PT-14.4* PTT-33.5 INR(PT)-1.3* [**2162-4-14**] 05:06AM BLOOD PT-15.4* PTT-150* INR(PT)-1.4* [**2162-4-6**] 02:20AM BLOOD PT-14.4* PTT-87.4* INR(PT)-1.3* [**2162-4-1**] 09:30PM BLOOD PT-12.8* PTT-103* INR(PT)-1.2* [**2162-4-1**] 05:10PM BLOOD PT-12.6* PTT-150* INR(PT)-1.2* [**2162-3-29**] 01:37PM BLOOD PT-18.0* PTT-28.7 INR(PT)-1.7* [**2162-4-16**] 04:08AM BLOOD Glucose-115* UreaN-32* Creat-1.4* Na-141 K-4.3 Cl-113* HCO3-25 AnGap-7* [**2162-4-15**] 03:04AM BLOOD Glucose-228* UreaN-33* Creat-1.4* Na-143 K-4.1 Cl-114* HCO3-25 AnGap-8 [**2162-4-14**] 09:52AM BLOOD Glucose-145* UreaN-34* Creat-1.5* Na-145 K-3.4 Cl-115* HCO3-24 AnGap-9 [**2162-4-14**] 05:06AM BLOOD Glucose-826* UreaN-30* Creat-1.5* Na-133 K-6.5* Cl-105 HCO3-21* AnGap-14 [**2162-4-10**] 02:59PM BLOOD Creat-1.8* Na-146* K-3.8 Cl-114* HCO3-22 AnGap-14 [**2162-4-9**] 02:57AM BLOOD Glucose-119* UreaN-54* Creat-2.2* Na-146* K-3.6 Cl-114* HCO3-24 AnGap-12 [**2162-4-8**] 03:48AM BLOOD Glucose-201* UreaN-61* Creat-2.6* Na-143 K-4.1 Cl-114* HCO3-20* AnGap-13 [**2162-4-6**] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139 K-4.2 Cl-106 HCO3-20* AnGap-17 [**2162-4-6**] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139 K-4.2 Cl-106 HCO3-20* AnGap-17 [**2162-4-5**] 01:57AM BLOOD Glucose-182* UreaN-51* Creat-2.7* Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 [**2162-4-2**] 03:22AM BLOOD Glucose-146* UreaN-43* Creat-1.9* Na-143 K-3.4 Cl-113* HCO3-19* AnGap-14 [**2162-3-31**] 04:24AM BLOOD Glucose-208* UreaN-48* Creat-1.7* Na-139 K-3.5 Cl-111* HCO3-16* AnGap-16 [**2162-3-29**] 10:41AM BLOOD Glucose-128* UreaN-56* Creat-1.7* Na-142 K-4.8 Cl-112* HCO3-15* AnGap-20 [**2162-3-29**] 02:45AM BLOOD Glucose-141* UreaN-60* Creat-1.8* Na-138 K-6.5* Cl-109* HCO3-13* AnGap-23* [**2162-4-13**] 05:32AM BLOOD ALT-12 AST-16 AlkPhos-73 TotBili-0.5 [**2162-4-12**] 03:03PM BLOOD ALT-15 AST-18 LD(LDH)-261* Amylase-129* [**2162-4-1**] 03:34AM BLOOD ALT-88* AST-76* LD(LDH)-246 AlkPhos-201* TotBili-0.8 [**2162-3-31**] 04:24AM BLOOD ALT-119* AST-206* LD(LDH)-320* AlkPhos-116* TotBili-0.8 [**2162-3-29**] 10:41AM BLOOD ALT-111* AST-600* LD(LDH)-1689* AlkPhos-119* TotBili-0.6 [**2162-4-12**] 03:03PM BLOOD CK-MB-4 cTropnT-0.04* [**2162-3-29**] 01:37PM BLOOD CK-MB-4 cTropnT-0.04* [**2162-3-29**] 10:41AM BLOOD CK-MB-4 cTropnT-0.03* [**2162-3-29**] 08:20AM BLOOD cTropnT-0.03* [**2162-3-29**] 02:45AM BLOOD cTropnT-0.04* [**2162-4-16**] 04:08AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0 [**2162-4-15**] 03:04AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0 [**2162-3-29**] 02:45AM BLOOD Albumin-2.3* [**2162-3-29**] 08:20AM BLOOD Calcium-7.0* Phos-6.6* Mg-2.1 [**2162-3-29**] 10:41AM BLOOD Albumin-1.8* Calcium-6.9* Phos-5.1* Mg-1.9 [**2162-3-29**] 01:37PM BLOOD Calcium-7.4* Phos-5.2* Mg-2.1 UricAcd-10.6* [**2162-3-29**] 01:37PM BLOOD Hapto-326* [**2162-3-30**] 10:02AM BLOOD Vanco-9.5* [**2162-3-31**] 06:04PM BLOOD Vanco-15.4 [**2162-4-1**] 07:07PM BLOOD Vanco-20.5* [**2162-4-2**] 08:10AM BLOOD Vanco-18.5 [**2162-4-8**] 05:43AM BLOOD Vanco-22.8* [**2162-4-9**] 05:57AM BLOOD Vanco-20.4* [**2162-4-12**] 06:00AM BLOOD Vanco-18.9 [**2162-4-13**] 05:32AM BLOOD Vanco-24.9* [**2162-3-29**] 02:58AM BLOOD Lactate-8.5* K-6.5* [**2162-3-29**] 04:44AM BLOOD Glucose-124* Lactate-9.6* K-6.2* [**2162-3-29**] 04:53AM BLOOD Lactate-9.3* [**2162-3-29**] 06:22AM BLOOD Lactate-9.6* [**2162-3-29**] 08:48AM BLOOD Glucose-205* Lactate-7.0* Na-139 K-5.4* Cl-113* calHCO3-13* [**2162-3-29**] 11:12AM BLOOD Lactate-4.7* [**2162-3-29**] 11:53PM BLOOD Lactate-2.9* [**2162-3-30**] 12:27PM BLOOD Lactate-2.7* [**2162-3-31**] 12:52AM BLOOD Lactate-2.2* [**2162-3-31**] 09:16AM BLOOD Lactate-2.7* [**2162-3-31**] 04:23PM BLOOD Lactate-2.4* [**2162-3-31**] 06:14PM BLOOD Lactate-2.1* [**2162-4-1**] 03:17PM BLOOD Lactate-1.7 [**2162-4-2**] 03:37AM BLOOD Lactate-1.5 [**2162-4-4**] 04:17AM BLOOD Lactate-2.1* [**2162-4-6**] 02:28AM BLOOD Lactate-3.8* [**2162-4-6**] 10:01AM BLOOD Lactate-5.4* [**2162-4-6**] 02:18PM BLOOD Lactate-4.4* [**2162-4-14**] 10:33AM BLOOD Lactate-1.7 [**2162-4-5**] 06:36PM PLEURAL WBC-[**Numeric Identifier 110572**]* RBC-[**Numeric Identifier 28746**]* Polys-98* Lymphs-0 Monos-1* Meso-1* [**2162-4-3**] 06:21PM PLEURAL WBC-1700* RBC-800* Polys-75* Lymphs-20* Monos-0 Baso-1* Meso-1* Other-3* [**2162-3-29**] 02:45AM estGFR-Using this Brief Hospital Course: 86 yo F with no known medical problems admitted shortness and breath cough. Hospital course was notable for admission to the ICU where she was found to have lung and renal abscesses, septic shock requiring vasopressor support, DVT and PE, and difficult to control atrial fibrillation. She was also noted to have a large esophageal mass suggestive of esophageal cancer with compression of the left main stem bronchus causing intermittent lung collapse and esophageal compression with dysphagia/aspiration. Patient had a long ICU course and transferred from the floor to the ICU multiple times. Ultimately, given the patient's multiple significant and severe medical problems, age, and progressively declining course despite maximal medical care, a discussion was held with the family and the decision was to transition the patient's care to comfort centered care and the patient passed away [**2162-4-19**] at 2:10AM. #Septic shock/Lung and renal abscesses: Patient presented in septic shock from pneumonia with empyema and was found to have lung and renal abscesses. She required multiple pressors and intubation. Her lactate peaked at 10. CT demonstrated multiple fluid collections as well as an esophageal mass (see below) that was compressing the L mainstem bronchus that was believed to be predisposing to her polymicrobial infection. Interventional pulmonology placed two chest tubes to drain the fluid collections. Gram stain showed GPCs, GNRs and gram positive rods. Cultures only grew strep angionosis. She was initially treated with broad spectrum antibiotics but was weaned down to vancomycin and flagyl per ID recommendations for a planned course of four weeks from the date of her last chest tube placement (day one [**4-5**]). She was weaned off pressors and succesfully extubated. She was treated with vanc/flagyl until she was made CMO on [**2162-4-16**]. #DVT/PE: Patient was found to have DVT on lower extremity ultrasound. CTA showed small subsegmental RLL PE. Patient was placed on heparin gtt. After her goals of care discussion anticoagulation was held on [**2162-4-16**]. #Esophageal Mass, likely esophageal cancer, with bronchial and esophageal obstruction: CT showed large mid esophageal soft tissue mass with now complete opacification of the left main bronchus either by invasion, hemorrhage, and/or secretions. There was persistent post-obstructive left lower lobe consolidation and bronchial secretions and patient did suffer collapse of her left lung. It was believed that this mass was the etiology of her polymicrobial septic shock, as well as persistent pleural effusions and left sided atelectatsis. Secondary to the obstruction of the esophagus and risks for aspiratoin, the patient was made NPO. She did transiently receive TPN, but this was discontinued when care was transitioned to comfort centered care. #Atrial fibrillation: Unclear if patient has history of afib, but this was likely exacerbated or caused by infection/sepsis. There may also have been contribution of irritation by esophageal mass. After hypotension resolved patient was managed on the medical floor with IV betablockers but required transfer back to the ICU for rapid atrial fibrillation and low blood pressures in the 90s. She was subsequently rate controlled with IV amiodarone drip in the ICU and transferred back to the medical floor. After family discussion regarding overall goals of care amiodarone was eventually discontinued. # Acute Renal failure: Creatinine 1.8 with unclear baseline. Her creatinine later increased to a peak of 2.8 which was believed to be ATN from septic shock. Her creatinine trended back down to 1.8. On the floor her creatinine remained at baseline. # Anemia: She required 3 UPRBC in setting of elevated lactate and septic shock. Hct stabilzed in mid 30s. #Goals of care discussion: Throughout hospitalization multiple family meetings/updates were held with multiple providers/teams. Palliative care was involved as were the social work and case management teams. With the patient's age of >80 years and multiple medical problems that continued to progress despite medical care (including IV amiodarone drip, TPN, antibiotics, and IV anticoagulation), the family decided to focus on comfort centered care on [**2162-4-16**]. The patient passed away on [**2162-4-19**] at 2AM. Medications on Admission: None Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: 1. Esophageal neoplasm 2. Septic shock 3. Atrial fibrillation 4. Deep venous thrombosis 5. Pulmonary Emboli 6. Digital necrosis of [**3-8**] metatsarsals 7. Occlusive narrowing of tibial arteries bilaterally 8. Pleural effusions 9. Pulmonary empyema Discharge Condition: expired

Admission Date: [**2188-11-30**] Discharge Date: [**2188-12-3**] Date of Birth: [**2116-12-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2698**] Chief Complaint: sub-sternal chest pain Major Surgical or Invasive Procedure: s/p cardiac cartheterization and bare metal stent on [**2188-11-30**] History of Present Illness: CC: chest pain HPI: 71 year old male with history of CAD s/p CABG '[**88**], GERD and presyncopal spells presented to OSH with 8/10 chest pain radiating to throat with nausea while shoveling snow. Patient also with shorter episodes of chest pain the day prior that spontaneously resolved. He states chest pain episodes have been more frequent in the past fgew weeks, but he could not discern his GERD symptoms which are also substernal from angina. He was found to have inferior ST elevations and transferred to [**Hospital1 18**] for urgent cath. During cath, SVG to R-PDA was moderately degenerated throughout with 40% prox stenosis and 99% stenosis involving anastomosis on PDA, bare metal stent was placed. ROS: no SOB, leg swelling. Past Medical History: s/p CABG [**2176**] BPH GERD syncope s/p appy s/p CCY Social History: Lives at home with wife and cat. Quit tobacco 30 yrs ago, no EtOH or other drug use. Family History: Non-contributory Physical Exam: Gen: AOx3, pleasant, NAD HEENT: anicteric, mucous membranes dry, OP clear CV: Normal S1, S2, RRR Pulm: CTAB-Ant Abd: (+) BS, soft, ND, mild TTP RUQ (baseline) Ext: WWP, no edema 2+ DP b/l. Groin: right groin site with angioseal, dsg intact. Pertinent Results: [**2188-11-30**] 01:44PM GLUCOSE-102 UREA N-19 CREAT-0.7 SODIUM-133 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-12 [**2188-11-30**] 02:34PM HGB-11.5* calcHCT-35 O2 SAT-97 [**2188-11-30**] 02:34PM K+-3.7 [**2188-11-30**] 02:34PM TYPE-ART PO2-155* PCO2-43 PH-7.38 TOTAL CO2-26 BASE XS-0 . EKG: ST elevation II, III, aVF. ST depressions I, aVL. . [**2188-11-30**] 01:44PM BLOOD CK(CPK)-86 CK-MB-4 cTropnT-<0.01 [**2188-11-30**] 09:30PM BLOOD CK(CPK)-403* CK-MB-51* MB Indx-12.7* cTropnT-1.75* [**2188-12-1**] 04:03AM BLOOD CK(CPK)-587* CK-MB-61* MB Indx-10.4* cTropnT-1.73* [**2188-12-1**] 04:53PM BLOOD CK(CPK)-344* CK-MB-40* MB Indx-11.6* cTropnT-1.48* [**2188-12-2**] 06:45AM BLOOD CK(CPK)-154 CK-MB-15* MB Indx-9.7* cTropnT-1.02* . CARDIAC CATHTERIZATION [**Numeric Identifier 65310**] - CCC *** PRELIMINARY *** PROCEDURE DATE: [**2188-11-30**] INDICATIONS FOR CATHETERIZATION: Coronary artery disease, Canadian Heart Class IV, unstable. Prior CABG [**2176**]. Prior PTCA [**2176**]. FINAL DIAGNOSIS: 1. Native three (3) vessel coronary artery disease. 2. Acute inferior ST elevation myocardial infarction. 3. Successful stenting of the SVG to PDA TD. COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated native three (3) vessel coronary artery disease. The left main coronary artery was normal with TIMI III flow throughout. The left anterior descending artery demonstrated a 90% proximal lesion just proximal to the D1 and S2 takeoff. The LAD also had a mid vessel total occlusion proximal to the LIMA - LAD touchdown site. The LCX had a 90% proximal lesion along with a totally occluded OM1. The RCA demonstrated a total mid vessel occlusion with the distal portion of the vessel filling via an SVG-PDA graft. The SVG-RPDA graft demonstrated a 40% ostial lesion along with a 99% touchdown stenosis involving the anastomosis site on the PDA with fresh thrombus. The SVG-D1 graft was toally occluded. The SVG-OM graft was widely patent. The LIMA-LAD graft was widely patent with TIMI III flow throughout. 2. Limited resting hemodynamics demonstrated mildly elevated left sided pressures (PCWP = 18 mm Hg). 3. Elevated Pulmonary artery saturations. ? Shunt Vs hyperdynamic circulation due to atropine induced tachycardia and supplimentary Oxygen therapy. 4. Successful predilation using 2.0 X 15mm Voyager balloon and stenting using 2.0 X 18mm Minivision stent of the SVG to PDA touchdown with lesion reduction from 99% to 0%. the final angiogram showed TIMI III flow with no dissection or embolisation. (see PTCA comments) TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 26 minutes. Arterial time = 1 hour 22 minutes. Fluoro time = 32 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 380 ml Premedications: ASA 325 mg P.O. Heparin gtt Integrellin gtt Clopidogrel 300 mg PO Anesthesia: 1% Lidocaine subq. Cardiac Cath Supplies Used: - [**Name (NI) **], PT [**Name (NI) **], 300CM - CORDIS, WIZDOM SS 300 - [**Name (NI) **], PT [**Name (NI) **], 300CM - [**Name (NI) **], PT [**Name (NI) **], 300CM - [**Name (NI) **], PT [**Name (NI) **], 300CM 2 GUIDANT, VOYAGER 15 6 CORDIS, MP A1 INTRODUCER GUIDE - CORDIS, TRANSIT - [**Company **], ULTRAFUSE X 200CC MALLINCRODT, OPTIRAY 200CC 100CC MALLINCRODT, OPTIRAY 100CC 2.0 GUIDANT, MINI VISION, 18 . Echocardiogram [**2188-12-3**]: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Brief Hospital Course: A/P: 71 year old male with CAD s/p CABG '[**77**] p/w ST elevation MI with bare metal stent to stenosis in SVG-RPDA. . # CV: Ischemia: s/p bare metal stent in SVG-RPDA. cycle cardiac enzymes post MI and cath. Continue ASA, Plavix, Metoprolol titrated up to 25 mg po bid as bp tolerated, ACEI restarted, statin increased to 80 mg. Integrillin was continued until 18 hrs post-cath. Daily EKGs. Pump: checked post-MI Echo with bubble study to evaluate heart function [**2187-12-4**] (results above). Rhythm: NSR, monitored on Telemetry without signficant events. . # GERD: Continued PPI . # FEN: Heart healthy diet, monitored electrolytes and repleted prn. . # Proph: PPI . # Dispo: PT cleared patient to go home, recommended cardiac rehab in 6 weeks. # Appointment with Dr [**Last Name (STitle) 10543**] at [**Hospital3 **] [**Month (only) 404**], Monday 9th/ [**2187**] Fax number [**Telephone/Fax (1) 65311**] Medications on Admission: acebutolol 200 po bid lipitor 40 po qday aricept 5 mg po qday prilosec 40 mg po qday paroxetine 10 mg po qday quinine sulfate qhs quinipril 40 mg po qday Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 90 days. Disp:*90 Tablet(s)* Refills:*2* 3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction GERD Discharge Condition: stable Discharge Instructions: Please call your physician or return to the hospital if you experience chest pain, palpitations, shortness of breath, increased leg swelling, lightheadedness, numbness or weakness. . It is essential that you continue to take all your medications exactly as prescribed. . Please call the hospital tomorrow afternoon at [**Telephone/Fax (1) 3071**] for the results of your echocardiogram. Followup Instructions: You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 10543**] on [**2188-12-8**] at 10:30 a.m. Please call [**Telephone/Fax (1) 4475**] to reschedule if you are unable to keep this appointment. Completed by:[**2188-12-4**]

Admission Date: [**2146-12-22**] Discharge Date: [**2146-12-28**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: ICH s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 89562**] is an 89 year-old right-handed woman with a history of hypertension who was initially evaluated at BIDN following a fall and was transferred to the [**Hospital1 18**] after she was found to have a right thalamic hemorrhage with intraventricular extension. . The patient is high-functioning at baseline. She lives independently. According to the patient's daughter, Ms. [**Known lastname 89562**] was in her usual state of health until at least the day prior to presentation. This morning, there was no answer at the patient's door when the meal service came to deliver food. Emergency services were contact[**Name (NI) **]. The patient was reportedly found on the floor of a bathroom. The patient's daughter shares that prior to transfer to the BIDN, the patient was "groggy" but could identify family members. She was, however, disoriented (eg she thought she was in the living room when she was actually in the bathroom) and was speaking "rag-time." . She was transferred to the BIDN for evaluation. There she was given morphine for head, left shoulder, and left hip pain from the fall. Imaging of the left hip, shoulder, c-spine, facial bones and head was performed. She was transferred to the [**Hospital1 18**] when the non-contrast CT of the head was discovered to show right thalamic hemorrhage. Past Medical History: - hypertension - hypothyroidism - macular degeneration - bilateral cataracts s/p repair Social History: - lives independently - 2 living children - previously worked in a high school cafeteria - avid reader prior to [**First Name8 (NamePattern2) **] [**Last Name (un) **] Family History: - negative for stroke, sz, migraine Physical Exam: NEUROLOGIC EXAMINATION: Mental Status: * Degree of Alertness: Sleeping, arouses to loud voice and tactile stim. States she is in the hospital for a "boo boo on my ear." * Orientation: Oriented to person, birthay (except year), indicates the current year is 1829 * Attention: inttentive. Able to name the days of the week forwards x 3 days * Memory: able to correctly identify day, month of birthdate. * Language: Language is fluent with semantic paraphasic errors and neologisms. Often makes statements that are grammatically correct but completely unrelated to context (eg "what should I get you for your brithday?") Repetition is intact. Comprehension appears intact; pt able to correctly follow midline and appendicular commands. Prosody is normal. Pt unable to name high (pen= "pediwinkle", knuckles = "cars") and low frequency objects (knuckles) without difficulty. * Calculation: Pt able to calculate number of quarters in $1.50 Cranial Nerves: * I: Olfaction not evaluated. * II: Pupils surgical, left slightly more reactive than right. * III, IV, VI: EOMI in horizontal plane * VII: Face grossly symmetric * VIII: Hearing intact to voice * IX, X: Palate difficult to visualuze * XII: Tongue protrudes in midline. Strength: * Left Upper Extremity: less voluntary movement tnan on right, able to grip * Right Upper Extremity: lifts at least versus gravity, offers some resistance to push, pull, grip strong * Left Lower Extremity: moves at least in plane of bed (difficult to further evaluate) * Right Lower Extremity: able to lift versus gravity Sensation: * Intact to tickle in all extremities Neuro exam on discharge/ changes from admit: Alert. Oriented to self and sometimes to hospital. Able to move right side against gravity and able to hold for >5 seconds. On the left her bicep was [**1-21**]. Delt /5 and IP /5 Pertinent Results: [**2146-12-22**] 08:40PM GLUCOSE-171* UREA N-24* CREAT-1.1 SODIUM-140 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [**2146-12-22**] 08:40PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-2.1 [**2146-12-22**] 08:40PM WBC-15.8* RBC-4.57 HGB-13.7 HCT-39.7 MCV-87 MCH-30.0 MCHC-34.5 RDW-13.4 [**2146-12-22**] 08:40PM PLT COUNT-325 [**2146-12-22**] 08:40PM PT-12.2 PTT-23.1 INR(PT)-1.0 CT head [**2146-12-25**] IMPRESSION: No change in the right thalamic hemorrhage extending into the ventricles, with no significant change in ventricular size and shape to suggest developing hydrocephalus. No new hemorrhage. CXR [**2146-12-24**] Lungs are clear. Heart size is normal. There is no pulmonary edema, pleural effusion or pneumothorax b/l Hip XR IMPRESSION: Degenerative changes throughout the imaged field of view as detailed above. No definite traumatic injury of the pelvis or bilateral hips identified. Left Wrist XR IMPRESSION: 1. No definite fractures. 2. Degenerative changes of the thumb CMC and STT joints, as described above. 3. Chondrocalcinosis suggesting CPPD. Brief Hospital Course: [**Known lastname 89562**] was admitted after being found down with AMS. Initial evaluation at [**Hospital1 **] [**Location (un) 620**] revealed a right thalamic bleed so transfer to [**Hospital1 18**] ICU was done. Here she was reevaluated clnically and with CT scan of the head and neck. The bleed was stable and her examination was stable so she was transferred to the floor for further care. On the wards she was stable with occasional events of A-fib with RVR to the 140's responsive to IV Beta Blocker. There were no complications and she was started on heparin SC. Her inital event was thought to be secondary to hypertension. Her blood pressure was within goal but needed some further titration IPH: Secondary to HTN. Stable with IVH extension A-fib with occasional RVR to 140's: responsive to metop 5mg IV. This has occured about once every other day. HTN: Goal less then 160 sytolic: Changed amlodipine to 7.5 mg daily on [**2146-12-28**] Speech and swallow: able to tolerate soft foods with thin liquids. ID: developed fever [**2146-12-28**]. Urine from [**2146-12-24**] grew out Klebsiella P. Sensitive to Ceftriaxone. started on [**2146-12-28**]. Medications on Admission: - toprol XL 200 mg po daily - norvasc 10 mg po daily - synthroid 88 mcg po daily - simvastatin 30 mg po 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 BID (2 times a day). 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain, fever. 7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Metoprolol Tartrate 5 mg IV Q4H:PRN SBP > 160 Hold for HR < 55 10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 11. HydrALAzine 10 mg IV Q6H:PRN SBP > 160 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. amlodipine Oral 15. CeftriaXONE 1 gm IV Q24H Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: New - Right Thalamic IPH - acute delirium Old - Hypothyroid - HTN - Macular degeneration - b/l cateract Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: you were admitted for a right sided thalamic bleed. You had multiple images of your brain completed which revealed a stable bleed. There was no surgical intervention that was done. You had Atrial fibrillation that was controlled most of the time but you required some PRN medications to help with control. You also were found to have a UTI and you were started on antibiotic for this. Followup Instructions: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- Neurology Location: [**Hospital Ward Name 23**] Center Floor 8. Time/Date: [**2-27**] at 3:30 Please call to ensure date/time one week prior. ([**Telephone/Fax (1) 7394**] Completed by:[**2146-12-28**]

Admission Date: [**2160-12-7**] [**Month/Day/Year **] Date: [**2160-12-22**] Date of Birth: [**2114-3-20**] Sex: F Service: MEDICINE Allergies: Methotrexate Attending:[**First Name3 (LF) 3256**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: [**2160-12-7**] endotracheal intubation [**2160-12-7**] femoral central venous catheter placement History of Present Illness: 46F xfer from OSH ([**Hospital3 **]) after being found down by VNA earlier today. Recent hosp admission for UTI, Klebsiella PNA completed antibiotics and discharged home. History is unclear, however [**Location (un) **] reports that she is on the liver transplant list. History of rheumatoid arthritis and ankylosing spondylitis on Florinef. Outside hospital, patient was intubated for her unresponsiveness. Received vancomycin and Zosyn. Also noted to have a left hip dislocation that was reduced in the ER. Hypotensive, requiring norepinephrine after 2 L of IV fluids. Transferred for further care. PH 7.1, CO2 50 with a bicarbonate of 18 on initial ABG. At outside hospital, attempted right and left IJ resulted in subcutaneous fluid extravasation. . In the ED, initial vitals she recieved hydrocortisone 100 mg IV because chronically on florinef and had a right femoral CVL placed. Also, she underwent a CT head which was negative for acute bleed and a CT torso which showed bilateral aspiration versus effusions. Her hip had to be reduced twice, once with vecuronium. . On arrival to the MICU, she was intubated and sedated with initial vital signs 88/69, 120, 14, 100% on AC (volume). . Review of systems not obtained because patient intubated. Past Medical History: h/o Tylenol OD [**10/2159**] and [**5-/2160**] c/b hepatic failure VAP foot necrosis [**2-6**] pressors Bilateral DVT [**1-/2160**] 8mm clean ulcer at prepyloric antrum seen on EGD [**2160-4-15**] (H.Pylori neg) c/b GIB bleed s/p transfusion 4U pRBCs Psychiatric disorder (anxiety vs bipolar) chronic pain h/o domestic abuse Crohn's disease anklyosing spondylitis Long term alcoholism h/o Hep A iron-deficiency anemia Distal ileum resection [**2-/2160**] CCY [**2156**] R hip replacement [**2153**] c/b osteomyelitis L hip replacement [**2156**] also c/b osteomyelitis back/knee surgeries per past notes Social History: Lives in apt in [**Location **] by herself. Not currently in a relationship per case worker, though has h/o domestic violence and had been living in a domestic violence shelter last year. Is divorced but has a positive relationship with her ex-husband. Daughter is 25 y/o and son is 23 y/o. HCP is [**Name (NI) 553**] [**Name (NI) 1968**] (HCP) - ([**Telephone/Fax (1) 80620**] Family History: Father - colitis? (frequent stomach pain) Mother - RA, ankylosing spondylitis Grandmother - ankylosing spondylitis Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.0, BP: 113/67, P: 119, R: 18 O2: 100% on 100% FiO2 General: intubated, sedated HEENT: Sclera anicteric, MMM, pupils fixed and non-reactive Neck: subcutaneous infiltration by saline, unable to assess LAD or JVP CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, no organomegaly GU: foley draining yellow urine Ext: cold, thready pulses, no clubbing, cyanosis or edema. left lower extremity with chronic ulceration [**Telephone/Fax (1) 894**] PHYSICAL EXAM: Vitals: 97.8 150/82 72 18 99%RA General: WDWN female, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: no lymphadenopathy, no JVD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, no organomegaly, right hip with small subcentimeter wound with minimal serous drainage Ext: no clubbing, cyanosis or edema. left lower extremity with chronic ulceration. left hand with erythema and edema from previous PIV, pink granulation tissue (much improved since admission), left hip without swelling or erythema, tender on palpation but pt able to ambulate Skin: several macules on right leg and lower back with central clearing c/w tinea corporis Neuro: A & O x 3, moving all extremities Pertinent Results: ADMISSION LABS: [**2160-12-6**] 11:20PM BLOOD WBC-17.4* RBC-4.27 Hgb-11.5* Hct-38.5 MCV-90 MCH-27.0 MCHC-29.9* RDW-15.0 Plt Ct-248 [**2160-12-6**] 11:20PM BLOOD Neuts-95.2* Lymphs-3.3* Monos-1.4* Eos-0 Baso-0 [**2160-12-6**] 11:20PM BLOOD PT-11.8 PTT-36.0 INR(PT)-1.1 [**2160-12-6**] 11:20PM BLOOD Glucose-65* UreaN-66* Creat-2.2* Na-141 K-4.2 Cl-107 HCO3-14* AnGap-24* [**2160-12-6**] 11:20PM BLOOD ALT-156* AST-430* CK(CPK)-[**Numeric Identifier 34197**]* AlkPhos-132* TotBili-0.3 [**2160-12-6**] 11:20PM BLOOD Lipase-10 [**2160-12-6**] 11:20PM BLOOD cTropnT-<0.01 [**2160-12-6**] 11:20PM BLOOD Calcium-6.7* Phos-7.4* Mg-2.4 [**2160-12-6**] 11:20PM BLOOD Osmolal-314* [**2160-12-6**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-POS [**2160-12-7**] 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17 Intubat-INTUBATED Vent-CONTROLLED [**2160-12-6**] 11:21PM BLOOD Lactate-0.6 [**2160-12-7**] 04:15PM BLOOD freeCa-1.02* . ABG TREND: [**2160-12-7**] 04:50AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 FiO2-50 pO2-78* pCO2-38 pH-7.09* calTCO2-12* Base XS--17 Intubat-INTUBATED Vent-CONTROLLED [**2160-12-7**] 07:12AM BLOOD Type-[**Last Name (un) **] Temp-38.0 Rates-22/0 Tidal V-450 PEEP-5 FiO2-60 pO2-62* pCO2-42 pH-7.21* calTCO2-18* Base XS--10 Intubat-INTUBATED Vent-CONTROLLED [**2160-12-7**] 09:44AM BLOOD Type-ART Temp-38.2 Rates-22/ Tidal V-450 PEEP-10 FiO2-50 pO2-31* pCO2-51* pH-7.20* calTCO2-21 Base XS--9 -ASSIST/CON Intubat-INTUBATED [**2160-12-7**] 12:21PM BLOOD Type-CENTRAL VE Temp-37.2 pO2-170* pCO2-35 pH-7.35 calTCO2-20* Base XS--5 -ASSIST/CON Intubat-INTUBATED Comment-GREEN TOP [**2160-12-8**] 09:44AM BLOOD Type-ART Temp-36.9 Tidal V-500 PEEP-8 FiO2-40 pO2-146* pCO2-40 pH-7.36 calTCO2-24 Base XS--2 Intubat-INTUBATED . [**Month/Day/Year 894**] LABS: [**2160-12-21**] 12:00PM BLOOD WBC-4.8 RBC-3.30* Hgb-9.0* Hct-28.7* MCV-87 MCH-27.3 MCHC-31.4 RDW-16.8* Plt Ct-448* [**2160-12-21**] 12:00PM BLOOD PT-21.7* INR(PT)-2.1* [**2160-12-21**] 12:00PM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-140 K-4.1 Cl-111* HCO3-23 AnGap-10 [**2160-12-16**] 03:42AM BLOOD ALT-38 AST-23 [**2160-12-21**] 12:00PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.5* . URINE: [**2160-12-6**] 11:25PM URINE Color-LtAmb Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2160-12-6**] 11:25PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2160-12-6**] 11:25PM URINE RBC-5* WBC-30* Bacteri-FEW Yeast-NONE Epi-2 [**2160-12-6**] 11:25PM URINE UCG-NEGATIVE [**2160-12-6**] 11:25PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG . MICRO: [**12-6**], 4, 6, 7 BLOOD CULTURES NGTD [**2160-12-7**] 11:00 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2160-12-7**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. HEAVY GROWTH. BETA STREPTOCOCCI, NOT GROUP A. MODERATE GROWTH. Blood Culture, Routine (Final [**2160-12-16**]): NO GROWTH. Blood Culture, Routine (Final [**2160-12-16**]): NO GROWTH. URINE CULTURE (Final [**2160-12-11**]): YEAST. >100,000 ORGANISMS/ML.. Stool Studies: FECAL CULTURE (Final [**2160-12-13**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2160-12-13**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2160-12-12**]): NO OVA AND PARASITES SEEN. FECAL CULTURE - R/O VIBRIO (Final [**2160-12-13**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2160-12-13**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2160-12-12**]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2160-12-12**]): Feces negative for C.difficile toxin A & B by EIA. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2160-12-17**]): Feces negative for C.difficile toxin A & B by EIA. [**2160-12-17**]: C. difficile Toxin PCR Negative . IMAGING: [**12-7**] CT C/A/P: TECHNIQUE: MDCT axial images were obtained from the chest, abdomen and pelvis with the administration of IV contrast. Multiplanar reformats were generated and reviewed. CT OF THE CHEST: Right pleural effusion with adjacent compressive atelectasis. Left base opacification likely represents collapsed left lower lobe which appears airless and filled with higher density material, possibly blood. The patient has a nasogastric tube which passes into the stomach. ETT tube appears approximately 4.7cm above the carina. The visualized heart and pericardium are unremarkable. CT OF THE ABDOMEN AND PELVIS: The intra-[**Month/Day (4) 1676**] vasculature and intra-[**Month/Day (4) 1676**] solid organs are incompletely evaluated in the absence of IV contrast. Within this limitation, the liver, pancreas, and bilateral adrenal glands appear unremarkable. Note is made of splenomegaly. Both kidneys show no evidence of large masses. A non-obstructive 9-mm stone is noted within the lower pole of the left kidney (601B, 32). Small stones are noted within the right kidney. The patient is status post cholecystectomy. Surgical sutures are noted in the RLQ, otherwise, intra-[**Month/Day (4) 1676**] loops of large and small bowel appear unremarkable. There is no free air or free fluid within the abdomen. Retroperitoneal and mesenteric lymph nodes do not meet size criteria for pathologic enlargement. The structures within the pelvis are incompletely evaluated due to the presence of streak artifact due to bilateral total hip replacements. Within this limitation, the patient is status post a Foley catheter. A right femoral vein catheter is identified. A possible rectal catheter is noted. Bilateral hip prosthesis are noted; the right femoral component appears well seated within the acetabular component; however, the left femoral component is not well seated within the left acetabular component. Decrease in vertebral body height of L1 vertebral body is noted with possible retropulsion of fragment into the spinal canal and indentation of the thecal sac. This is of indeterminate chronicity, but likely represents more chronic process with the presence of what looks like kyphoplasty material within L1 vertebral body. Intra-[**Month/Day (4) 1676**] vasculature is not well evaluated in the absence of contrast technique. IMPRESSION: 1. Right pleural effusion with adjacent compressive atelectasis. Left base opacification likely represents collapsed left lower lobe which appears airless and filled with higher density material, possibly blood. 2. Left lower pole renal calculus. 3. Incomplete evaluation of the pelvis due to streak artifact. 4. Left total hip arthroplasty prosthesis shows femoral component is not well seated within the acetabular component. 5. Loss of vertebral body height of L1 vertebral body with possible retropulsion of fragments into the spinal canal; this is of indeterminate chronicity, however, appears to be chronic due to presence of what appears to be kyphoplastic material. . [**12-7**] CT HEAD:TECHNIQUE: Contiguous axial images were obtained through the head without the administration of IV contrast. Multiplanar reformats were generated and reviewed. There is no evidence of acute fracture or traumatic dislocation. Bilateral mastoid air cells are clear. Minimal mucosal thickening is noted within bilateral maxillary sinuses. There is no evidence of acute intracranial hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. [**Doctor Last Name **]-white matter differentiation is preserved with no evidence of large acute major vascular territory infarction. IMPRESSION: No acute intracranial pathological process. ADDENDUM AT ATTENDING REVIEW: There is marked anterior rotation of the odontoid process relative to a thickened appearance of the body of C2. The finding likely represents a fracture/subluxation deformity. There is resultant prominent central canal narrowing at this level. There is no prevertebral soft tissue swelling at this locale. It is possible that the finding represents a prior, healed fracture, but clearly this question must be resolved, through either obtaining prior records/imaging studies immediately, and/or subsequent spinal CT imaging. In the meantime, the patient's neck needs to be stabilized. . [**12-8**] CT CSPINE: COMPARISON: CT head from [**2160-12-7**] and portable C-spine radiograph from [**2160-12-7**]. TECHNIQUE: Helical 2.5-mm axial MDCT sections were obtained from the skull base through the level of T2. Sagittal and coronal reformations were obtained and reviewed. FINDINGS: There is a large mass of new bone formation causing fusion of the C1 and C2 vertebral bodies anteriorly, with anterior subluxation of C1 with respect to C2(400b:27). This results in severe encroachment on the spinal canal by the posterior arch of C1. The degree of subluxation is unchanged from the prior study. There is no fracture identified. There is extensive fusion of every facet joint from C2 to T3, comprising all the levels imaged. There is also interbody fusion involving every cervical level. There has been surgical anterior fusion at C6-7. There is extensive fusion of the lamina and interlaminar ligaments throughout the visualized levels. In the portion of thoracic spine included in the study, there is fusion of costovertebral and costotransverse articulations. Comparison with a torso CT of [**2160-12-8**] reveals similar ankylosis in the lumbar spine and sacroiliac joints. These findings indicate a spondyloarthropathy with manifestations typical of ankylosing spondylitis. Correlation with the remainder of her medical history will be helpful. IMPRESSION: 1. Anterior subluxation of C1 on C2 without evidence of fracture. The anterior arch of C1 is fused to the odontoid process via a thick layer of bone that contributes to the subluxation. This produces severe encroachment on the spinal canal by the posterior arch of C1. 2. There are extensive fusions of multiple spinal joints most suggestive of ankylosing spondylitis. 3. No evidence of acute fracture. . [**12-7**] PELVIS PLAIN FILM: Comparison is made to selected images from an [**Month/Day (4) 1676**] pelvic CT scan dated [**2160-12-7**]. SINGLE PORTABLE AP PELVIC FILM WAS OBTAINED [**2160-12-7**] AT 0452: Bilateral total hip replacements are seen. The femoral and acetabular components appear to be well approximated on this single AP view. The distal end of both femoral components is not included on the image. There is no evidence of loosening of the femoral components. Hypertrophic bone is seen lateral to the right femoral component. A right femoral catheter is in place. No displaced fracture of the pelvis is appreciated. Surgical chain sutures are seen in the right lower quadrant, suggesting prior colonic surgery. A Foley catheter is in place. Several radiopaque densities are seen lateral to the left femoral component within the soft tissues which may be sutural in etiology. Clinical correlation is advised. IMPRESSION: Bilateral total hip replacements with both appearing to be normally positioned on this single portable view. No evidence of displaced fracture of the pelvis. Left upper extremity ultrasound [**2160-12-11**]: IMPRESSION: Non-occlusive thrombus within one of two paired brachial veins, which extends to the axillary vein. Portable chest x-ray [**2160-12-11**]: IMPRESSION: Persistent sizable parenchymal infiltrate in left lower lobe area. No new abnormalities in this portable chest examination. Brief Hospital Course: Ms. [**Known lastname 40984**] is a 46 year old female with a history of suicide attempts and subsequent liver disease, multiple infections including ESBL Klebsiella and osteomyelitis who takes chronic steroids for ankylosis spondylitis presented from an outside hospital intubated and requiring pressors. . ACTIVE PROBLEMS BY ISSUE: # Acute metabolic acidosis without respiratory compensation: Her pH upon admission to ICU was 7.1 with a bicarb of 14, later worsened to 7.09 with bicarb of 12. The possible etiologies of her primary metabolic acidosis include intoxication versus sepsis. The active [**Doctor Last Name 360**]/s seem to have suppressed her respiratory drive (additional respiratory acidosis) as well as causing a primary metabolic acidosis. She was treated with IV fluids with bicarbonate as well as hyperventilation on mechanical ventilation in order to improve the acidosis and elevated pCO2. Also, the toxicology and psychiatry services were consulted to assist with identifying the cause of her ingestion. Finally, she was started empirically on piperacillin/tazobactam with vancomycin to cover for possible aspiration pneumonia. . # Respiratory failure: She was intubated upon arrival but able to be ventilated well including a recruitment procedure to open her atelectatic lung seen on CT. She was extubated easily and did well on room air afterwards. As discussed above, it was thought that she aspirated while she was impaired from an unknown ingestion. Her CT chest was consistent with some small bilateral pneumonia. Following stabilization and extubation, induced sputum results returned positive for MRSA. She completed a 7 day course of vancomycin. She remained afebrile throughout remainder of course on the medical floor. PICC was discontinued prior to [**Doctor Last Name **]. . # Hypotension: Pt was hypotensive on admission to ICU. Her hypotension is of unclear etiology. It seems possible that she had sepsis--likely from pneumonia. Also, she may have been down long enough to miss her home florinef dose, resulting in hypotension. Lastly, the ingestion itself could have caused hypotension. She was treated with IV fluids, antibiotics as above, and stress doses of steroids. Blood pressures were stable during floor course. She was started on captopril when she became hypertensive with subsequent good control. . # Psychologic issues: We suspect that she had a purposeful ingestion with suicidal attempt. Blood tox was positive for benzos and tricyclics. Urine tox was positive for benzos, cocaine, and opiates. However, the patient did not admit suicide ideation; she intermittently reported that she may have accidentally ingested more medications than intended. Psychiatry was consulted and they recommended a 1:1 sitter. She was placed on section 12. She was followed by psychiatry and often refused full interviewing. She did not admit to suicide ideation but given her prior suicide attempts and depression with inability to care for herself, she was transferred to psych facility for further care. All of her psychiatric medications were held during hospital stay. She was started on low dose seroquel on the floor prior to transfer to help with sleep. . # Rhabdomyolysis: Her admission Creatinine was 2.2 (baseline is < 1.0) with phosphate >7 and CK of [**Numeric Identifier 24587**]. She was treated with IV fluids and alkalinization of the urine (with bicarb). Her creatinine improved to baseline and her CK trended down quickly. . # Transaminitis: She has a history of liver disease secondary to toxic ingestions. Her AST/ALT ratio suggests EtOH damage. APAP < 2 at OSH. LFTs normalized by time of [**Numeric Identifier **]. . # Odontoid fracture and Hip dislocation: Patient originally arrived in the ED with dislocated hip which was reduced. However, while intubated she awoke and again dislocated her hip while agitated. It has been put in a brace after a second reduction. Her CT head showed an old odontoid fracture, confirmed with CT neck. She was kept immobilized until cleared by ortho spine team. For her hip, ortho recommended that she continue with posterior hip precautions. She is weight bearing as tolerated. . # Left upper extremity DVT: Patient failed bilateral internal jugular central lines in the outside hospital and then failed a left subclavian and left IR-guided PICC here. Imaging looks like there is some type of central obstruction, L brachiocephalic vein no flow past it on venogram. She was eventually able to get a midline at level of axillary. Ultrasound showed left upper extremity DVT. She was initially started on heparin gtt with coumadin. She was then transitioned to lovenox with coumadin. INR was therapeutic for several days between 2 and 3 by time of [**Numeric Identifier **] on 3mg of warfarin daily. Pt currently is at risk of falling (due to her ankylosing spondylitis and hip dislocations) and syncope from substance abuse. However, given that she will be transferred to an extended care facility, it was felt that benefits of anticoagulation would outweigh the risks at this time. When ready for [**Numeric Identifier **], there should be another discussion of anticoagulation. After rehabilitation from both physical and mental viewpoint, risks/benefits of anticoagulation should be re-assessed. In the meantime, fall precautions should be continued at psych facility . # Diarrhea: Pt had several loose BMs daily. C.diff was negative x 2. Given amount of diarrhea, she was empirically started on oral flagyl 500mg TID. C.diff PCR was sent in the meantime. PCR returned negative and flagyl was discontinued. She was started on immodium with symptomatic relief . # Tinea corporis: Pt had several macular patches on lower back and right leg with central clearing. This was consistent with tinea corporis. She was treated with clotrimazole cream [**Hospital1 **]. . # Pain control: Pt with longstanding history of narcotic use. She frequently demanded IV dilaudid for nonspecific complaints, including [**Hospital1 1676**] pain. Also has ankylosing spondylitis, left hip dislocation, and left hand IV infiltration of levophed from OSH that can contribute to pain. Pain consult obtained who recommended maintaining current narcotic regimen of oral dilaudid q6h. She was also given lidoderm patch and ibuprofen for pain relief. Oral dilaudid was transitioned to oral oxycodone prior to [**Hospital1 **] which patient reported was more satisfactory. . # Communication: [**Name (NI) 553**] [**Name (NI) 1968**] (HCP) - ([**Telephone/Fax (1) 80620**]; [**First Name5 (NamePattern1) **] [**Name (NI) 80606**] (son) - [**Telephone/Fax (1) 80609**] Medications on Admission: clonazepam 1 mg [**Hospital1 **], 0.5 mg daily tizanidine 2 mg qhs ranitidine 150 mg [**Hospital1 **] trazodone 50 mg daily gabapentin 800 mg tid fentanyl patch 50 mcg/hr every 72 hours ketoconazole tramadol 50 mg qid macrobid 100 mg [**Hospital1 **] [**Hospital1 **] Medications: 1. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): On for 12 hours daily. 3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Use twice daily until [**2160-12-31**]. 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for diarrhea. [**Month/Day/Year **] Disposition: Extended Care Facility: [**Hospital1 **] 4 [**Hospital1 **] Diagnosis: Overdose Depression/ Hx of suicide attempt Pneumonia Left upper extremity DVT Hypertension Tinea corporis [**Hospital1 **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). [**Hospital1 **] Instructions: It was a pleasure taking care of you in the hospital. You were admitted after being found in your home unconscious. You were intubated and in the ICU. You likely had an ingestion that caused you to lose consciousness. You will be transferred to a psychiatric facility where you will continue to receive mental health care. During your hospital stay, you were treated for pneumonia with an IV antibiotic; you finished this course. You were also started on a blood thinner called coumadin for a blood clot found in your left arm. You will need to have levels of this medication in your blood monitored 2-3 times weekly. After psychiatric and physical rehabilitation, the risks and benefits of blood thinners should be revisited so that we can determine how long you should stay on this medication. Please see attached sheet for your new medications. Followup Instructions: You will be seen by psychiatrists and physicians at your facility. Completed by:[**2160-12-22**]

Admission Date: [**2114-12-24**] Discharge Date: [**2115-1-6**] Date of Birth: [**2070-12-17**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 943**] Chief Complaint: Hypotension with elevated lactate, code sepsis. Major Surgical or Invasive Procedure: Right internal jugular venous catheter placement. History of Present Illness: 44 yoM PMH ESRD secondary to Brights disease on HD s/p two failed renal transplants, HCV, CHF with EF 20%, AF on coumadin who presented to the ED with a two week history of diffuse abdominal pain with one day of nausea and vomiting [**2114-12-24**]. Two weeks prior to admission the patient began to experience diffuse dull abdominal pain without nausea or vomiting and loose stools 2-3 times per day. The patient believed this was secondary to fluid overload. One week prior to presentation the patient complained of subjective fevers, cough productive of yellow sputum. His nephrologist gave him a five-day course of azithromycin. The patient had persistent symptoms and was started on levofloxacin by his PCP two days prior to admission. The patient had a history of tylenol use 3g/day for 5 days prior to admission for fever, body aches. The day prior to admission the patient began to experience worsened abdominal pain associated with nausea, a few episodes of vomiting, nonbilious/nonbloody, and diarrhea 4-5 times per day, watery, nonbloody. . In the ED the patient was found to be hypotensive with lactate of 5.6 and a code sepsis was called. He was given Vanco, Flagyl and Zosyn for presumed infection. He was given Decadron for presumed adrenal insufficiency. He was also given Calcium gluconate, sodium bicarbonate, Insulin and D50 for hyperkalemia. A CVL was placed and he received 3L of NS with normalization of pressures. He was transferred to the MICU. . In the MICU the patient's LFTs were significantly elevated and peaked at ALT 3016, AST 2956, LDH [**2064**], INR 4.3 on [**12-25**]. This was thought to be secondary to shock liver in the setting of hypotension/sepsis versus tylenol toxicity despite negative serum tylenol. LFTs subsequently trending down. . Upon transfer to the floor, the patient continues to complain of cough productive of yellow sputum. Denies chest pain, shortness of breath. The patient denied any fevers/chills, abdominal pain, nausea, vomiting. Diarrhea improving. Denies dysuria/hematuria; minimal urine output while on HD. Denies lightheadedness. Denies myalgias/arthralgias. Review of systems otherwise negative in detail. Past Medical History: 1. End-stage renal disease secondary to glomerulonephritis on hemodialysis status post two failed transplants [**2089**] and [**2097**] 2. Coronary artery disease status post myocardial infarction and stent [**2105**] 3. Congestive heart failure with ejection fraction 10%, status post right sided placement of ICD 4. Cerebrovascular accident [**2105**] without residual complications or deficits 5. Atrial fibrillation 6. Hypertension 7. Basal cell and squamous cell skin cancers status post excision and radiation to lower face 8. Gout 9. Erectile dysfunction 10. Right lung pneumonia with pleurisy 11. Hepatitis C, genotype 2 Social History: He is married, lives in [**Location 13011**] with wife of 11 years, son and daughter. [**Name (NI) **] owns and runs a landscaping/contracting business and works for the city sanding the streets during the winter. He denies tobacco or recreational drug use. Family History: Mother, maternal uncle, and grandfather with [**Name2 (NI) **] grandmother, Lymphoma in paternal grandfather, peripheral vascular disease in maternal grandmother, no h/o kidney disease, other CA, heart disease, CVA, or psychiatric diseases. Physical Exam: VITAL SIGNS: 98.6 112/68 130 18 98RA GENERAL: NAD, pleasant and cooperative. HEENT: PERRL, EOMI, OP clear, MMM, anicteric sclerae NECK: no masses, no LAD, no JVD, no carotid bruit, RIJ in place HEART: irreg irreg, nl s1s2, holosystolic murmur [**3-5**] over precordium, laterally displaced PMI, no rub LUNGS: cta b/l, no crackles or wheezes. ABDOMEN: soft, nd, +bs, no organomegaly, tender in RLQ, negative [**Doctor Last Name **] sign, no rebound, no guarding EXTREMITIES: no cyanosis, no clubbing; no edema, 1+ dp, pulses b/l. NEUROLOGIC: awake, alert, a&ox3, cn ii-xii intact; strength 5/5 bilaterally, sensory and coordination grossly intact, reflesxes 1+ bilaterally SKIN: petechia on trunk, AV fistula in L arm, positive thrill Pertinent Results: Labwork on admission: [**2114-12-24**] 12:15PM WBC-14.0*# RBC-3.54* HGB-11.5* HCT-34.7* MCV-98 MCH-32.5* MCHC-33.2 RDW-14.6 [**2114-12-24**] 12:15PM PLT COUNT-286 [**2114-12-24**] 12:15PM NEUTS-77.9* LYMPHS-14.1* MONOS-6.7 EOS-0.2 BASOS-1.1 [**2114-12-24**] 12:15PM PT-23.1* PTT-29.9 INR(PT)-2.3* [**2114-12-24**] 12:15PM GLUCOSE-62* UREA N-90* CREAT-14.8*# SODIUM-139 POTASSIUM-7.1* CHLORIDE-86* TOTAL CO2-23 ANION GAP-37* [**2114-12-24**] 12:15PM ALT(SGPT)-1122* AST(SGOT)-1469* LD(LDH)-1523* ALK PHOS-156* AMYLASE-59 TOT BILI-1.5 [**2114-12-24**] 12:15PM LIPASE-43 [**2114-12-24**] 12:15PM ALBUMIN-4.0 CALCIUM-10.7* PHOSPHATE-11.2*# MAGNESIUM-2.8* [**2114-12-24**] 12:15PM CORTISOL-36.0* [**2114-12-24**] 12:27PM LACTATE-5.9* . CHEST (PA & LAT) [**2114-12-24**] IMPRESSION: Clear lungs, mild pulmonary congestion and cardiomegaly, unchanged. . CT ABD W&W/O C [**2114-12-25**] IMPRESSION: 1) Cardiomegaly and hepatomegaly with abnormal liver perfusion likely secondary to passive congestion (nutmeg liver). No focal hepatic abscess or adjacent hematoma. 2) Cholelithiasis and sludge/vicarious excretion of IV contrast. Small amount of pericholecystic fluid is present. The fluid could be due to patient's liver dysfunction/third spacing from CHF. If cholecystitis is of clinical concern, HIDA scan can be performed provided the total bilirubin is not elevated. 3) Hyperdense renal cortex in left lower quadrant transplanted kidney. Findings are most likely due to chronic rejection or prior ATN. There is apparent thickening of the arterial wall supplying the transplant. No hydronephrosis or perinephric collection. 4) Minor anatomic variant involving liver vasculature as described above. Hepatic veins and portal venous system appear widely patent. 5) 6 mm lesion in head of pancreas. Continued follow up of this area is recommended on future studies. 6) Areas of ground glass opacity and intralobular septal thickening in the lung bases, most likely due to fluid overload/CHF. Nodular areas of opacity are also present which could be due to infection. Continued followup is reccomended. 7) Small lymph nodes and vague retroperitoneal stranding. Findings could be due to CHF. . ECG Study Date of [**2114-12-25**] 2:41:34 AM Atrial fibrillation with rapid ventricular response Intraventricular conduction delay - possible atypical left bundle branch block Anterior myocardial infarct, age indeterminate - may be old Nonspecific ST-T wave changes Since previous tracing of [**2114-2-7**], ventricular rate faster . ECHO Study Date of [**2114-12-28**] Conclusions: 1. The left atrium is moderately dilated. 2. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. Left ventricular dysnchrony is present. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The effective regurgitant orifice is >=0.40cm2 6. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 7. There is a trivial/physiologic pericardial effusion. 8. Compared with the report of the prior study of [**2114-1-8**], LV function is probably worse. . CHEST (PA & LAT) [**2114-12-29**] IMPRESSION: Evidence for pulmonary venous hypertension. Cardiomegaly. No focal consolidation. . Labwork on discharge: [**2115-1-6**] 06:30AM COMPLETE BLOOD COUNT White Blood Cells 8.7 K/uL 4.0 - 11.0 Red Blood Cells 2.74* m/uL 4.6 - 6.2 Hemoglobin 9.7* g/dL 14.0 - 18.0 Hematocrit 29.3* % 40 - 52 MCV 107* fL 82 - 98 MCH 35.6* pg 27 - 32 MCHC 33.3 % 31 - 35 RDW 18.1* % 10.5 - 15.5 BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 128* K/uL 150 - 440 [**2115-1-6**] 06:30AM RENAL & GLUCOSE Glucose 121* mg/dL 70 - 105 Urea Nitrogen 56* mg/dL 6 - 20 Creatinine 7.5*# mg/dL 0.5 - 1.2 Sodium 138 mEq/L 133 - 145 Potassium 3.8 mEq/L 3.3 - 5.1 Chloride 99 mEq/L 96 - 108 Bicarbonate 27 mEq/L 22 - 32 Anion Gap 16 mEq/L 8 - 20 ENZYMES & BILIRUBIN Alanine Aminotransferase (ALT) 146* IU/L 0 - 40 Asparate Aminotransferase (AST) 45* IU/L 0 - 40 Lactate Dehydrogenase (LD) 274* IU/L 94 - 250 Alkaline Phosphatase 151* IU/L 39 - 117 Bilirubin, Total 1.6* mg/dL 0 - 1.5 CHEMISTRY Albumin 3.1* g/dL 3.4 - 4.8 Calcium, Total 7.4* mg/dL 8.4 - 10.2 Phosphate 4.1 mg/dL 2.7 - 4.5 Magnesium 2.2 mg/dL 1.6 - 2.6 [**2115-1-6**] 06:30AM RENAL & GLUCOSE Glucose 121* mg/dL 70 - 105 Urea Nitrogen 56* mg/dL 6 - 20 Creatinine 7.5*# mg/dL 0.5 - 1.2 Sodium 138 mEq/L 133 - 145 Potassium 3.8 mEq/L 3.3 - 5.1 Chloride 99 mEq/L 96 - 108 Bicarbonate 27 mEq/L 22 - 32 Anion Gap 16 mEq/L 8 - 20 ENZYMES & BILIRUBIN Alanine Aminotransferase (ALT) 146* IU/L 0 - 40 Asparate Aminotransferase (AST) 45* IU/L 0 - 40 Lactate Dehydrogenase (LD) 274* IU/L 94 - 250 Alkaline Phosphatase 151* IU/L 39 - 117 Bilirubin, Total 1.6* mg/dL 0 - 1.5 CHEMISTRY Albumin 3.1* g/dL 3.4 - 4.8 Calcium, Total 7.4* mg/dL 8.4 - 10.2 Phosphate 4.1 mg/dL 2.7 - 4.5 Magnesium 2.2 mg/dL 1.6 - 2.6 [**2115-1-6**] 10:29AM BASIC COAGULATION (PT, PTT, PLT, INR) PT 27.9* sec 10.4 - 13.1 PTT 47.7* sec 22.0 - 35.0 INR(PT) 2.9* 0.9 - 1.1 Brief Hospital Course: 44 year-old male with past medical history of ESRD on HD, HCV, presenting with hypotension and elevated lactate, presumed sepsis without source found. The patient was noted to have elevated LFTs on admission. The patient was found to be HIT Ab positive. . 1. Sepsis: There was no source found, but patient had received antibiotics prior to admission. The patient remained afebrile and hemodynamically stable throughout transfer to the floor. The patient had leukocytosis on admission but this resolved prior to transfer. The patient completed an empiric seven-day course of vancomycin/zosyn and ten-day course of flagyl. The patient's immunosuppressive therapy with cyclosporine for history of renal transplant was discontinued; prednisone 10 mg QOD was continued. CXR x 2 without evidence of pneumonia. The patient's blood, urine, stools, and sputum cultures were negative at the time of discharge. C. difficile toxin B was negative. The patient complained of continued cough and loose stools which were improving prior to discharge. . 2. Hypotension: Resolved prior to transfer to the floor. Likely sepsis given elevated lactate. Hypovolemia possible in setting of poor po prior to admission. Cardiac etiology unlikely; no significant change in cardiac function and cardiac enzymes unrevealing. Adrenal insufficiency was unlikely with random cortisol of 36, however, the patient on chronic steroids; the patient was continued on prednisone 10 mg every other day for history of renal transplant. The patient received treatment for sepsis as above. . 3. Elevated LFTs/coagulopathy: Secondary to shock liver versus tylenol toxicity. The patient was initially maintained on mucomyst gtt but this was discontinued when the patient's liver function tests improved. There was likely a component of congestion secondary to CHF. This was unlikely secondary to HCV as there was no change in immunosuppression and only mild active inflammation on very recent biopsy. Unlikely to be due to recent liver biopsy. The patient's liver function tests continued to trend down prior to discharge. . 4. Atrial fibrillation: The patient's coumadin was initially held in the setting of liver failure and elevated INR. The patient's digoxin and amiodarone were initially held in the setting of renal and liver failure and the patient's rate was subsequently poorly-controlled to heart rate 130-140s. The patient was followed by his primary cardiologist, Dr. [**Last Name (STitle) 911**], during admission. The patient's amiodarone was restarted and increased from previous per his recommendations. Digoxin was not restarted. The patient's elanopril was discontinued on admission and the patient was started on captopril; there was an attempt to up-titrate the dose but the patient's blood pressure did not tolerate the increase. The patient was discharged on captopril 6.25 twice daily. The patient's blood pressure does not tolerate beta-blocker therapy. The patient was restarted on coumadin prior to discharge. The patient's rapid ventricular rate is most likely compensatory for low ejection fraction; rate control to 110-120s is acceptable. The patient's rate was at goal 110s-120s on discharge. The patient will follow-up with Dr. [**Last Name (STitle) 911**] as an outpatient. . 5. Acute on chronic renal failure: Baseline creatinine [**5-2**]. The patient is on HD status post two failed renal transplants. The differential for the patient's acute renal failure included acute tubular necrosis and cyclotoxicity (recently on azithromycin). The patient's ACE inhibitor was initially held. The patient's creatinine did not improve to baseline and was 7.5 prior to discharge. The patient was followed by the renal service throughout hospitalization. The patient continued to receive hemodialysis per his MWF schedule. The patient was started on sensipar for elevated PTH. The patient was continued on prednisone 10 mg QOD for history of renal transplant. The patient's cyclosporine was discontinued. Amphogel was discontinued and cinecalcet was added to the patient's regimen. . 6. Thrombocytopenia/HIT Ab positive: HIT antibodies were sent because of the patient's thrombocytopenia. The patient's HIT antibodies were positive. The patient had been on heparin SC and heparin flushes in the MICU but these were discontinued prior to transfer to the floor. The patient was followed by hematology during admission. The patient had a right basilic vein thrombosis visualized but no other signs or symptoms of thrombosis. After discussion with hematology and pharmacy, the patient was started on argatroban and bridged to coumadin. The patient's INR goal was 2.5-3.5 given his history of liver disease. . 7. Congestive heart failure. EF of 10% per echo [**12-28**] with 3+ MR, 2+ TR. Mixed ischemic/nonischemic dilated cardiomyopathy. Patient has a fixed LAD/anterior defect on MIBI on 2/[**2114**]. The patient is status post ICD placement [**1-1**]. The patient was started on captopril as above. The patient's blood pressure does not tolerate beta-blocker therapy. The patient's volume status was addressed at hemodialysis. The patient was assessed for biventricular ICD by EP; the decision was made not to place at this time given the patient's narrow QRS duration and especially in the setting of recent sepsis. The patient will follow-up with Drs. [**Last Name (STitle) 911**] and [**Name5 (PTitle) 437**] in [**5-3**] weeks. The patient will receive outpatient cardiopulmonary assessment for possible cardiac transplant. . 8. Coronary artery disease status post myocardial infarction and stent [**2105**]. The patient was without complaints of chest pain throughout admission. The patient was continued on aspirin. The patient's elanopril was discontinued and the patient was started on captopril as above. The patient's blood pressure does not tolerate beta-blocker therapy. . 9. Nucleated red blood cells. There were 20 NRBC/100 white blood cells on the patient's blood smear on transfer to the floor, with low grade hemolysis and high reticulocyte count. Hematology was consulted and believed this was likely secondary to hyperactive marrow stimulated in the setting of recent sepsis. This resolved prior to discharge. Medications on Admission: Prednisone 10 mg PO QOD B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Aspirin 81 mg Tablet PO DAILY Coumadin 1 mg PO DAILY Amiodarone 100 mg [**Hospital1 **] Cyclosporine Amphogel Elanopril Discharge Medications: 1. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD (). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*2* 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for abdominal pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Sepsis 2. Shock liver 3. Heparin-induced thrombocytopenia . Secondary: 1. End-stage renal disease on hemodialysis 2. Coronary artery disease status post myocardial infarction and stent [**2105**] 3. Congestive heart failure with ejection fraction 10%, status post right sided placement of ICD 4. Cerebrovascular accident [**2105**] without residual complications or deficits 5. Atrial fibrillation 6. Hypertension 7. Basal cell and squamous cell skin cancers status post excision and radiation to lower face 8. Gout 9. Erectile dysfunction 10. Right lung pneumonia with pleurisy 11. Hepatitis C, genotype 2 Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, abdominal pain, nausea, vomiting, diarhea, black stools or blood in your stools, or any other concerning symptoms. . Please take your medications as prescribed. - You cyclosporine was discontinued for now; you will restart at outpatient dialysis per Dr. [**Last Name (STitle) 1860**]. - Your amphogel was discontinued. - Your elanopril was discontined. - You should take captopril 6.25 mg twice daily to control your heart rate. - Your amiodarone was increased to 200 mg once daily. - You should take fosrenal 500 mg three times daily with meals to control phosphorus because of kidney failure. - You should take cinecalcet 30 mg once daily to control calcium and phosphorus because of kidney failure. - You should take protonix 40 mg once daily to protect your stomach when taking prednisone. - You should take coumadin 2 mg once daily and follow-up in coumadin clinic on Monday. . Please keep your appointments as below. Followup Instructions: Please follow-up in coumadin clinic on Monday regarding your INR levels. . The office of Drs. [**Last Name (STitle) 911**] and [**Name5 (PTitle) 437**] should contact you regarding follow-up appointments. Please contact Dr.[**Name (NI) 5786**] office at ([**Telephone/Fax (1) 7236**] or Dr.[**Name (NI) 3536**] office at ([**Telephone/Fax (1) 13786**] if you do not hear from their representatives or have any questions. . Follow-up with your nephrologist: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) 708**]:[**Telephone/Fax (1) 435**] Date/Time:[**2115-1-7**] 2:00 . [**Month/Day/Year **] test for heart transplant evaluation: Provider: [**Name10 (NameIs) 10081**] TESTING Phone:[**Telephone/Fax (1) 1566**] Date/Time:[**2115-1-14**] 1:15 . Follow-up with your primary care doctor, Dr. [**Last Name (STitle) 14757**] [**Name (STitle) 13674**], on [**1-17**] at 5:30pm. Please call [**Telephone/Fax (1) 14758**] if you need to reschedule. . Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-4-16**] 3:30 Provider: [**Known firstname **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2115-4-16**] 4:00

Admission Date: [**2148-3-19**] Discharge Date: [**2148-3-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Placement of single chamber pacemaker (ventricular) History of Present Illness: 88 yo M with a history of paroxysmal a fib, CHF, ASD, goiter, PVD, polycythemia [**Doctor First Name **], chronic GIB on warfarin and recently started on atenolol, admitted with complaints of shortness of breath found to have profound bradycardia with high degree heart block. . The patient is a poor historian. A recent discharge summary from an admission starting on [**2148-3-12**] at [**Hospital3 **] describes symptomatic shortness of breath noted by [**Name Initial (MD) **] home NP. The patient was treated for worsening anemia (Hct 23 on admission down from previous baseline of 35 in [**2147-11-13**]) in the setting of supratherapeutic INR. The patient's hematocrit improved to 27 and INR to 2.4 after 4 U PRBCs and 2U FFP. EGD during this hospitalization revealed non-bleeding ulcers in the stomach and Barrett's esophagus. Colonoscopy was negative. The patient was also diuresed at that time for likely acute on chronic CHF exacerbation. His dry weight at discharge was 83kg. Echo revealed EF>60%. The patient was newly started on atenolol 25mg daily at the time of discharge. ACEi was not started because of acute on chronic renal failure (Cr of 1.9 up from previous 1.5 many months prior). Heart rate was 60-80 prior to discharge. The patient was discharged to rehab. . The patient was at rehab for approximately 1 week. At rehab on the day of admission, the patient was noted to have oxygen saturations down to 80% on RA with subjective SOB. 4L nc was applied w/ improvement in sats to 88%. HR was found to be 35-42. . The patient initially presented to [**Hospital1 **] [**Location (un) 620**] prior to transfer to [**Location (un) 86**]. In the ED, the patient was persistently bradycardic to 30-40 with complete heart block vs. high degree AV block on EKG. The patient was evaluated by electrophysiology consult team and started on isoproterenol with improvement in HR to 50-60 range. The patient was hemodynamically stable throughout with sbp 100-130 and asymptomatic. . On review of symptoms, he 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. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Cardiac Risk Factors: Diabetes . Cardiac History: Prior CAD, OSH records not currently available CHF ASD RBBB PVD . Other: Multinodular goiter GERD with esophagitis and non-bleeding gastric ulcers on recent EGD ([**2-20**]) Polycythemia [**Doctor First Name **] DM, diet controlled Nephrolithiasis Social History: Lived alone and administered his own meds prior to recent hospitalization. Had home NP. No tob or EtOH. Family History: Family history noncontributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: 97.2 51-59 138-143/58-64 18 96% 6L NC Gen: Well-appearing elderly man in NAD. Integumentary: Chronic venous stasis changes in the bilateral lower extremities. HEENT: PERRL. Pink, moist oral mucosa without lesions. CV: Regular rhythm, bradycardic with normal S1 and S2. [**4-18**] systolic murmur at the right upper sternal border. Pansystolic mrumur at the apex. Pulm: Bibasilar crackles L>R. Abd: Soft, nondistended, no masses or organomegaly. Ext: No edema. Pertinent Results: ADMISSION LABS: [**2148-3-18**] 05:20PM BLOOD WBC-3.7* RBC-3.06* Hgb-8.5* Hct-27.6* MCV-90 MCH-27.8 MCHC-30.8* RDW-20.6* Plt Ct-176 [**2148-3-18**] 05:20PM BLOOD Neuts-55.1 Bands-0 Lymphs-32.2 Monos-9.1 Eos-2.9 Baso-0.7 [**2148-3-18**] 05:20PM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-1+ Macrocy-3+ Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Target-2+ [**2148-3-18**] 05:20PM BLOOD PT-22.5* PTT-42.7* INR(PT)-2.2* [**2148-3-18**] 05:20PM BLOOD Glucose-97 UreaN-40* Creat-1.8* Na-145 K-4.7 Cl-109* HCO3-25 AnGap-16 [**2148-3-18**] 05:20PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.5 Iron-24* [**2148-3-20**] 03:20AM BLOOD TSH-0.46 CARDIAC ENZYMES: [**2148-3-18**] 05:20PM BLOOD cTropnT-0.05* [**2148-3-18**] 11:57PM BLOOD CK-MB-NotDone [**2148-3-18**] 11:57PM BLOOD cTropnT-0.05* [**2148-3-19**] 08:15AM BLOOD cTropnT-0.06* [**2148-3-19**] 08:15AM BLOOD CK(CPK)-85 [**2148-3-18**] 11:57PM BLOOD CK(CPK)-96 [**2148-3-18**] 05:20PM BLOOD CK(CPK)-95 [**2148-3-18**] EKG: Sinus bradycardia at a rate of 34 with likely atrial tachycardia with high grade AV block vs. CHB. Also right bundle branch block. Downgoing T's in V4-V6. No prior for comparison. [**2148-3-18**] CXR: Pulmonary edema; the markedly abnormal cardiac silhouette suggests either underlying cardiomyopathy or pericardial effusion (or both). 2D-ECHOCARDIOGRAM ([**2147-3-20**]): The left atrium is markedly dilated. The right atrium is markedly dilated. A secundum type atrial septal defect is present with right to left shunting. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is depressed (<2.0L/min/m2). The right ventricular cavity is markedly dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. The main pulmonary artery is dilated. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Brief Hospital Course: The patient was admitted with bradycardia with high degree heart block. Atenolol use in the setting of acute renal failure likely worsened his bradycardia, but it was felt that his underlying conduction disorder had worsened and that he would benefit from placement of a pacemaker. He was on a dopamine drip prior to placement of the pacemaker but was weaned off after the procedure. A single chamber ventricular pacemaker was placed on [**2148-3-22**]. He had significant blood losses during the procedure, requiring transfusion of one unit of PRBC's. His Hct remained stable after the transfusion. Heparin for his AFib was restarted the morning after the procedure, and coumadin was restarted 48 hours after pacer placement. eh was also started on aspirin 81 mg QD. On admission, his heart failure had been exacerbated by the bradycardia, and he had evidence of volume overload with crackles on lung exam. He was aggressively diuresed and had improvement in his volume status. he was discharged on lasix 40 mg QD, to be further adjusted as an out-patient. He was admitted with acute on chronic renal failure likely secondary to hypoperfusion with his bradycardia (Cr 2.0 on admission; baseline uncertain but pt has history of DM and vascular disease). Creatinine improved somewhat with control of his CHF exacerbation and placement of the pacemaker. He was discharged with Cr 1.3. ISSUES FOR FOLLOW-UP: (1) Please measure daily weights. Mr. [**Known lastname 97347**] cardiologist will make adjustments to his lasix medication according to his weights. (2) Please check INR, CBC, and chem-10 on [**2148-3-28**] at the rehab facility. Please fax results to Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] (cardiologist) at [**Telephone/Fax (1) 25173**]. He will make any needed changes to Mr. [**Known lastname 97347**] medications. Medications on Admission: HOME MEDICATIONS (at time of most recent discharge [**3-22**]): Warfarin 3mg Daily KCl 10mEq Daily Lasix 40mg TThSaSu, 60mg MWF Protonix 40mg twice daily - newly prescribed Atenolol 25mg Daily - newly prescribed Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): For your blood pressure. . 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): Please adjust dosage to INR goal of 2.0 - 3.0. . 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): For your blood pressure. . 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 2 days: Please continue through [**2148-3-26**] (last dose to be given on [**2148-3-26**]). 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] - [**Location (un) 745**] Discharge Diagnosis: Primary Diagnoses: Bradycardia Secondary Diagnoses: Congestive heart failure-- diastolic Gastroesphageal reflux disease Diabetes mellitus-- diet controlled Discharge Condition: Stable-- heart rate in the 50 - 60's; satting in the mid to upper 90's on 2 Liters supplemental oxygen; breathing comfortably. Discharge Instructions: You were admitted for a slow heart rate and received a pacemaker. Because your heart rate was low, you had an exacerbation of your heart failure, requiring removal of fluid from your body with medications. Several changes were made to your medications while you were in the hospital: (1) You should no longer take atenolol. (2) You were started on two new medicines (amlodipine and metoprolol) to control your blood pressure. (3) Your Coumadin (also called warfarin) was increased to 5 mg each night. This will need to be adjusted to your blood levels, which should be followed closely. (4) You were put on three days of cephalexin (an antibitoic) after your procedure. You only need to take this through [**2148-3-26**]. (5) Your lasix dose is now 40 mg daily. You shoud follow-up with yoru cardiologist to see how this medicine should eb adjusted accoridng to how much fluid you are retaining. (6) You were started on aspirin, to help prevent clotting. Followup Instructions: You have the following appointments: (1) Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2148-3-29**] 9:30 -- this is to follow-up on your new pacemaker. (2) You have appointment to see Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], your cardiologist, on Wednesday, [**2148-4-3**] at 2:30 pm. Their phone number is ([**Telephone/Fax (1) 97348**]. (3) You will have blood work drawn on [**2148-3-28**] and faxed to Dr. [**Name (NI) 97349**] office. He will make any neccessary changes to your medications after he sees these results.

Admission Date: [**2118-10-23**] Discharge Date: [**2118-11-5**] Date of Birth: [**2035-3-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2565**] Chief Complaint: Shortness of breath, hypoxia Major Surgical or Invasive Procedure: Central Venous Catheterization Radial Arterial Catheterization Endotracheal Intubation History of Present Illness: On admission to medical floor: This is a 83 yo M with HTN, HLD, AAA 5.7cm and recent hospitalization for diverticulosis initially presenting with cough and SOB. On [**10-21**], patient experienced significant DOE, even when walking across the room. He went to [**Hospital **] Hospital on [**10-23**] for evaluation where a V/Q scan showed poor perfusion in the RLL and CXR suggested RLL PNA. He received azithro, CTX, and some lasix and was sent to [**Hospital1 18**]. Upon presentation, he had no focal lung sounds, was talking in full sentences, but was tired out by moving. Bedside echo showed no effusion or ventricular collapse. An EKG showed TWI V1, V3, unchanged from previous. A repeat CXR was unimpressive and not suggestive of PNA. Trop was elevated to 0.16, creatinine was 3.6 (unknown baseline). He was started on a heparin drip and received vanco 1g to supplement OSH Abx. CT w/o contrast was performed showing hyperdense material in the right main pulmonary artery extending in the segmental branches, concerning for large pulmonary embolus with mild enlargement of right cardiac [**Doctor Last Name 1754**] raising concern for possible right heart strain. No TPA was administered. LENIs showed extensive RLE DVT and thrombus in the posterior tibial vein in the LLE. Echo showed moderately dilated RV with free wall hypokinesis. Retrievable IVC filter was placed on [**10-24**]. Patient's creatinine rose on [**10-25**] with concern for low UOP and patient was bolused. . Patient reports no recent immobilization or travel, no malignancy, and no history of clots in his family. He has had no previous clots that he knows of. . Currently, patient reports improved dyspnea, no chest pain, no current cough, no fever or chills. He successfully got up to the chair to eat lunch today. He reports no leg pain and has noted no swelling. . ROS: as above, no dysuria, no diarrhea, no PND, no orthopnea, no productive cough, no joint pains, no numbness or weakness, no sinus tenderness. Past Medical History: Diverticulosis Glaucoma HTN Dyslipidemia AAA 5.6 cm, scheduled for surgery at OSH during the time of admission Chronic kidney disease Social History: [**11-27**] PPD from WW2 until [**2077**]. Rare etoh. Was in the service in WW2, likely asbestos exposure, thereafter had a regional manager's position at a paper company. Married to his wife, who is relatively healthy. Family very involved and supportive. Family History: No clots. Father was a smoker and had throat cancer. Mother died during childbirth. Physical Exam: On admission: VS: Temp: 97.6 BP:138/87 / HR:90's RR: 24 O2sat 100% on NRB GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout. slight crackles on the left CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e. Right leg is [**Hospital1 2824**] than the left. No palpable cords. negative [**Last Name (un) **] sign SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps RECTAL: negative per ED Pertinent Results: Labs on admission: [**2118-10-23**] 05:30PM BLOOD WBC-10.9 RBC-3.14* Hgb-10.3* Hct-31.2* MCV-99* MCH-33.0* MCHC-33.2 RDW-14.5 Plt Ct-229 [**2118-10-23**] 05:30PM BLOOD Neuts-78.8* Lymphs-13.1* Monos-6.8 Eos-0.9 Baso-0.3 [**2118-10-23**] 05:30PM BLOOD PT-15.7* PTT-20.0* INR(PT)-1.4* [**2118-10-23**] 05:30PM BLOOD Glucose-100 UreaN-43* Creat-3.6* Na-145 K-4.9 Cl-113* HCO3-19* AnGap-18 [**2118-10-23**] 05:30PM BLOOD cTropnT-0.16* [**2118-10-23**] 05:30PM BLOOD Albumin-4.2 [**2118-10-23**] 05:30PM BLOOD D-Dimer-6229* [**2118-10-23**] 05:51PM BLOOD Lactate-1.7 [**2118-10-26**] 12:24PM BLOOD FACTOR V LEIDEN-PND STOOL [**11-2**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2118-11-3**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 4:30A [**2118-11-3**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Labs on discharge: Micro studies: Blood cultures [**2118-10-23**]: negative x 2 MRSA screen [**10-23**]: negative Ancillary tests: CXR on admission [**10-23**]: Mild bibasilar atelectasis. Cardiomegaly. Otherwise, unremarkable study. . CT chest w/o contrast [**10-23**]: 1. Hyperdense material in the right main pulmonary artery extending in the segmental branches, concerning for large pulmonary embolus with mild enlargement of right cardiac [**Doctor Last Name 1754**] raising concern for possible right heart strain. Findings were urgently discussed with Dr. [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **] 10 p.m. on [**2118-10-23**], by Dr. [**Last Name (STitle) 10304**]. 2. Emphysema. 3. Bilateral lower lobe bronchiectasis, with subtle ground-glass opacities at the lower lobes and area of ground glass opacity in lingula, could suggest incipient atelectasis; however, cannot exclude infectious disease involving lower airways. 4. Several subcentimeter pulmonary nodules. Followup CT chest in 6 to 12 months is recommended to document stability, if clinically warranted. 5. Atherosclerotic changes at the SMA, with proximal dilatation of SMA which indirectly could suggest stenosis at the origin of SMA although suboptimal evaluation due to lack of IV contrast. . TTE [**2118-10-24**]: Moderately dilated right ventricle with free wall hypokinesis. Mild left ventricular hypertrophy with normal regional and global systolic function (LVEF 55-60%). Dilated ascending aorta. . Bilateral lower extremity U/S [**2118-10-24**]: Extensive right lower extremity deep venous thrombosis as above and thrombus also seen in the posterior tibial vein on the left. . CXR [**2118-10-26**]: In comparison with the study of [**10-23**], there is probably little overall change. Again there is enlargement of the cardiac silhouette with opacification at the left base consistent with atelectasis and effusion. The overall appearance is somewhat worsened due to the low lung volumes. No evidence of vascular congestion or pleural effusion. Blunting of the right costophrenic angle persists. CXR postintubation [**11-4**] there has been interval placement of an endotracheal tube ending 4.5 cm above the carina. A nasogastric tube is new with the tip in the stomach. A right internal jugular catheter projects over the mid SVC. Right pleural effusion is stable. Increased opacification at the left lung base represents worsening atelectasis and effusion. There is no pneumothorax. The cardiac and mediastinal silhouette and hilar contours are stable. TTE [**11-4**] There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). The right ventricular cavity is dilated with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2118-10-24**], the right ventriclre is less dilated and less hypocontractile. Pan CT [**2118-11-5**] 1. Diffuse panproctocolonic wall thickening with pericolonic edema concerning for a pancolitis. Differential includes infectious, inflammatory, or ischemic etiologies. Per discussion with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 1833**], the patient currently has a Clostridium difficile infection and these findings are in keeping withthis diagnosis. 2. Increased left basilar consolidation, concerning for interval development of pneumonia. 3. Abdominal ascites particularly adjacent to the spleen, liver and paracolic gutters. 4. Large infrarenal abdominal aortic aneurysm. Brief Hospital Course: Mr. [**Known lastname 87816**] was an 83 year old man with hypertension, dyslipidemia and a 5.7cm AAA who, in the week prior to his planned AAA repair had a diverticular bleed and shortly thereafter developed a large PE in his right PA that caused hypoxia and right heart strain. He was diagnosed and monitored in the MICU on heparin, slowly transitioning from NRB to nasal canula for oxygen. He did well and while his right heart strain improved, he developed severe, complicated c.difficile colitis with recalcitrant shock and ventillatory needs that required intubation. He ultimately passed on [**11-4**]. . #. Acute pulmonary embolus/bilateral deep venous thromboses - patient was admitted to [**Hospital1 18**] after transfer from an outside hospital for hypoxia and a V/Q scan that illustrated a right lung filling defect. After admission, noncontrast CT was obtained and showed a large pulmonary embolus in the right lung vasculature. Patient was started on a heparin drip, with warfarin shortly afterwards. IV heparin was stopped 24 hours after therapeutic INR was achieved. Bilateral ultrasounds of the lower extremities were performed and showed. Upon reaching the medicine floor, the patient remained on 6 liters of O2 by nasal cannula, on one occasion requiring a face mask for desaturation below 90%, from which he quickly recovered. . # Hypoxia: patient was consistently hypoxic during his time on the medical floor, with likely contributing factors being his clot burden and underlying emphysema. Before being transferred to the medical floor from the ICU, the patient was taken off a non-rebreather mask and placed on nasal cannula. Patient was provided albuterol inhalers and nebulizer treatments, as well as ipratropium inhalers around the clock to optimize respiratory status. Albuterol treatments were discontinued after the patient developed an episode of atrial fibrillation. He worked with physical therapy and slowly improved for a period of time from an oxygenation standpoint. On [**2118-11-3**], patient was noted to be tachypneic to the 30s-low 40s, with oxygen saturations dropping from low 90s to 87-89% on 6 liter of O2. A trigger was called. Physical exam showed rales present, mostly in the left lung. A dose of Lasix was administered due to concern for fluid overload after continuous IV fluid administration due to the patient's elevated creatinine at the time. A non-rebreather was placed with improvement in oxygen saturations to the mid-90s and improvement in respiratory rate. Patient was given nebulizer treatment and 20 mg IV Lasix. ABG was performed with pH 7.45, pCO2 30, pO2 61 on 6 liters of oxygen. Chest X-ray was ordered and showed no evidence of pulmonary vascular congestion or pneumonia, but had signs of worsened atelectasis and pleural effusion as compared to a previous X-ray on [**11-2**], when the patient first developed a leukocytosis. Urine and blood cultures were ordered after the patient spiked a fever to 101 F, and the patient was started on IV cefepime and vancomycin empirically. He was transferred to the MICU. . #. Clostridium difficile colitis: on [**2118-11-2**], patient began developing numerous episodes of diarrhea along with leukocytosis, and testing for Clostridium difficile was ordered. A positive result returned on [**2118-11-3**] and the patient was begun on PO flagyl for treatment. Later on that day, it was decided to switch the patient's treatment to IV flagyl as well as PO vancomycin for likely severe C. difficile infection. Despite antibiotic therapy, the patient continued to fare poorly with this infection. He went into septic shock. On [**11-5**] a central line and arterial line were placed for rescusitation. Vasopressors were begun. Unable to keep up with the work of breathing, Mr. [**Known lastname 87816**] was intubated on the AM of [**11-4**]. He was transfused one unit of pRBCs to preserve oxygenation but remained on large doses of vasopressors. In the early AM of [**11-5**], his blood pressure became untenable on neosynephrine and he became increasingly dependent on 3 pressors. A CT torso was obtained that showed severe colitis with few other positive findings. His family was called to the bedside and he passed at 6am on [**11-5**]. . #. Acute kidney injury on chronic kidney disease: given an equivocal results of FEUrea, likely etiology was prerenal failure with progression to acute tubular necrosis. Urinalysis was performed and was non-revealing. The patient's baseline creatinine was 3. Nephrotoxins were avoided and patient's medications were renally dosed. Patient was kept at even fluid balance. On [**2118-11-3**], his creatinine began to rise in conjunction with the numerous episodes of diarrhea that the patient began to experience found to be due to Clostridium difficile infection. IV fluids were administered until the time of hypoxia leading to his MICU transfer. . #. Urinary retention: the patient developed urinary retention during his hospitalization which was thought to possibly be due to the addition of trazodone to help with sleep, or from some constipation that the patient developed during his hospital course. There was no known history of prostate disease, and rectal exam performed on the medical floor revealed no nodularity or enlargement of the prostate, and patient was guaiac negative. A Foley catheter had to be placed due to urinary retention and trazodone was discontinued, but urine retention did not resolve at the time of transfer to the MICU. . # Atrial fibrillation: patient was noted to be in atrial fibrillation on [**2118-10-29**], with possible precipitants being his pulmonary process, perhaps mild dehydration and the result of his beta-blocker being held. Patient was started on metoprolol for rate control which was uptitrated until regular rate was achieved. He was already on anticoagulation for his pulmonary embolism and deep venous thromboses. The patient was monitored on telemetry throughout the rest of his time on the hospital floor, and was maintained in sinus rhythm. . #. Anemia: Patient was anemic upon presentation with guaiac negative stools. Active type and screen with crossmatched units of blood were maintained. Vitamin B12 and folate were checked, with a noted low vitamin B12 level. The patient was started on intramuscular cyanocobalamin. Hematocrit was trended throughout hospitalization. . #. Hypertension: patient's blood pressure was controlled while off medication during admission. His enalapril was held given acute kidney injury, and his HCTZ, nadolol and amlodipine was held due the patient's normotensive status. Metoprolol was started when the patient developed an episode of atrial fibrillation while on the medical floor. . #. Abdominal aortic aneurysm: the patient was scheduled to undergo elective repair of AAA at an outside hospital while he was admitted to [**Hospital1 18**]. Blood pressures were checked often, with a plan to obtain a stat echocardiogram if he became hypotensive. . #. Dyslipidemia: the patient was continued on his home statin medication while he was admitted. . #. Glaucoma: the patient was continued on his glaucoma medications during admission. Medications on Admission: HCTZ 25 mg MWF Nadolol 80 mg every third day Enalapril 5mg Amlodipine 10 mg Lipitor 80 mg Tricor 145 mg Fiorinal Timolol .5% [**Hospital1 **] Alphagan .1% [**Hospital1 **] Pilocarpine 4% QID Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: Submassive Pulmonary Embolism Severe C.Difficile Colitis Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:[**2118-11-6**]

Admission Date: [**2165-1-11**] Discharge Date: [**2165-1-13**] Service: MEDICINE Allergies: Ampicillin / Penicillins / Iron Attending:[**First Name3 (LF) 1190**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: right groin central line placement History of Present Illness: [**Age over 90 **] year-old female nursing home resident with history of advanced dementia, Parkinson's, diabetes mellitus, transferred from nursing home on [**2165-1-11**] with shortness of breath, hypoxia (O2 sat in the 70%'s on 100% NRB), BP 60/40, fever to 101F, and mental status change after aspiration. In the ED, found to be febrile to 101.8, tachycardic, hypotensive and in respiratory distress. Given the lack of record of code status, she was intubated and admitted to the MICU for respiratory failure and mental status change secondary to aspiration pneumonia. Patient has no health care proxy. In light of her prior deterioration at the nursing home, now with septic shock on pressors and multiple antibiotics, the decision was made by her primary care physician and her MICU team to extubate her and change the focus of care to comfort. Past Medical History: Advanced dementia Parkinson's osteoporosis paranoid schizophrenia s/p frontal lobotomy [**2128**] depression s/p hernia repair s/p left wrist fracture DM II s/p R ORIF h/o lacunar infarcts glaucoma Physical Exam: Vital signs temp 99.6, BP 56/36, HR 74, RR 13, O2 sat 89% Gen: comfortable-appearing elderly woman, unresponsive HEENT: PERRL Chest: Lungs with coarse BS throughout Heart: RRR, no murmurs Abdomen: Soft, NT, ND, no masses Extr: right groin line, distal lower extremities cold and blue Pertinent Results: [**2165-1-11**] 10:00PM GLUCOSE-157* UREA N-29* CREAT-0.5 SODIUM-146* POTASSIUM-3.2* CHLORIDE-112* TOTAL CO2-29 ANION GAP-8 [**2165-1-11**] 10:00PM CK-MB-5 cTropnT-0.04* [**2165-1-11**] 10:00PM PHOSPHATE-1.6* MAGNESIUM-1.4* [**2165-1-11**] 10:00PM CORTISOL-14.0 [**2165-1-11**] 10:00PM HCT-27.4* [**2165-1-11**] 04:25PM TYPE-ART TEMP-37.8 RATES-/16 O2-100 PO2-257* PCO2-43 PH-7.45 TOTAL CO2-31* BASE XS-5 AADO2-435 REQ O2-73 INTUBATED-INTUBATED VENT-CONTROLLED [**2165-1-11**] 04:25PM LACTATE-1.3 [**2165-1-11**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2165-1-11**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [**2165-1-11**] 03:00PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2165-1-11**] 02:00PM GLUCOSE-173* UREA N-46* CREAT-0.9 SODIUM-155* POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-35* ANION GAP-12 [**2165-1-11**] 02:00PM CK(CPK)-23* [**2165-1-11**] 02:00PM cTropnT-0.06* [**2165-1-11**] 02:00PM CK-MB-NotDone [**2165-1-11**] 02:00PM CALCIUM-10.1 PHOSPHATE-2.2* MAGNESIUM-2.0 [**2165-1-11**] 02:00PM VIT B12-1031* FOLATE-15.6 [**2165-1-11**] 02:00PM WBC-16.0* RBC-3.50* HGB-10.7* HCT-32.8* MCV-94 MCH-30.6 MCHC-32.7 RDW-12.5 [**2165-1-11**] 02:00PM NEUTS-85* BANDS-10* LYMPHS-3* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2165-1-11**] 02:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ [**2165-1-11**] 02:00PM PLT COUNT-226 [**2165-1-11**] 02:00PM PT-13.2 PTT-53.1* INR(PT)-1.1 [**2165-1-11**] CXR: lines and tubes in good position mild cardiomegaly, LLL atelectasis vs. consolidation [**2165-1-11**] head CT: no acute bleed of mass effect Extensive hypodensity within the subcortical white matter, particularly in the frontal lobes, consistent with small vessel ischemic change or prior completed infarct. Diffuse dilatation of the lateral ventricles consistent with a combination of age related involutional change and ex vacuo dilatation. Brief Hospital Course: Assessment/Plan: [**Age over 90 **] year-old female with advanced dementia, Parkinsin's, diabetes, paranoid schizophrenia, admitted with septic shock secondary to aspiration pneumonia. After discussion, the pt became comfort measures only. She was placed on a morphine drip and given ativan prn for discomfort, as wel as a scopolamine patch. She remained somnolent and unarousable. On the day following her transfer to the floor, she passed away. Medications on Admission: on transfer from MICU: morphine drip. Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Discharge Condition: Deceased

Admission Date: [**2161-8-30**] Discharge Date: [**2161-10-7**] Date of Birth: [**2130-8-4**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 922**] Chief Complaint: fever to 103 Major Surgical or Invasive Procedure: IR removal of Tunnelled HD line [**8-30**] tissue AVR [**2161-9-18**] redo homograft aortic root replacement [**2161-9-29**] PICC line placement History of Present Illness: 31M with h/o ESRD on HD, HTN, went to HD yesterday. At HD found to have Temp 103, pt w/persistent fevers and chills for 1 day prior to admission. Pt did notice a couple of days ago some minor purulence around tunnelled HD line. Pt with similar admission in [**5-/2161**] with fevers and CONS, tunnelled HD line was removed and replaced on [**2161-5-29**]. He completed a 2 week course of vanco. TEE in [**Month (only) 116**] apparently showed mitral valve vegetation. Past Medical History: 1. ESRD- membranous glomerulonephritis, dx in childhood, renal biopsy [**2158**], HD x 5 yr, on Renal Transplant list 2. HTN 3. Hyperlipidemia 4. Chronic fatigue syndrome 5. H/o pyloric stenosis in childhood - surgically repaired Social History: Originally from [**Male First Name (un) 1056**]. Now lives by himself in Mission [**Doctor Last Name **]. ETOH [**2-20**] drinks/month. Tobacco - smokes 1/2ppd x10 years. Denies other drug use, no IVDU. Works in the electrical engineering dept. at [**Hospital1 112**]. Family History: mother - breast ca at 45, survivor, aunt - died of MI at 50, no other family hx of renal disease, no DM or other CA in the family Physical Exam: Vitals- 103.9 154/80 120 18 98%RA wt 66.1kg General- NAD, speaking in full sentences HEENT- dry MM, OP Clear, no exudates, PERRL, EOMI, no Cervical LAD Pulm- CTA b/l, no crackles, no wheezing CV- Reg Sinus Tach, Nml S1,S2, No M/R/G Abd- Soft ND/NT +BS Extrem- No C/C/E, Warm, 2+DP pulses B/L Neuro-A&OX3, no focal deficits, Pertinent Results: TEE [**2161-9-3**]: Aortic valve endocarditis with associated severe aortic regurgitation. Large aortic paravalvular abscess. Micro: [**2161-8-30**] = 4/4 bottles MSSA, line tip with MSSA, urine ngtd. Since [**2161-8-31**], 18/18 bottles ngtd (last on [**2161-9-9**]). [**2161-9-30**] Upper Extremity U/S Extensive thrombus in the right subclavian vein with thrombus in the left subclavian vein at its junction with the internal jugular. [**2161-9-29**] ECHO PRE-BYPASS: 1. The left atrium is normal in size. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 2. Regional left ventricular wall motion is normal. 3. Overall left ventricular systolic function is mildly depressed. There is mild global right ventricular free wall hypokinesis. 4. A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally and the annulus appears to be well seated. Trace central AI is seen. A paravalvular aortic valve leak is seen, directed eccentrically. An abscess cavity is noted in the perimembranous portion of the interventricular septum, with color flow noted through the cavity.. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. POST-BYPASS: Pt is in sinus tachycardia and is on dobutamine, phenylephrine and epinephrine. 1. A aortic homograft is seen in the aortic position. No AI is seen. Leaflets open well. 2. No flow is detected across the septum to suggest a VSD. 3. Inferior, inferolateral walls are mild- moderately depressed, global function is mildly depressed 4. Aorta is intact Brief Hospital Course: Mr. [**Known lastname 11041**] was admitted to the [**Hospital1 18**] on [**2161-8-30**] for further work-up of his fever. Blood cultures revealed MSSA bacteremia and an infectious disease consult was obatined. Vancomycin and gentamicin were started and an echo was performed. This revealed acute endocarditis with new aortic regurgitation and a paravalvular abscess. The cardiac surgery service was consulted for surgical evaluation and Mr. [**Known lastname 11041**] was worked-up in the usual preoperative manner. It was preferred to wait 4-6 weeks prior to surgery given his active endocarditis. Given the length of stay and his multiple medical issues, the remainder of the discharge summary will be broken down into systems. Renal: The renal service continued to follow Mr. [**Known lastname 11041**] and manage his hemodialysis. His electrolytes were repleted as needed. Transplant: Given his positive blood cultures and his history of multiple line infections, the transplant service was consulted. His old tunneled catheter was removed and a temporary internal jugular line was placed. The transplant service decided that he would be best served with a more permenant catheter for upcoming dialysis. On [**2161-9-9**], Mr. [**Known lastname 11041**] [**Last Name (Titles) 1834**] removal of his right internal jugular line and placement of a left internal jugular PermaCath. He remained on the transplant surgery list. [**2161-9-30**] an ultrasound was obtained as his lines were not flushing easily. This revealed extensive thrombus in the right subclavian vein with thrombus in the left subclavian vein at its junction with the internal jugular. His lines were left in place with as access was needed and some of the clot was extracted. Dental: A dental consult was obtained who recommended he have his wisdom teeth removed prior to his valve surgery based on a physical exam and x-rays. Clindamycin was prophylactically dosed for his extraction. On [**2161-9-14**], Mr. [**Known lastname 11041**] [**Last Name (Titles) 1834**] extraction of three impacted third molar teeth and 3 impacted supernumerary teeth without complication. He tolerated the procedure well without complications. He had a slight fever two days following his teeth extraction which delayed his surgery however his fevers were not related to his extractions. Infectious Disease: Given his admission for endocarditis, the infectious disease service was consulted for assistance in Mr. [**Known lastname 48504**] management. Based on cultures and the patients allergy to penicillin, vancomycin was used. As beta lactam therapy was the choice therapy, the allergy service was asked to comment on his penicillin allergy. Penicillin desensitization was recommended which was commenced without complication. Mr. [**Known lastname 11041**] was then transitioned to nafcillin. Surveillance cultures remained negative. It was recommended to continue nafcillin until [**2161-10-28**]. Mr. [**Known lastname 11041**] continued to have periodic fever spikes in the presence of a normal white cell count and normal healing wounds. Pan-cultures continued to remain negative. Cardiac: The cardiac surgical service and cardiology service followed Mr. [**Known lastname 11041**] closely. It was planned that his surgery may be performed when surveillance blood cultures were negative. His volume status and hemodynamics were optimized. A nicotine patch was used to help with smoking cessation. He was taken to the OR on [**9-18**], [**Month/Day (4) 1834**] tissue AVR (please see operative note for details of surgical procedure). He was weaned off pressors, continued on hemodialysis treatments, and was extubated over the next 48 hours, and transfeerred to the telemetry floor on POD # 2. He was followed closely by the ID service. OR cultures revealed MSSA, and penicilln was felt to be the best treatment. As the patient had an allergy to penicillin, he was brought back to the ICU for desensitization which he tolerated well. On [**9-24**], he had an echocardiogram which revealed dehiscence of his prosthetic aortic valve with abscess. On [**2161-9-29**], he was taken to the OR for a re-do AVR/homograft. Please see operative report for details of procedure. On postoperative day one, he self extubated himself without any complication. An ultrasound of the upper extremities was obtained due to a question of clot in the SVC in the OR. This revealed bilateral subclavian vein thrombus, and anticoagulation was initiated. His drains and pacing wires were rmeoved per protocol. His volume overload was removed by hemodialysis. Heparin was continued until his INR became therapeutic on coumadin. On postoperative day three, he was transferred back to the step down unit for further recovery. The physical therapy service worked with him to help increase his strength and mobility. Mr. [**Known lastname 11041**] continued to make steady progress and was discharged home on [**2161-10-7**]. He will resume his regular hemodialysis schedule. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist, the infectious disease service, his primary care physician and the renal service as an outpatient. Medications on Admission: Pt not compliant with meds, only taking Renagel and renal caps. The other indicated meds not taken. Atorvastatin Calcium 20mg qd Furosemide 80mg qam, 40mg qpm Epoetin Alfa 4,000U QMOWEFR Atorvastatin 20mg qd Sevelamer 2400mg Tablet TID w/meals Labetalol 200mg TID Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Aortic valve endocarditis ESRD/HD HTN elev. chol. chronic fatigue DVT repair of pyloric stenosis as a child Discharge Condition: good Discharge Instructions: no lifting > 10# for 10 weeks may shower, no bathing or swimming for 1 month no creams, lotions, or powders to any incisions call for fever greater than 100, redness or drainage no driving for one month Followup Instructions: with Dr. [**Last Name (STitle) **] in [**1-19**] weeks with Dr. [**Last Name (STitle) 914**] in [**3-21**] weeks [**Telephone/Fax (1) 170**] with Dr. [**Last Name (STitle) **] ([**Hospital **] clinic) [**10-23**] at 11:30 AM with Dr. [**First Name (STitle) 437**] (card)in [**2-20**] weeks HD Tues-Thurs-Sat Completed by:[**2161-10-13**]

Admission Date: [**2144-12-27**] Discharge Date: [**2145-1-6**] Date of Birth: [**2086-10-17**] Sex: F Service: ADMISSION DIAGNOSIS: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2145-1-6**] 15:16 T: [**2145-1-6**] 15:54 JOB#: [**Job Number **]

Admission Date: [**2185-7-20**] Discharge Date: [**2185-8-8**] Date of Birth: [**2185-7-20**] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: A 2315 gm product of a 34 5/7 weeks gestation born to a 34 year old gravida 4, para 2 mother with prenatal screens, A positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune and Group B Streptococcus unknown. Pregnancy complicated by partial previa with bleeding episodes during pregnancy. She was born by cesarean section due to the previa. Apgar scores were 8 at one minute and 9 at five minutes. No fever or rupture of membranes at delivery. The infant transferred to the Neonatal Intensive Care Unit for further evaluation. PHYSICAL EXAMINATION ON ADMISSION: Birthweight 2315 gm, 50th percentile, length 46.5 cm, 50th percentile, head circumference 31.5 cm, 50th percentile. Normocephalic, anterior fontanelle open and flat. Palate intact. Neck supple. Intercostal retractions, intermittent grunting and occasional nasal flaring noted. No murmur, regular rate and rhythm. Femoral pulses equal bilaterally. Abdomen soft with active bowel sounds, no masses or distention. Capillary refill, brisk, warm and well perfused. Hips stable, clavicles intact, normal premature female genitalia. Anus patent. Spine intact. No sacral dimple. HOSPITAL COURSE: Respiratory - Infant initially in room air, increased continuing retractions noted. Infant placed on nasal prongs CPAP 7 cm of water, decreased to 6 cm of water, requiring room air. Day of life No. 1, increasing respiratory distress and FIO2 requirement. Decision was made to intubate. The infant received a total of three doses of Surfactant this hospitalization. Maximum ventilatory settings of 20/6 with a rate of 20 requiring 30 to 40 percent FIO2. Chest x-ray revealed left pneumomediastinum/pneumothorax. Repeat chest x-ray on day of life No. 3 showed resolution of the pneumomediastinum. Ventilatory settings were decreased and the infant extubated to nasal cannula on day of life No. 3. The infant required nasal cannula from day of life No. 4 to day of life No. 7. The infant has remained in room air from day of life No. 7 with respiratory rates 40s to 60s and oxygen saturations greater than 95 percent. The infant has not had any apnea or bradycardia this hospitalization. The infant did not receive methylxanthines this hospitalization. Cardiovascular - No murmur. Infant has remained hemodynamically stable this hospitalization. Fluids, electrolytes and nutrition - The infant was initially receiving nothing by mouth, 80 cc/kg/day of D10/W. Glucoses have remained stable this hospitalization. Enteral feedings were started on day of life No. 3 and advanced to full volume feedings of 150 cc/kg/day by day of life No. 5. Maximum caloric density is Similac Special Care 24 cal/oz achieved on day of life No. 7. The infant is currently taking a minimum of 130 cc/kg/day of Similac 20 cal/oz p.o., calories were decreased on day of life No. 18 and most recent weight is 2695 gm ([**2185-8-7**]). Most recent electrolytes on day of life No. 4 showed a sodium of 138, potassium 4.7, chloride 108, bicarbonate 21. The infant received single phototherapy for a total of four days from day of life No. 4 to day of life No. 7. Maximum bilirubin level on day of life No. 4 was 14.1 with direct of 0.4. The most recent bilirubin level of day of life No. 8 was 4.8 with direct of 0.3. Hematology - Complete blood count on admission revealed white count 8900, hematocrit 47.3 percent, platelets 250,000, 28 neutrophils and 1 band. The infant has not received any transfusions this hospitalization. Infectious disease - The infant received a total of 48 hours of Ampicillin and Gentamicin to rule out sepsis upon admission. Blood cultures remain negative to date. Neurology - Normal neurologic examination. Sensory - Hearing screening was performed with automated auditory brain stem response, infant passed in both ears. Psychosocial - Parents involved. CONDITION ON DISCHARGE: Stable on room air. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 38807**], MD, phone number [**Telephone/Fax (1) 37949**]. CARE/RECOMMENDATIONS: Feedings at discharge - Similac 20 cal/oz p.o. minimum 130 cc/kg/day p.o. Medications - None. Carseat position screening - State newborn screen - Sent on [**7-23**], and [**8-3**], no abnormal results have been reported. Immunizations received - Hepatitis B vaccine was given on [**2185-7-31**]. Immunizations recommended - Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks; 2. Born between 32 and 35 weeks with two of the following, daycare during respiratory syncytial virus season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; 3. With chronic lung disease. Influenza Immunizations recommended annually in the fall for all infants once they reach six months of age, before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers. Follow up appointments - 1. Primary pediatrician. 2. [**Hospital6 407**]. DISCHARGE DIAGNOSIS: Prematurity. Status post respiratory distress. Status post rule out sepsis. Status post indirect hyperbilirubinemia. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2185-8-8**] 03:29:26 T: [**2185-8-8**] 07:46:04 Job#: [**Job Number 57751**]

Admission Date: [**2139-12-20**] Discharge Date: [**2139-12-24**] Date of Birth: [**2066-3-22**] Sex: F Service: [**Location (un) 259**] MEDICINE HISTORY OF PRESENT ILLNESS: Patient is a 73 year-old female with past medical history significant for hypertension, breast cancer, history of alcohol abuse who was transferred to the Medical Service with diagnosis of colonic ischemic. Patient originally presented to [**Hospital3 628**] with lower abdominal cramping followed by severe low back pain. She ten was found to have palpable abdominal mass and had later bowel movements with bright red blood mixed with liquid stool. Because of the concern for aortic enteric fistula she was emergently transferred to [**Hospital1 188**] for further evaluation. At [**Hospital1 190**] emergent body CT scan was performed and showed no fistula. However, it was positive for 4.5 cm abdominal aneurysm with a large intramural thrombus. Push enteroscopy was negative. The patient was found to be in DIC and was given two units of fresh frozen plasma and one unit of blood. This was followed by sigmoidoscopy which showed changes consistent with ischemic colitis as well as sigmoid diverticulosis. The patient was transferred back to the Surgical Intensive Care Unit and remained stable overnight. She was then transferred to medical service for further management of colonic ischemia. PAST MEDICAL HISTORY: Hypertension, breast cancer, constipation, status post left mastectomy, status post hysterectomy, status post appendectomy. MEDICATIONS ON ADMISSION: Cardura XT 40 mg once a day, Ameredex 1 tablet once a day, Lipitor and nasal spray. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is married, smokes one pack a day, drinks one to two glasses of whisky every day. PHYSICAL EXAMINATION: Temperature 97.1, blood pressure 128/70, pulse 76, respirations 18, oxygen saturation 97 percent on room air. General: in no acute distress, alert, oriented times two. Head, eyes, ears, nose and throat: Extraocular movements intact. Pupils equal, round and reactive to light and accomodation bilaterally. Oropharynx clear. Neck supple. Cardiovascular: regular rhythm and rate, no murmurs, rubs or gallops. Pulmonary: clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, positive bowel sounds. Extremities no edema, 2+ dorsal pedal pulses bilaterally. PERTINENT LABORATORIES: White cell cont 12.6, hematocrit 33.5, PT 12.9, PTT 25.4, INR 1.1. Sodium 145, potassium 3.3, chloride 108, bicarb 28, BUN 19, creatinine 0.7, glucose 149. HOSPITAL COURSE: The patient was kept in the hospital for three days for observation. She was started on prophylactic antibiotics, Levofloxacin or Flagyl for a four day course. Her hematocrit remained stable. Her gastrointestinal series resolved after receiving two units of fresh frozen plasma and one unit of packed red blood cells. She had a brief episode of post procedure delirium which resolved the next day. She remained oriented times three with no mental statu changes for the duration of the hospital stay. She was discharged to hoe on [**12-24**] in good condition. DISCHARGE DIAGNOSIS: Ischemic colitis. Transient delirium. DISCHARGE MEDICATIONS: Flagyl 500 mg p.o. 3 times a day for two days. Levofloxacin 500 mg p.o. once a day for two days, Lopressor 25 mg p.o. twice a day, lactulose p.r.n. FOLLOW UP: The patient will follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital 53879**] Medical Center. She is also informed that she needs repeat colonoscopy in eight to twelve weeks. Patient was given a choice between having colonoscopy at [**Hospital 53879**] Medical or calling [**Hospital1 346**] and scheduling an appointment with the gastroenterology department here. With regards to her abdominal aortic aneurysm vascular surgery was consulted and felt the patient did warrant consideration for elective surgical resection given the size and extent of the aneurysm (5cm infrarenal. A follow up appt with vascular surgery should be arrange approx 6 weeks after discharge DISCHARGE DIET: The patient is instructed to continue a low residue diet for another week and then start high fiber diet, activity as tolerated. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**] Dictated By:[**Name8 (MD) 2509**] MEDQUIST36 D: [**2139-12-24**] 12:26 T: [**2139-12-24**] 14:12 JOB#: [**Job Number 53880**]

Admission Date: [**2106-2-18**] Discharge Date: [**2106-2-21**] Date of Birth: [**2056-2-27**] Sex: M Service: CARDIOTHORACIC Allergies: Oxycodone Attending:[**First Name3 (LF) 165**] Chief Complaint: constrictive pericarditis Major Surgical or Invasive Procedure: Pericardiectomy for constrictive pericarditis. History of Present Illness: This 49-year-old patient with history of pericarditis since the 80s after a viral infection presented with worsening excised tolerance, lower extremity edema and abdominal swelling. Further investigations revealed severe calcific constrictive pericarditis confirmed by echo and cardiac angiogram and he was admitted for elective pericardiectomy. The coronary arteries were normal. There was no valvular pathology. Past medical history was significant for type 2 diabetes mellitus, atrial flutter- fibrillation and the constrictive pericarditis, obstructive sleep apnea, depression, asthma and CVA in [**2100**] with no residual deficiencies. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes 2. CARDIAC HISTORY: Constrictive pericarditis (TTE [**1-12**] showed EF 55%); hx of pericarditis since the 80s Atrial flutter / fibrillation s/p CV (on coumadin and sotalol) -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Obesity Obstructive sleep apnea (uses CPAP) Depression Asthma CVA [**2100**] - no residual deficits Renal calculi s/p lithotripsy Social History: lives with life, unemployed and filing for disability from merchant marine job -Tobacco history: chewing tobacco daily for 3-4 years; smoked [**2-4**] PPD for 13 years, quit in [**2082**] -ETOH: occasional -Illicit drugs: none Family History: mother died at age 54 and had a stroke at age 35. Father died at age 65 r/t an embolus following surgery Physical Exam: Physical Exam: On admission: VS: T 97.8, 108/75, 81, 20, 96% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Obese neck, cannot assess for JVP, no LAD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Distant heart sounds. LUNGS: Mild thoracic scoliosis. Resp were unlabored, no accessory muscle use. Bibasilar rales ABDOMEN: Obese, soft, NTND. No HSM or tenderness. EXTREMITIES: [**1-3**]+ edema to knees bilaterally, chronic venous stasis changes on anterior shins R>L; 1x1cm on anterior shin superficial ulcer with clear fluid expressed PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2106-2-20**] 11:25AM BLOOD WBC-11.8* RBC-3.89* Hgb-11.6* Hct-34.3* MCV-88 MCH-29.9 MCHC-33.8 RDW-14.2 Plt Ct-113* [**2106-2-18**] 12:12PM BLOOD PT-13.3 PTT-24.2 INR(PT)-1.1 CXR: FINDINGS: In comparison with the study of [**2-18**], the monitoring and support devices have been removed. Specifically, there is no interval. There is no pneumothorax. Enlargement of the cardiac silhouette persists with some diffuse prominence of interstitial markings consistent with elevated pulmonary venous pressure. ECHO: Pt presented for pericardectomy. LV systolic function was normal with no segmental wall motion abnormalities and a LVEF>55%. The valves are essentially normal. RV function was normal. A patent foramen ovale is present. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve leaflets are structurally normal. The pericardium appears thickened. Lateral mitral annular tissue Doppler measures E' 19cm/sec. [**2106-2-19**] 04:04AM BLOOD Glucose-165* UreaN-12 Creat-0.9 Na-139 K-3.8 Cl-103 HCO3-29 AnGap-11 Brief Hospital Course: The patient was brought to the operating room on [**2-18**] where the patient underwent Pericardiectomy. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 3 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged [**2-21**] in good condition with appropriate follow up instructions. Medications on Admission: duloxetine 60', gabapentin 200mg qAM, 200mg in afternoon, 300mg qHS, Lasix 80", sotalol 120", Metformin 1500mg qAM, 1000mg qHS, KCL 20", insulin regular hum U-500 20 with each meal Discharge Medications: 1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 3. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO LUNCH (Lunch). 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. metformin 500 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 7. metformin 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain for 10 days: prn for pain. Disp:*40 Tablet(s)* Refills:*0* 9. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 10. potassium chloride 20 mEq Packet Sig: One (1) PO twice a day. 11. Insulin Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Lunch Dinner Bedtime U500 25U U500 25U U500 25U U500 25U U500 Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia 71-200 mg/dL 0 Units 0 Units 0 Units 0 Units 201-240 mg/dL 20 Units 20 Units 20 Units 20 Units 241-280 mg/dL 25 Units 25 Units 25 Units 25 Units 281-320 mg/dL 30 Units 30 Units 30 Units 30 Units 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: constrictive pericarditis. Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Dr [**Last Name (STitle) **] office should call you with an appointment. They have been notified to contact you, If they do not please call his office. Name: [**Last Name (LF) **], [**First Name3 (LF) **] Department:Surgery Office Location:W/LMOB 2A Office Phone:([**Telephone/Fax (1) 1504**] Dr [**Last Name (STitle) **] office should call you with an appointment. They have been notified to contact you, If they do not please call his office. Name: [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] Title:MD Organization:[**Hospital1 18**] Office Location:W/[**Hospital Ward Name **] 4 Patient Phone:([**Telephone/Fax (1) 2037**] You have to come i for a wound check, This is [**3-2**] at 1010 hrs. Come to [**Hospital Ward Name 121**] 6 Please schedule an appointment in [**1-5**] weeks with your PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] S Address: 650 EVERGREEN [**Doctor Last Name **], [**Location (un) 36372**],[**Numeric Identifier 107172**] Phone: [**Telephone/Fax (1) 107173**] Fax: [**Telephone/Fax (1) 107174**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2106-2-21**]

Admission Date: [**2164-9-10**] Discharge Date: [**2164-9-18**] Date of Birth: [**2138-7-2**] Sex: F Service: MED Allergies: Reglan Attending:[**First Name3 (LF) 1055**] Chief Complaint: low back pain vaginal bleeding Major Surgical or Invasive Procedure: ultrasound guided D+C History of Present Illness: 26 yo G1P1 s/p NSVD 9 weeks ago w/ persistent LBP, low grade fevers and some vaginal bleeding. She presented to [**Hospital 1562**] [**Hospital **] clinic on [**2164-9-7**] and had a D&C & hysteroscopy and was sent home. She developed nausea, vomiting and epigastric abdominal pain that radiated to her back and presented to [**Hospital 1562**] Hospital on [**2164-9-8**]. At [**Hospital 1562**] Hospital, she had a chest CT that was unremarkable. 3 hrs post-IV contrast and 45min post-phenergan she developed acute respiratory distress and was intubated. She received solumedrol, sc epinephrine, benadryl. She was hypertensive to the 150/100's and a subsequent CXR showed pulmonary edema. She was transferred to the ICU. CTA on [**9-9**] was neg for PE, pos for b/l pleural effusions and pulmonary edema. She was diuresed, and her cardiac enzymes were noted to be elevated. A TTE at that time was notable for EF 40%, and her enzymes were attributed to demand ischemia and diastolic dysfunction. CXray w/ pulm edema and pt transfered [**Hospital1 18**] ICU for further evaluation. Past Medical History: sinus congestion s/p appy Social History: lives at home w/ husband, 9 week old dtr, [**Name (NI) **]; no drugs, EtOH, Family History: noncontributory Physical Exam: 98.9 122/65 134 23 100%; AC 500 18 5 40%; RSBI 40 on SBT; Gen: cauc W lying in bed in NAD awake, alert, responding appropriately, intubated HEENT: PERRL, EOMI Heart: tachy, RRR, S1, S2, no m/r/g Lungs: CTBLA, no rales Abd: + epigastric tenderness, umbilical tenderness w/ palpation, shifting dullness Ext: no edema, nail polish b/l Pertinent Results: [**9-17**]: Neck U/S: Negative ultrasound of the right neck, without evidence of vascular occlusion, dissection, or gross neck mass. [**9-12**]:Pelvic U/S: Vascular, echogenic and shadowing structure within the uterine cavity. Given the vascularity, the findings are concerning for retained products of conception. [**9-11**]: CT Chest w/o contrast: 1) Diffuse bilateral pulmonary consolidative opacities, which may represent a multifocal pneumonia or ARDS. Moderate sized bilateral pleural effusions are present. 2) Ill-defined pancreas with associated peripancreatic fat stranding consistent with acute pancreatitis. No focal fluid collections are present. 3) Non-obstructing, small, right renal calculus. 4) High density material within the uterine cavity likely representing residual blood products. [**9-10**]: TTE: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. There is moderate global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed. 3. Mild (1+) mitral regurgitation is seen. 4. There is mild pulmonary artery systolic hypertension. [**2164-9-12**]: Pathology- Product of conception: 1. Necrotic calcified and hyalinized placental tissue. 2. Implantation site fragments. [**2164-9-15**] TSH <0.02; Free T4 3.3 [**2164-9-10**] 11:28PM CK-MB-19* MB INDX-4.9 cTropnT-0.81* [**2164-9-10**] 11:28PM WBC-18.1* RBC-2.87* HGB-9.1* HCT-26.0* MCV-90 MCH-31.8 MCHC-35.2* RDW-16.7* [**2164-9-10**] 11:28PM PLT COUNT-50* [**2164-9-10**] 11:28PM PT-16.0* PTT-23.7 INR(PT)-1.6 [**2164-9-10**] 11:28PM FDP-80-160* [**2164-9-10**] 01:56PM GLUCOSE-175* UREA N-42* CREAT-1.1 SODIUM-144 POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-20* ANION GAP-16 [**2164-9-10**] 01:56PM ALT(SGPT)-104* AST(SGOT)-186* LD(LDH)-2329* CK(CPK)-420* ALK PHOS-53 AMYLASE-404* TOT BILI-4.3* [**2164-9-10**] 01:56PM LIPASE-178* [**2164-9-10**] 01:56PM CK-MB-21* MB INDX-5.0 cTropnT-0.82* [**2164-9-10**] 01:56PM ALBUMIN-3.0* CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-1.7 [**2164-9-10**] 01:56PM HAPTOGLOB-<20* Brief Hospital Course: 1. Respiratory Distress - the patient arrived to the ICU intubated. Chest x-ray w/ bilateral interstitial infiltrates. Etiology likely multifactorial including ARDS secondary to pancreatitis/retained products of conception and pulmonary edema given cardiac EF of 35%. Over the course in the ICU, the patients pulmonary status rapidly improved w/ diuresis. She was extubated on HD 3. On HD 5, she was transferred to the floor on 6L nasal cannula. She continued to receive gentle diuresis while on the floor. By HD 6, she only required 3L nasal cannula and by HD7, she had oxygen saturation of 96-99% on Room Air. She no longer received diuresis on her last hospital day. On discharge, her oxygen saturation was 98-99% on Room Air. She will have a follow up [**Month/Day/Year 113**] in [**12-20**] weeks to evaluate for resolution of her cardiomyopathy. 2. Fever - the likely source of the patient's fever was pancreatitis and/or the her retained products of conception. The patient was initially started on broad spectrum antibiotics including zosyn, clindamycin, and doxcycline. As culture data returned her antibiotic regimen was weaned appropriately. On HD 7, she was changed from IV meds to po levo/flagyl for possible pneumonia vs myometritis. Since she had no laboratory/radiological evidence of either condition, her antibiotics were stopped on HD 8. She remained afebrile off of antibiotics. 3. Pancreatitis - On admission, the patient was kept NPO w/ NG tube to suction. By hospital day 3 the patient was having bowel movements and with no abdominal pain. She was started on a regular diet which she tolearted well. The pt did not have further nausea/abdominal pain. Although her amylase/lipase trended up throughout the admission, she was not symptomatic so it was decided to stop trending her enzymes. She was seen by GI the day before discharge and it was decided that she should follow up for an MRCP then with Dr. [**Last Name (STitle) 3315**] for o/p work up of the etiology of her pancreatitis. 4. Anemia - The patient was given several units of blood (total 6U) for low blood counts while she was in the ICU. It was thought that the etiology of her anemia was a combination of low grade DIC (as her platelets also decreased, her DDimer was elevated and her fibrinogen nadired at 250) and blood loss during her U/S guided D+C. She was transferred to the floor on [**9-14**] (HD 5) and from that point on her hematocrit was stable between 25-28. She did not require any blood transfusions while on the floor. 5. Thrombocytopenia- On admission, the patient's platelets were 44. The differential for her low platelets included DIC, HIT (pt given lovenox) and HELLP. Her PTT/INR was 22.3/1.5,D-dimer 4514, fibrinogen-258 which was suggestive of low grade DIC (although if truly DIC picture would expect fibrinogen to be lower). A HIT antibody was sent which was negative. The timing and clinical picture (9 wks s/p SVD and no labs suggestive of hemolysis, no hypertension) was less consistent with HELLP syndrome. Her platelets trended up throughout the admission. At discharge, the patient's platelets were 480. 6. ARF - the patient's baseline creatine is 0.5 and at admission was 1.2. Initial urine lytes before hydration were consistent w/ a pre-renal picture. Subsequently, however, muddy brown casts consistent with ATN were noted in the patient's urine. Over the course of her ICU stay, the patients Cr trended downward as she autodiuresed well. Her creatinine remained at her baseline on her last three hospital days. 7. Hyperthyroidism-On admission, the patient was tachycardic ~130s (sinus). It was thought that the tachycardia was secondary to volume depletion vs infection. Her HR ranged from 100-170s, but trended in 100-120s with gentle hydration/antibiotics. On the day of transfer to the floor, the patient remained in the 120s so other sources of sinus tachycardia, including thyroid function, were evaluated. Her TSH was <0.02 and her free T4 was elevated. She was started on low dose beta-blocker for control of her heart rate. It was titrated up over a few days to maintain a HR 60-80 with hopes that by controlling her HR it would be less stressful to her heart and her cardiomyopathy would resolve. Endocrine was consulted for the question of hyperthyroid therapy and they felt that PTU or methmimazole would not be necessary during this admission and rate control would be sufficient. They also wanted to send several tests to evaluate for thyroiditis, hashimotos, and [**Doctor Last Name 933**] disease (her mother has had a thyroidectomy for [**Name (NI) 933**]). She will follow up with Endocrine as an o/p for the results of these labs and possible further treatment. 8. Elevated Blood Sugars-Throughout the admission, her fasting fingersticks ranged from 100-170. In the setting of illness, these numbers were not acted on but she was told to follow up for a fasting glucose as an outpatient. 9. Retained Products of Conception-THE POC were removed on [**2164-9-12**]. The patient had minimal vaginal bleeding after the procedure. An intraop US showed no further retained POC. The pathology from the DandC was consistent with necrotic villi. She will follow up with her OB/GYN as o/p in 2 weeks. 10. Anisocoria-On the day of transfer to the floors, it was noted that the patient's pupils were not equal R>L by more than 1 mm. (comparison of old pictures showed this was not previously the case.) Over the next two days, it was also noted that she developed ptosis of the right eyelid. She was seen by neurology, who thought the presentation was consistent with Horners and could be secondary to right IJ placement. An US of her neck was done which was negative for carotid dissection, hematoma, mass. At no point did the patient have other focal neurological symptoms. It was thought that the anisicoria should resolve on its own and the pt could follow up with neurology in the future if it did not resolve. Medications on Admission: motrin, vit, tylenol #3, amoxicillin; Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:*120 Tablet, Chewable(s)* Refills:*1* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 3. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hyperthyroidism Pancreatitis Heart Failure Retained Products of Conception Discharge Condition: stable Discharge Instructions: 1. Hyperthyroidism, please continue to take the lopressor 37.5 mg twice a day. You do not need medicine specifically for your thyroid at this time, but you should follow up with endocrinology for further management of your hyperthyroidism. Please call your primary care physician sooner if you experience increased palpitations, diarrhea, lightheadedness, fatigue. 2. Heart Failure Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 5 lbs. Adhere to 2 gm sodium diet. Also, you need to have a transthoracic echocardiogram in [**12-20**] weeks to reevaluate your heart function. 3. Pancreatitis-you should eat a low fat diet.You should eat [**2-21**] small meals a day, instead of 3 large meals a day. You should follow up for an MRCP at the scheduled time below. Please make an appointment with Dr. [**Last Name (STitle) 3315**] for some time after the MRCP is completed. (Dr. [**Last Name (STitle) 3315**] - [**Telephone/Fax (1) 4538**]) 4. Elevated glucose on finger sticks-you should follow up with your primary care physician for [**Name Initial (PRE) **] fasting blood glucose to evaluate for glucose intolerance. Your blood sugars were mildly elevated while you were in the hospital 100-150s. Followup Instructions: Please follow up with your primary care physician within the next week. Please follow up with your OB/GYN in 2 weeks. Provider: [**Name10 (NameIs) **] LAB TESTING Where: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) CARDIOLOGY Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2164-10-10**] 9:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9671**](Endocrinology) Where: [**Last Name (un) **] Phone:[**Telephone/Fax (1) 2378**], Date/Time:[**2164-10-18**] 1:00 (please arrive at 12:30 pm to register) ---please have your thyroid function tests-TSH, free T4, total T3 checked before this visit Provider: [**Name10 (NameIs) 706**] MRI Where: [**Hospital6 29**] [**Hospital6 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2164-9-29**] 10:45 Please make an appointment to follow up with Dr. [**Last Name (STitle) 3315**] [**Telephone/Fax (1) 4538**](after [**2164-9-29**] so he has the results of your MRCP).

Admission Date: [**2131-7-24**] Discharge Date: [**2131-7-28**] Date of Birth: [**2075-9-18**] Sex: F Service: Cardiothoracic Service CHIEF COMPLAINT: Shortness of breath HISTORY OF PRESENT ILLNESS: The patient was a 55 year old female who was recently discharged from [**Hospital6 649**] on [**2131-6-5**] after undergoing a workup for shortness of breath. She had originally presented to [**Hospital3 9683**] in [**2131-5-5**] with left scapular and left arm pain which was triggered by physical activity. She had denied at that time any shortness of breath, nausea, vomiting or cough. She was evaluated at [**Hospital1 **] Emergency Room and found to have electrocardiogram changes and was transferred to [**Hospital6 1760**] for further evaluation. She was catheterized in [**2131-6-4**] which demonstrated a normal left main, a 50% proximal stenosis of the left anterior descending, 100% mid stenosis of the left anterior descending and 80% stenosis of the diagonal, and a 50% stenosis of the left circumflex and 100% stenosis of the right posterolateral artery. Echocardiogram demonstrated an ejection fraction of 40 to 45% with a mildly dilated left atrium, moderate symmetric left ventricular hypertrophy, septal distal, inferior and apical hypokinesis and 1+ mitral regurgitation. On that admission the patient underwent stenting of a left anterior lesion. She tolerated the procedure well and was sent home and now returns for coronary artery bypass graft. The patient has remained well with no symptoms. PAST MEDICAL HISTORY: Significant for - 1. Coronary artery disease status post stent to the left anterior descending; 2. Sarcoidosis with pulmonary involvement; 3. Noninsulin dependent diabetes mellitus times 15 years; 4. Blindness secondary to diabetic retinopathy. MEDICATIONS ON ADMISSION: Lopressor 50 mg p.o. b.i.d., Aspirin 325 mg p.o. q.d., Protonix 40 mg p.o. q.d., Glucophage 500 mg p.o. b.i.d., Amaryl 4 mg p.o. b.i.d., Lisinopril 10 mg p.o. q.d. and Plavix which was stopped preoperatively. ALLERGIES: Penicillin and Novocaine, both of which cause shortness of breath. SOCIAL HISTORY: She is retired and lives alone and denies tobacco and ethyl alcohol use. PHYSICAL EXAMINATION: The patient is an obese female in no acute distress. Temperature is 98, pulse 79, blood pressure 184/68, breathing at 20, 99% on room air. Her oropharynx is clear. Her chest is clear to auscultation bilaterally. She is regular with no murmurs, rubs or gallops. Her abdomen is obese, soft, nontender with no palpable masses. She has trace edema bilaterally. LABORATORY DATA: Laboratory studies prior to admission included white count 6.2, hematocrit 36, platelets 170, PT 12.7, PTT 26.7, INR 1.1, sodium 137, potassium 5.3, chloride 101, bicarbonate 26, BUN 24, creatinine 0.9, ALT 19, AST 14, alkaline phosphatase 92, total bilirubin 0.8. Lactic dehydrogenase is 143. Chest x-ray showed lungs clear, no pleural effusions. Electrocardiogram showed sinus rhythm at a rate of 70, left axis deviation and Q waves in V1 through V2 with ST segment elevation and T wave inversions. No acute ischemic changes. Cardiac catheterization and echocardiogram as above. HOSPITAL COURSE: On the day of admission the patient went to the Operating Room and she underwent coronary artery bypass graft times three. The grafts were left internal mammary artery to the left anterior descending, saphenous vein graft to obtuse marginal and saphenous vein graft to ramus intermedius. During the procedure she also underwent mediastinal lipoma resection, and lymph node biopsy which was sent to Pathology. She tolerated the procedure well and was transferred to the Cardiothoracic Intensive Care Unit, A-V paced at 88 and on Propofol drip. Postoperatively she remained hemodynamically stable and was making adequate urine with minimal chest tube output. The patient was weaned to extubation without incident. On postoperative day #1 her pulmonary catheter was discontinued. The patient was assisted to the chair and she remained hemodynamically stable requiring no pressor support. She was transferred to the floor on postoperative day #1. On postoperative day #2 her chest tubes were removed, the Foley catheter was removed, her Beta blocker was increased. She remained hemodynamically stable and was seen by Physical Therapy and began ambulation. On postoperative day #3 her epicardial wires were removed. She was at activity level 4, as otherwise had been tolerating a diet and is stable for discharge to rehabilitation. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post coronary artery bypass graft times three 2. Sarcoidosis, no pulmonary involvement 3. Insulin dependent diabetes mellitus 4. Blind secondary to diabetic retinopathy 5. Mediastinal lymph node biopsy showing granulomatous lymphadenitis. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg p.o. b.i.d. 2. Glucophage 500 mg p.o. b.i.d. 3. Amaryl 4 mg p.o. b.i.d. 4. Protonix 40 mg p.o. q.d. 5. Lasix 20 mg p.o. b.i.d. times seven days 6. Potassium chloride 20 mEq p.o. b.i.d. times seven days 7. Motrin 400 mg p.o. q. 6 hours prn 8. Colace 100 mg p.o. b.i.d. 9. Aspirin 325 mg p.o. q.d. 10. Percocet 5/325 one to two p.o. q. 4 hours prn 11. Lisinopril 10 mg p.o. q.d. 12. Insulin sliding scale CONDITION ON DISCHARGE: Stable. DISPOSITION: The patient is discharged to rehabilitation to undergo physical therapy and wound monitoring. The patient will follow up with Dr. [**Last Name (STitle) **] in four weeks and the patient will follow up with primary care physician in two weeks, she will call for an appointment. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2131-7-28**] 09:30 T: [**2131-7-28**] 10:00 JOB#: [**Job Number 21531**]

Admission Date: [**2152-9-10**] Discharge Date: [**2152-9-12**] Date of Birth: [**2091-11-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 598**] Chief Complaint: left hand numbness, neck pain Major Surgical or Invasive Procedure: none History of Present Illness: 60 year old restrained driver S/P MVA [**2152-9-10**] was taken to [**Hospital3 4107**] and transferred to [**Hospital1 18**] with C3-4 disc protrusion. He complained of numbness in left hand and fingers as well as neck pain and right shoulder pain. He was admitted to the Trauma Service for further management. Past Medical History: Type II Diabetes Hypercholesterolemia Social History: Tobacco ; none ETOH : occasionally Family History: non contributory Physical Exam: Temp 98.8 HR 65 BP 173/79 RR 12 O2 sat 98% HEENT NCAT conjunctiva pink, sclera anicteric, PERRLA Neck some tenderness to palpation, collar in place Chest clear, equal breath sounds, no deformity COR RRR Abd soft, non tender Ext non tender, no lacerations, no edema Pertinent Results: [**2152-9-10**] 10:40AM PT-12.0 PTT-26.6 INR(PT)-1.0 [**2152-9-10**] 10:40AM PLT COUNT-234 [**2152-9-10**] 10:40AM NEUTS-69.3 LYMPHS-23.6 MONOS-4.8 EOS-1.7 BASOS-0.5 [**2152-9-10**] 10:40AM WBC-10.6 RBC-4.90 HGB-13.7* HCT-41.1 MCV-84 MCH-28.0 MCHC-33.5 RDW-14.5 [**2152-9-10**] 10:40AM GLUCOSE-93 UREA N-14 CREAT-0.8 SODIUM-141 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17 [**2152-9-10**] Abdominal CT : . No acute intrathoracic, abdominal or pelvic injury or evidence of fracture. 2. Probable bilateral simple renal cysts. 3. Small paraesophageal hernia. [**2152-9-10**] Head CT :1. No acute intracranial abnormality. 2. Fluid level in the left maxillary sinus may be related to chronic sinus disease. Limited evaluation of the facial bones demonstrates no evidence of fracture. However, clinical correlation is recommended to evaluate for facial trauma versus sinus disease. NOTE AT ATTENDING REVIEW: The left maxillary sinus finding could represent a minor degree of mucosal thickening, although the complete maxillary sinuses were not imaged on this stud [**2152-9-10**] C Spine CT : 1. No evidence of acute fracture or malalignment. 2. Multilevel degenerative change, most evident at C3-4, where there is a moderate central disc protrusion causing indentation of the anterior thecal sac and cord compression. Acuity of this finding is unknown. In addition, there is ossification of the posterior longitudinal ligament at C3. These findings may predispose the patient to cord injury in the setting of trauma, and MRI is recommended for further evaluation if clinically indicated. [**2152-9-10**] MRI C Spine : Disc protrusion at C3-4, which has mass effect on the ventral aspect of the cord. There is artifactually-increased T2-signal in the cord, without definitivee evidence of cord edema. While this could represent an acute disc herniation, an acute-on-chronic, or simply chronic process are also possible. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the TSICU and evaluated by the Trauma Service and the Ortho/spine service. He remained hemodynamically stable, his neck was stabilized with a cervical collar and within 24 hours his left hsnd paresthesias resolved. He underwent an MRI of the C spine which showed a C3-4 disc protrusion with no evidence of cord edema. This could be acute, acute on chronic or just a chronic finding. As his physical exam improved he was transferred out of the ICU and was up and ambulating on the surgical floor with a cervical collar in place. His blood sugars were checked QID however he was not placed on his routine Janumet as his sugars were in the 100-130 range. He will continue to check his sugars at home, record them and call his endocrinologist tomorrow for further management. After follow up by the ortho/spine service he was cleared for discharge with instructions to wear his cervical collar at all times except for showers and follow up with Dr. [**Last Name (STitle) 1007**] in 2 weeks. At the time of discharge he was up and ambulating without difficulty, tolerating a diabetic diet and his pain was controlled with Ibuprofen. He was placed on Prilosec for use during his therapy with Ibuprofen. Medications on Admission: Janumet 50/1000 mg Po QAM Janumet 50/500mg PO QPM Zocor 20mg PO Daily ASA 81 mg po Daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headache, fever. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*1* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. Janumet 50-1,000 mg Tablet Sig: One (1) Tablet PO QAM. 6. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: MVA with C3-4 protrusion with cord indentation/compression Type II Diabetes Discharge Condition: stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. * Check your blood sugar three times a day and record. Call your endocrinologist tomorrow with most recent blood sugars to discuss resuming Janumet. * continue to wear cervical collar at all times until seen by Dr. [**Last Name (STitle) 1007**]. You may remove it for showers only. *No driving until cleared by Dr. [**Last Name (STitle) 1007**] CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Call Dr. [**Last Name (STitle) 1007**] [**Telephone/Fax (1) 1228**] for a follow up appointment in 2 weeks Call Dr. [**Last Name (STitle) 10543**] at [**Telephone/Fax (1) 4475**] for a follow up appointment in 2 weeks [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2152-9-12**]

Admission Date: [**2183-10-9**] Discharge Date: [**2183-10-25**] Date of Birth: [**2122-10-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 11220**] Chief Complaint: retroperitoneal bleed s/p fall Major Surgical or Invasive Procedure: IVC filter placement Lumbar artery embolization Triple Lumen catheter placement Blood Product Transfusion PICC line placement History of Present Illness: This is a 61yoF with hx of bipolar d/o, nephrogenic diabetes insipidus, hypothyroidism, recently diagnosed RLE peroneal DVT on warfarin, admitted to the TSICU s/p fall for management of RP bleed. The pt was discharged to Rehab from [**Hospital1 18**]-[**Location (un) 620**] on [**2183-10-1**] after an admission for altered mental status that was ultimately attributed to lithium toxicity and an untreated UTI, during which time she was found to have a RLE peroneal DVT and started on warfarin. On [**10-9**] the pt had a witnessed slip and fall and was taken to [**Hospital1 **]-N for hypotension where she was found to have HCT 19. Noncon CT scan revealed a large left RP hematoma and transferred to [**Hospital1 18**] for further management. In the TSICU the pt was hemodynamically unstable despite volume resuscitation, was given ultimately 11u prbc and 8u ffp. IR was consulted and on [**10-10**] placed an IVC filter and embolized 2 bleeding lumbar arteries after which she stabilized. No further blood transfusions since [**10-10**]. Hemodynamically stable. Pt still with some delirium/agitation, though alert and oriented. The patient is currently being transferred for management of diabetes insipidus. Per the team they have been trying to free water resuscitate but having difficulty following with her large diuresis (8-10L uop daily). Na has ranged from 138-151 (currently 145). Currently, patient feels short of breath and palpitations. States that she has a cough that is productive with yellow phlegm. Denies hemoptyiss. Denies headache, chest pain (both pressure and pleuritis) nausea, vomiting, abdominal pain, distention, and leg pain. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Currently passing flatus and gas Past Medical History: hypothyroidism hypertension osteoarthritis spinal stenosis w low back pain ?parkinsonism ?PMR hypersalivation h/o dry mouth Social History: She is not working. She drinks alcohol socially. She does not smoke. She is married. Her activity level is quite low at baseline because of pain. Family History: Parents with alcoholism. Sister and brother with "issues" per husband. [**Name (NI) **] known fam history of suicide. Physical Exam: On Transfer: VS 98.7 118 153/74 24 88-92%RA GENERAL - NAD, mildly tachypneic, speaking in [**3-27**] word sentences HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM NECK - supple, no thyromegaly, no JVD, IJ site clean/dry/intact HEART - tachycardic LUNGS - poor air movement, bilateral wheezes throughout with faint rales at bases ABDOMEN - soft, obese, distended, hyperactive, initially high pitched BS, difficult to assess organomegaly given EXTREMITIES - WWP, L>R edema, no calf pain, pain with passive ROM of knee NEURO - awake, A&Ox3, CNs II-XII grossly intact Discharge Exam: 98.4 119/72, 98, 18, 94%RA GENERAL - appears unwell, pale, rigoring, clammy HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM HEART - tachycardic LUNGS - faint wheezes ABDOMEN - soft, obese, distended, nontender, normal BS, difficult to assess organomegaly given, stable subcutaneous nodule in LLQ GU: IR site, c/d/i, foley in place EXTREMITIES - WWP, trace edema, hadn exam unremarkable Pertinent Results: Admission Labs: [**2183-10-9**] 02:05PM BLOOD WBC-10.9 RBC-2.72* Hgb-8.5* Hct-25.2* MCV-93 MCH-31.4 MCHC-33.9 RDW-17.4* Plt Ct-343# [**2183-10-9**] 02:05PM BLOOD Neuts-84.0* Lymphs-11.2* Monos-4.5 Eos-0.2 Baso-0.1 [**2183-10-9**] 03:30PM BLOOD PT-18.4* PTT-51.7* INR(PT)-1.7* [**2183-10-9**] 02:05PM BLOOD Glucose-140* UreaN-18 Creat-1.2* Na-138 K-6.1* Cl-108 HCO3-17* AnGap-19 [**2183-10-9**] 02:05PM BLOOD Calcium-8.0* Phos-5.1*# Mg-1.9 Discharge Labs: [**2183-10-25**] 05:52AM BLOOD WBC-7.7 RBC-3.36* Hgb-10.0* Hct-31.0* MCV-92 MCH-29.7 MCHC-32.2 RDW-14.6 Plt Ct-854* [**2183-10-20**] 06:10AM BLOOD Neuts-81.4* Lymphs-7.6* Monos-9.8 Eos-0.8 Baso-0.4 [**2183-10-25**] 05:52AM BLOOD Glucose-89 UreaN-12 Creat-0.9 Na-142 K-4.5 Cl-108 HCO3-23 AnGap-16 [**2183-10-25**] 05:52AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.2 Other Notable Labs: Micro: [**2183-10-20**] 4:40 pm BLOOD CULTURE **FINAL REPORT [**2183-10-23**]** Blood Culture, Routine (Final [**2183-10-23**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final [**2183-10-21**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) 12708**] [**Last Name (un) 12707**] AT 8:28AM ON [**2183-10-21**]. Aerobic Bottle Gram Stain (Final [**2183-10-21**]): GRAM NEGATIVE ROD(S). [**2183-10-20**] 9:53 am URINE Site: NOT SPECIFIED **FINAL REPORT [**2183-10-23**]** URINE CULTURE (Final [**2183-10-23**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- 4 S 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S 1 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R Imaging: CXR: Interval placement of a right internal jugular catheter with tip projecting at the expected level of the high superior vena cava. CXR: Mild cardiomegaly is accompanied by worsening pulmonary vascular congestion. Persistent areas of patchy and linear atelectasis in the juxtahilar regions, and in the retrocardiac area. Likely layering left pleural effusion resulting in hazy increased opacity throughout the left hemithorax. TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No definite aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No definite valvular dysfunction identified. CTA Chest: 1. The exam is equivocal. There is no central PE. Left lower lobe heterogeneity in arteries is probably due to artifact and less likely to pulmonary embolism. A VQ scan can be helpful. 2. Right pleural effusion is minimal and left pleural effusion is mild-to-moderate and both have increased since [**10-9**]. The left one has hemorrhagic density. CXR: Improvement of congestive pattern, new pulmonary abnormalities. CXR: As compared to the previous radiograph, the lung volumes have decreased. As a consequence, there is crowding of the vascular and bronchial structures at the lung bases and a newly appeared retrocardiac atelectasis. However, there is no evidence for acute lung changes such as pneumonia or pulmonary edema. No pleural effusions. Unchanged borderline size of the cardiac silhouette. Brief Hospital Course: HOSPITALIZATION SUMMARY: 61yoF with history bipolar disorder, nephrogenic diabetes insipidus, hypothyroidism, recently diagnosed RLE peroneal DVT on warfarin initially presented s/p fall found to have RP bleed called out to medicine for management for diabetes insipidus who hospital course was complicated by: hypoxia, tachycardia, polyuria, delirium and Ecoli/Pseudomonas Bacteremia from UTI. ACTIVE ISSUES: # Gram Negative Rod Sepsis: On HD12, patient developed acute onset leukocytosis to 19 and spiked a fever to 103.1. Patient was pancultured and UA revealed a UTI. She was initially started CTX however patient continued to spike fevers and was broadened to Vancomycin and Zosyn. On HD13, it was found that she had GNRs in her blood. Ciprofloxacin was added. She continued to have positive blood cultures until [**10-22**]. She defervesced on [**10-22**] AM and was ultimately narrowed to cefepime. CT Torso was completed and ruled out perinephric abscess. A PICC line placed. Patient ill need 2 weeks of cefepime. Last dose will be [**11-5**]. # Retroperitoneal Bleed: Patient was admitted initially to surgical service after found to be hypotensive and with Hct of 19. She was subsequently found to have a large retroperitoneal bleed in the setting of an INR of 2.9 from anticoagulation for known DVT. Patient was given a total of 11 units of pRBCs and 8 units of FFP. Given her instability she was taken emergency to angiography from embolization to stop the bleeding. Patient was observed in the surgical ICU for several days with stable blood counts. She was then transferred to the general medicine floor for ongoing management. Given recent life threatening bleed, anticoagualtion was not restarted (see below) and IVC filter was placed. # Hypoxia/Tachypnea: Upon transfer to the medical service, patient was noted to be tachypneic and mildly hypoxic to 88-92% on room air. Chest xray revealed pulmonary congestion consistent with hypervolemic state. She was given one dose of lasix with improvement of oxygen saturations. CTA chest was completed which was equivocal for PE however given recent bleed and improvement of oxygen saturation, anticoagulation was not inititated (see below). She remained intermittently tachypneic however it seemed related to anxiety given relately normal chest xrays. She did suffer from a cough which was thought to be related to mild reactive airway disease. Her symptoms improved with nebulizer treatments. # Tachycardia: Patient developed sinus tachycardia while admitted. Initially it was thought to be related to intravascular depletion given large blood loss and underlying nephrogenic diabetes insipidis (see below). However volume repletion was difficult given hypoxia. PE was also considered given hypoxia and recent DVT. CTA was pursued however was equivocal. TSH was checked and was normal. Psychogenic causes (given history of bipolar disorder) and medication related tachycardia (largely duloxetine) were also considered however after discussion with psychiatry this appeared less likely. Patient ultimately started on metoprolol with good response. # Polyuria/Nephrogenic Diabetes Insipidus: After aggressive fluid resuscitation and in the setting of underlying nephrogenic diabetes insipidus from chronic lithium use patient developed polyuria (urinating upwards to 13L per day). She as a resulted developed hypernatremia to 151 and while in the surgical ICU was given D5W. She was also started on amloride however given hyperkalemia, it was discontinued. While on the medical floor, she continued to have polyuria. Renal was consulted and recommended increasing access to free water and allowing for autoequilibration. By HD#[**6-29**], she seemed to remain euvolemic without requiring any interventions. # Delirium: On arrival to [**Hospital1 18**], in the setting of acute illness, patient was delirious. Psychiatry was consulted who suggested using olanzapine [**Hospital1 **] with prn doses. With resolution of acute illness, delirium improved dramatically. # Recent DVT: Patient was recently diagnosed with DVT and was placed on lovenox and coumadin. It was thought that her RP bleed was related to a fall in the setting of being anticoagulated. While patient remained stable and Hct was stable, she remained a fall risk. Anticoagulation in this setting was deemed a major risk. While her CTA chest was equivocal she clinically improved without anticoagulation. A discussion was had with the patient and husband regarding the risks and benefits of anticoagulation and it was decided to hold on anticoagulation until patient becomes stronger from a mobility standpoint. This will need to be readdressed in a couple of weeks. # Deconditioning: Given extensive hospitalization, patient became deconditioned. Physical therapy saw patient and recommended rehab. It should be noted that the goal of Mrs. [**Known lastname **] is to ultimately return home once she is stronger. # Bipolar Disorder: Patient with prior history bipolar and had been on lithium in the past. Recently she had lithium toxicity and lithium was ultimately stopped. After discussion with [**Hospital1 18**] psychiatry and outpatient psychiatry, patient was started on olanzapine for mood stabilization. # IV Contrast Filitration: On HD#15, patient underwent CT torso to evaluate for abscess/fluid collection given persistent fevers (see below). While at CT, IV contrast infiltrated skin. Plastics and hand were consulted who felt hand was safe. They recommended hand elevation and frequent exams. On discharge there was no evidence of compartment syndrome or skin necrosis. TRANSITIONAL ISSUES: - RP Bleed: Patient's hematocrit has been stable. She will need follow up CBC on [**2183-11-6**] to ensure Hematocrit stability - GNR Bacteremia: Patient will continue cefepime until [**11-6**]. At this time, PICC line can be discontinued - Tachycardia: Patient should have metoprolol titrated for goal HR < 90. - Anticoagulation: Coumadin held given recent bleed and fall risk however anticoagulation should be readdressed once patient is stronger. Medications on Admission: levodopa/carbodopa 25/100mg tid, levoxyl 88mcg daily, remeron 30mg daily, colace 100mg [**Hospital1 **], neurontin 300mg tid, senna prn, cymbalta 60mg daily, protonix 40mg daily, tylenol prn, MOM prn, dulcolax prn, coumadin 5mg daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H pain 2. Carbidopa-Levodopa (25-100) 1 TAB PO TID 3. Duloxetine 60 mg PO DAILY 4. Gabapentin 300 mg PO TID 5. Mirtazapine 30 mg PO HS 6. Pantoprazole 40 mg PO Q24H 7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 8. Benzonatate 100 mg PO TID:PRN cough 9. CefePIME 2 g IV Q12H 10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 11. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing, increased WOB 12. Lidocaine 5% Patch 1 PTCH TD DAILY 13. Metoprolol Tartrate 50 mg PO TID 14. Miconazole Powder 2% 1 Appl TP QID:PRN to affected areas 15. OLANZapine (Disintegrating Tablet) 2.5 mg PO QAM 16. OLANZapine (Disintegrating Tablet) 5 mg PO QHS 17. OLANZapine (Disintegrating Tablet) 2.5 mg PO Q4H:PRN agitation 18. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 19. Docusate Sodium 100 mg PO BID 20. Levoxyl *NF* (levothyroxine) 88 mcg Oral daily 21. Milk of Magnesia 15-30 mL PO Q4H:PRN constipation/indigestion 22. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: retroperitoneal bleed deep vein thrombosis sinus tachycardia septicemia from 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). Discharge Instructions: You were admitted to the hospital because you feel and were found to have a large bleed in your belly. It required embolization of one the arteries in your belly. You also required several units of blood to replace the blood your lost. While admitted you developed a urinary tract infection which spread to your blood and made you very sick. We treated you with antibiotics and the bacteria cleared from your blood. Because of the severity of your infection however you will require IV antibiotics for several days. The last day of antibiotics will be on [**2183-11-6**]. Your heart rate was also elevated while you were admitted and we started you on a medication to slow your heart rate. You were originally on Coumadin (a blood thinning medication) to help treat the clot in your leg that you developed several weeks ago. Because of the bleed that your suffered and because you remain at risk for bleeding, we have decided to hold Coumadin until you become stronger. This will need to be readdressed when you are stronger. Followup Instructions: You will need to follow up with your PCP when you are discharged from rehab. You will also need to follow up with your psychiatrist when you are discharged from rehab. [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**] Completed by:[**2183-10-26**]

Admission Date: [**2142-4-28**] Discharge Date: [**2142-6-11**] Date of Birth: [**2120-10-16**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Shellfish Attending:[**First Name3 (LF) 30**] Chief Complaint: Purpura, fever, "flu-like" symptoms Major Surgical or Invasive Procedure: Oral Intubation Central Line Placement [**2142-5-14**]: Placement of 8.0 Portex tracheostomy tube, placement of #19 French Ponsky percutaneous endoscopic gastrostomy tube, flexible bronchoscopy. [**2142-5-23**]: PICC Line Placement [**2142-5-28**]: Right foot incision and drainage. [**2142-5-30**]: Bilateral incision and drainage with debridement of both feet. History of Present Illness: The patient is a 21 year old African-American male with no significant past medical history who presented to the ED on [**2142-4-28**] after being transferred from [**Hospital 1474**] Hospital. The patient had presented to [**Hospital1 1474**] via his family on [**2142-4-27**] at 5:30 pm with the chief complaint of generalized body aches. He complained of left knee pain after recently suffered an injury to his left knee (scraped) while playing basketball for which he was evaluated for at an OSH. He also complained of nausea, vomiting, diarrhea, and headache. . At [**Hospital1 1474**], the patient was noted to have a temperature of 103, P 122, BP 128/69. He was sat'ing 99% on RA. The patient was found to have a left swollen knee and purpura fulminans. He was given Ceftriaxone 2 gm IV (split dose), doxycycline 100 mg PO, vancomycin 1 gm IV. He also received an estimated 3.5 liters. . The patient's ABG at [**Hospital1 1474**] at 12:40 am was as follows: . 7.33/27/103/13.6 . His Chem7 at [**Hospital1 1474**] was notable for a K of 3.2, gap of 15, Cr 2.4. . At [**Hospital1 1474**], the left knee was tapped. He was then transferred to [**Hospital1 18**] for further evaluation. . On arrival, the CXR concerning for ARDS with: . Diffuse faint opacity bilaterally with increased interstitial markings, worrisome for atypical diffuse infection such as virus or PCP. . His ABG at [**Hospital1 18**] was as follows: . 7.11/47/116/16 with a lactate of 9.6 at 5:15 am on [**2142-4-28**]. . He was subsequently intubated. His SBP dropped to the 80s and he was thus started on levophed now at 0.458. Solumedrol and later decadron were given. Central line with continuous Svo2 monitor placed. . ROS: as per HPI, unable to get further info as pt int/sed Past Medical History: PMH: Asthma . Past Surgical History: None Social History: The patient works at [**Company 2486**]. He is married but separated and currently sexually active (unprotected) with a female partner. The patient had travelled to [**State 2748**] three weeks ago. No animal/rodent contact. Physical Exam: On admission to the ED: Tc=97.7 P=97->136 BP=102/49 RR=23 92% on RA . On arrival to MICU . Tc= P=136 BP=115/63 RR=28 Gen - int/sed HEENT - PERRLA Heart - tachy, nl s1s2, no mrg Lungs - clear Abdomen - soft nt nd nabs Ext - wwp Skin - diffuse purpura over arms/legs, including soles and palms Neuro - mae, sedated on meds Pertinent Results: [**2142-4-28**] 03:00AM FIBRINOGE-142* D-DIMER->[**Numeric Identifier 961**]* [**2142-4-28**] 03:00AM PT-27.7* PTT-80.6* INR(PT)-2.9* [**2142-4-28**] 03:00AM PLT SMR-LOW PLT COUNT-81* [**2142-4-28**] 03:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+ [**2142-4-28**] 03:00AM NEUTS-73* BANDS-10* LYMPHS-4* MONOS-1* EOS-1 BASOS-0 ATYPS-1* METAS-10* MYELOS-0 [**2142-4-28**] 03:00AM WBC-11.0 RBC-5.19 HGB-14.4 HCT-44.4 MCV-86 MCH-27.8 MCHC-32.5 RDW-13.6 [**2142-4-28**] 03:00AM CORTISOL-42.0* [**2142-4-28**] 03:00AM TOT PROT-4.8* CALCIUM-6.9* PHOSPHATE-3.8 MAGNESIUM-1.1* [**2142-4-28**] 03:00AM CK-MB-9 [**2142-4-28**] 03:00AM ALT(SGPT)-14 AST(SGOT)-36 CK(CPK)-1401* ALK PHOS-108 AMYLASE-92 TOT BILI-0.6 [**2142-4-28**] 03:00AM GLUCOSE-86 UREA N-20 CREAT-3.1* SODIUM-141 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-11* ANION GAP-26* [**2142-4-28**] 03:01AM LACTATE-9.6* [**2142-4-28**] 04:45AM URINE RBC-[**1-28**]* WBC-[**5-5**]* BACTERIA-MANY YEAST-NONE EPI-0 [**2142-4-28**] 04:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [**2142-4-28**] 04:45AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.023 [**2142-4-28**] 05:15AM PO2-116* PCO2-47* PH-7.11* TOTAL CO2-16* BASE XS--14 [**2142-4-28**] 06:30AM JOINT FLUID NUMBER-NONE [**2142-4-28**] 06:30AM JOINT FLUID NUMBER-NONE [**2142-4-28**] 06:30AM JOINT FLUID WBC-4100* HCT-14.0* POLYS-89* LYMPHS-9 MONOS-2 . CXR [**2142-4-28**] - The heart is normal in size. The mediastinal contours are within normal limits. Note is made of increased interstitial markings bilaterally, worrisome for atypical infection such as virus or PCP. [**Name10 (NameIs) 67451**] arch is somewhat prominent. . CT HEAD [**2142-4-28**] - No evidence of hemorrhage, shift of normally midline structures, or hydrocephalus. [**Doctor Last Name **]-white differentiation appears grossly preserved. Air- fluid levels are noted within the frontal, maxillary and sphenoid sinuses. There is also opacification of the ethmoid airspaces. . MRI HEAD/CSPINE ([**2142-5-12**])- No evidence of intracranial enhancement, mass effect, or hydrocephalus. No focal signal abnormalities or acute infarcts. Extensive soft tissue changes in the mastoid air cells and the paranasal sinuses could be related to intubation. No evidence of epidural abscess or hematoma. No spinal cord compression seen. Clinical correlation recommended. . CT TORSO ([**2142-5-13**]) - CT OF THE CHEST WITHOUT IV CONTRAST: The endotracheal tube is above the level of the carina. The NG tube is in satisfactory position. There are multiple sub 5-mm pulmonary nodules diffusely throughout the lung fields. There are small bilateral pleural effusions as well as bibasilar atelectasis. There is diffuse anasarca. There is evidence of pulmonary edema. There are no visualized lymph nodes meeting CT criteria for pathology on this unenhanced scan. The pleural effusions measures simple fluid in Hounsfield units. . CT OF THE ABDOMEN WITHOUT IV CONTRAST: On this unenhanced scan, the liver, adrenal glands, gallbladder, spleen, pancreas, kidneys, and ureters are normal. The small bowel is normal. The large bowel is distended and fluid- filled, and featureless. Again there is diffuse anasarca. There is no visualized lymphadenopathy or free fluid, given the limitations of this unenhanced scan. The aorta is of normal caliber. There is no evidence of retroperitoneal hematoma. . CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum is fluid-filled and distended. The bladder contains a Foley catheter. There is diffuse anasarca. No free fluid. No inguinal lymphadenopathy. . PORTABLE CHEST OF [**2142-5-29**] Tracheostomy tube and right PICC line remain in standard position. Cardiac silhouette appears prominent but stable in size. Pulmonary vascularity is within normal limits. Previously reported basilar areas of consolidation are no longer evident. There are no new areas of consolidation, but the extreme periphery of the right lung base laterally has been excluded, precluding assessment of this region. . ECHOCARDIOGRAM [**2142-5-25**]: The left atrium is 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. Overall left ventricular systolic function is normal (LVEF 70%). 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. There is a trivial/physiologic pericardial effusion. . TEE [**2142-6-1**] (under general anesthesia): No thrombus/mass is seen in the body of the left or right atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). A Chiari network is present in the right atrium (normal finding). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. No masses or vegetations are seen on the aortic, mitral, tricuspid or pulmonic valves. There is a trivial pericardial effusion or pericardial fat present. . CXR [**2142-6-6**]: Portable chest radiograph reviewed. The PICC tip is unchanged in position overlying the mid SVC. The heart and mediastinal contours are stable. The lungs are suboptimally evaluated given exposure, but appear clear. The pleura appear clear. Pulmonary vasculature appear normal. IMPRESSION: No evidence for PICC migration. . Culture Data: [**2142-4-28**]: Blood Cx x 2. No growth. [**2142-4-28**]: Urine. No growth. [**2142-4-28**]: Synovial fluid from left knee. 1+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. [**2142-4-28**]: Stool. No growth. [**2142-4-28**]: BAL. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. [**2142-4-28**]: Sputum culture. Rare oropharyngeal flora. No microorganisms seen. [**2142-4-29**]: Blood Cx x 2. No growth. [**2142-4-30**]: Blood Cx x 2. No growth. [**2142-4-30**]: Urine. No growth. [**2142-5-1**]: Blood Cx x 2. No growth. No fungus, no mycobacteria. [**2142-5-1**]: Stool. C. diff negative. [**2142-5-1**]: Urine x 2. No growth. [**2142-5-2**]: Sputum. [**9-19**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2142-5-4**]): RARE GROWTH OROPHARYNGEAL FLORA. YEAST. [**2142-5-2**]: Sputum. No growth. [**2142-5-3**]: Blood x 2. No growth. [**2142-5-3**]: Urine. No growth. [**2142-5-3**]: BAL. No growth. No Legionella. No PCP. [**Name10 (NameIs) **] PMN's. [**2142-5-3**]: Urine. No growth. [**2142-5-4**]: Blood x 2. No growth. [**2142-5-4**]: Sputum. No growth. No PMN's. [**2142-5-4**]: Blood x 2. No growth. [**2142-5-5**]: Stool. Negative for C. diff. [**2142-5-5**]: Blood. No growth. [**2142-5-5**]: Urine. No growth. [**2142-5-6**]: Stool. Negative for C. diff. [**2142-5-6**]: Blood. No growth. No fungus, no mycobacteria. [**2142-5-6**]: Catheter tip. No significant growth. [**2142-5-7**]: Stool. Negative for C. diff. [**2142-5-8**]: Blood x 2. No growth. [**2142-5-8**]: Urine. No growth. [**2142-5-8**]: Sputum. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. OROPHARYNGEAL FLORA ABSENT. YEAST. MODERATE GROWTH. YEAST. SPARSE GROWTH. 2ND MORPHOLOGY [**2142-5-9**]: Sputum. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2142-5-11**]): OROPHARYNGEAL FLORA ABSENT. YEAST. MODERATE GROWTH. YEAST. SPARSE GROWTH. 2ND MORPHOLOGY. [**2142-5-10**]: Blood x 2. No growth. [**2142-5-10**]: Urine. No growth. [**2142-5-12**]: Blood x 2. No growth. [**2142-5-12**]: Urine. No growth. [**2142-5-12**]: Sputum. No growth. [**2142-5-13**]: Blood x 2. No growth. [**2142-5-13**]: Urine. No growth. [**2142-5-13**]: Sputum. OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. [**2142-5-15**]: Blood x 2. No growth. [**2142-5-15**]: Urine. No growth. [**2142-5-15**]: Sputum. No growth. [**2142-5-17**]: Blood x 2. No growth. [**2142-5-17**]: Urine. No growth. [**2142-5-17**]: Right foot wound culture. 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. No bacterial growth. [**2142-5-17**]: Left foot wound culture. 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. No bacterial growth. [**2142-5-22**]: Blood Culture (1 set). No growth. **[**2142-5-22**]: Blood Culture (1 set). Coag negative staph, oxacillin resistant. [**2142-5-23**]: Catheter tip. No significant growth. [**2142-5-24**]: Blood Culture x 3. No growth. [**2142-5-25**]: Blood Culture x 2. No growth. [**2142-5-26**]: Blood Culture. No growth. **[**2142-5-27**]: Stool. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. [**2142-5-27**]: Blood Culture. No growth. **[**2142-5-27**]: Wound, right foot. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. YEAST. RARE GROWTH. [**2142-5-28**]: Blood Culture. No growth. **[**2142-5-28**]: Wound, right foot. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. YEAST. SPARSE GROWTH. **[**2142-5-28**]: Wound, right foot. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. YEAST. RARE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. **[**2142-5-30**]: Wound, left foot. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. **[**2142-5-30**]: Wound, left foot. SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH SKIN FLORA. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. OF THREE COLONIAL MORPHOLOGIES. [**2142-6-5**]: Urine. No growth. [**2142-6-5**]: Blood. STILL PENDING. [**2142-6-5**]: Sputum. OROPHARYNGEAL FLORA ABSENT. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Brief Hospital Course: ADMISSION IN INTENSIVE CARE UNIT: 21 year old male with no known significant PMH p/w menongococcemia, purpura fulminans, ARDS and DIC. His hospital course, by problem list is as follows. . 1) SEPTIC SHOCK/PURPURA FULMINANS: [**11-28**] Blood culture bottles at [**Hospital 1474**] hospital were positive for N. meningitidis, although near-daily cultures of blood, sputum, and urine throughout the patient's ICU stay remained negative. On admission to the ICU, the patient recieved a 4 day course of Xigris and a 7 day course of empiric stress dose steroids (Hydrocortisone/fludricortisone). To treat his infection, he had an 8d course of cephalosporin (for meningococcemia; recieved ceftriaxone x 6d then cefepime), vancomycin, and flagyl. He persistently spiked nightly fevers to 103, and he had a profound leukocytosis up to 98.6K, with L shift. Culture data remained negative, and his only source was a questionable LLL pneumonia on CXR. Bedside flexible bronchoscopy and a BAL were pristine, so antibiotics were discontinued on hospital day 9. He briefly defervesced after changing of his central venous catheter, but then continued to have nightly fevers. He recieved another 10d course of vancomycin, cefepime, and flagyl empirically. When these antibiotics were discontinued, his white count had normalized, although he continued to have low grade fevers. Infectious disease was consulted upon admission, and followed the patient throughout his hospital stay. . The patient also was noted to have progressive acral necrosis of his fingers and toes. This was followed daily by the ICU team, and plastic/hand surgery and podiatry were consulted. There was no evidence of wet gangrene/progressive infection, and the necrosis was allowed to demarcate. By discharge from the ICU, this had been stable for one week, and the patient's necrosis remained limited to the distal 1.5 phalanxes of bilateral hands (largely sparing the thumbs), as well as the distal phalanx of bilateral feet. Occupational therapy was consulted to help the patient with this, and the patient will be followed as an outpatient or at rehab by OT. He also will follow up weekly with hand surgery and podiatry to assess need for amputation (versus allowing auto-amputation). . The patient also had diffuse lower extremity bullae and purpura, which were cared for supportively with [**Hospital1 **] bacitracin as well as xeroform dressings. . #) PERSISTENT FEVERS: Intravenous access was difficult to obtain, and access was maintain via L subclavian central venous catheter. This was removed in the setting of persistent fevers and IR placed a PICC line. Blood cultures revealed Methicillin Resistant Staph Epidermidis and pt was started on Vancomycin for 14 day course. C. diff toxin assay were also positive and the patient was started on metronidazole. Pt. was sent to OR for surgical wound debridement with podiatry of the R foot, wound cultures revealed pseudomonas and ceftazidime was started for full Gram negative coverage. . 2) ACUTE RENAL FAILURE: Upon admission, the patient was noted to have a Cr 3.1, BUN 20 from presumed normal baseline. This trended up to a maximum Cr of 7.3 on HD#6. The renal team was following the patient throughout his stay, and thought the renal failure was likely Acute Tubular Necrosis from his sepsis. Dialysis was considered, but the patient never met acute indications for dialysis. He was treated prn with high dose diuretics (Lasix 200mg IV and Diuril 500mg IV up to [**Hospital1 **]) for decreased urine output in the context of anasarca. However, predominately, he was treated supportively, and from HD#7, his creatine began to trend down and he autodiuresed significantly. By discharge from the ICU, his creatinine had normalized to 0.8. . 3) RESPIRATORY FAILURE: The patient was intubated on arrival due to respiratory distress/fatigue with profound metabolic acidosis. Initial chest xrays were consisted with ARDS, and the patient was maintained on lung protective ventilation. As mentioned above, daily chest xrays showed questionable pneumonia versus pulmonary edema. The patient was on vancomycin, cefepime and flagyl; and was also diuresed. His chest xrays continued to show significant edema, however, his vent settings were able to be weaned over his stay. He was not able to pass a spontaneous breathing trial, and extubation was also deferred because the patient had significant oral lesions and glossal edema, raising the concern for difficulty in reintubation. The patient therefore recieved a tracheostomy tube and PEG tube with thoracic surgery. He tolerated the procedure well, and postoperatively was quickly able to be transitioned to a trach mask, then a passamuir valve over the course of 2 days. His respiratory status remained stable throughout the remainder of his ICU stay. . 4) CARDIOVASCULAR SYSTEM - The patient had several different cardiovascular issues during his stay. On HD#1 an ECHO showed severely depressed LV function, with estimated EF < 15%. Repeat ECHO on HD#4 showed improved, but still severly depressed LV function, EF 30%. This was not repeated during his ICU stay. He also had one episode of non-sustained (~30 BEATS) ventricular tachycardia. His hemodynamics were stable and his electrolytes were normal at this time, however, and he had no further episodes of similar tachycardias. He was maintained on telemetry throughout this stay. He did have elevation of his cardiac biomarkers, which peaked on hospital day #7 with a Troponin T of 4.21. His CKs had been elevated (thought due to his acral necrosis), and his EKGs were unchanged. The troponinemia was ascribed to his renal failure and systolic heart failure (as opposed to an NSTEMI), and indeed, the rise and fall improved with resolution of his renal function. He should have a repeat ECHO as an outpatient, in [**3-1**] weeks after hospital discharge. . Additionally, after resolution of his initial sepsis, the patient was persistently tachycardic (HR usually 120s-130s, up to 150s, always sinus rhythm), and hypertensive (SBPs up to 180s-190s). The etiology was thought to be due to a combination of pain, anxiety, and fevers, and a generalized state of sympathetic excess. The patient was started on amlodipine, hydralizine, and metoprolol. . 5) NEUROLOGIC - As the patient's sedation was weaned in advance of possible extubation, he was noted to have questionable neurologic deficits. Specifically, he was not moving his upper extremities spontaneously, and while he was able to follow commands by eye blinking, he did not appear to demonstrate any tracking movements with his eyes. As he had been on Xigris, and also had significant microvascular pathology in other organ systems, an MRI HEAD/CSPINE was obtained to rule out intracerebral or spinal hematoma, bleeds, or infection. This examination was normal. An ophthamologic consult was also obtained to perform a dilated pupil retinal exam. This showed diffuse bilateral retinal hemorrhages, and outpatient follow up was reccomended. His tracking gaze, and upper extremity movement continued to improve as sedation was weaned. . 6) FLUIDS/NUTRITION - The patient was maintained on tube feeds throughout his admission. Initially, he had high residuals, and therefore, was supplemented with parenteral nutrition. Nutrition service provided useful reccomendations. By discharge, the patient had passed a speech and swallow examination, and was tolerating po intake with his PM valve in place. From a fluids standpoint, the patient required initial aggressive fluid rescuscitation for his sepsis and insensible volume losses, and was significantly volume overloaded throughout his stay, although this improved dramatically with forced- and auto-diuresis, and improvement of his renal function. . . . . . . . . . . . . . . . . . ................................................................ TRANSFER TO FLOOR. The patient's renal failure normalized; his creatinine returned to normal. The patient was breathing room air through a tracheostomy tube; the trach tube was removed on [**2142-6-6**]. Soon afterward, he was tolerating PO food; the G-tube was removed on [**2142-6-10**]. The patient spiked low-grade temperatures until [**2142-5-27**], when his temperature remained below 100.4F. Cultures were positive for the following: - MRSE in blood and wound culture ([**5-22**] in blood, [**5-28**] in wound) - + C. diff ([**2142-5-27**]) - + Yeast in wound cultures ([**5-30**] in wound culture) - Pseudomonas in wound cultures ([**5-28**] in wound culture) For these organisms, the patient was continued on vancomycin (started [**5-22**]), cefepime to ciprofloxacin (started [**5-29**]), and metronidazole (started [**2142-5-28**]). He will continue to get a full six week course of these antibiotics. . His foot wounds were dressed daily by podiatry, using Duoderm gel on dry sterile dressings and xenoform on leg wounds, bacitracin on leg bullae. His fingers were dressed with dry sterile dressing between the fingers to minimize maceration. . The patient is discharged to a rehab facility in stable condition for continued physical therapy, daily dressing changes, and IV antibiotic treatment (vancomycin). He requires substantial pain control especially for his dressing changes, and he has developed a tolerance to morphine; his pain is controlled with 2-4mg morphine EVERY MORNING before dressing changes, and he has tolerated a sliding scale of morphine (1-8mg) for physical therapy and any additional dressing changes or examinations of the wounds. He is discharged in stable condition, tolerating PO fluids/regular diet, breathing room air, and afebrile. Medications on Admission: Albuterol inhaler Discharge Medications: 1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 30 days. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 30 days. 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 30 days. 7. Vancomycin 500 mg Recon Soln Sig: 1750 (1750) mg Intravenous Q 12H (Every 12 Hours) for 30 days. 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for break through pain: Please hold for sedation or RR<8. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 12. Morphine 10 mg/mL Solution Sig: 1-8 mg Intravenous every twelve (12) hours as needed for pain: Please give prior to dressing changes. 13. Metoprolol Tartrate 100 mg Tablet Sig: One [**Age over 90 1230**]y (150) mg PO DAILY (Daily). 14. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain: for breakthrough pain. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary: Meningococcemia Respiratory Failure Disseminated intravascular coagulation Acute respirator distress syndrome Clostridium difficile infection MRSE bacteremia Wound infections Discharge Condition: Stable, afebrile, tolerating PO, oxygenating 100% on room air, tracheostomy tube and G-tube removed. Discharge Instructions: You were admitted for meningococcemia; your hospital course was complicated by disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), and hypotension. You also have been diagnosed with MRSE bacteremia (bacteria in the blood), for which you are taking vancomycin; C. difficile colitis (a diarrheal illness), for which you are taking Flagyl; and several different bacteria and yeast that have infected the wounds, for which you are taking ciprofloxacin and fluconazole. These antibiotics will continue for four and a half more weeks. Please take all of your medications as directed. If you develop a fever, shortness of breath, new pain, or other concerning symptoms, please seek medical advice immediately. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] (Infectious Disease), Phone: [**Telephone/Fax (1) 457**] Date/Time: [**2142-7-31**] 10:00AM Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Internal Medicine), Phone: [**Telephone/Fax (1) 250**] Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2142-6-14**] 10:30 Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2142-6-19**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM (Podiatry) Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2142-6-20**] 1:30

Admission Date: [**2102-4-20**] Discharge Date: [**2102-4-26**] Date of Birth: [**2055-2-21**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 7744**] Chief Complaint: Found down Major Surgical or Invasive Procedure: Central venous line placement Intubation and mechanical ventilation Extubation History of Present Illness: The patient is a 47 year old with PMHx COPD who was found down in hotel room. Per report, he had been having several days of N/V/D with possible AMS x1 day. He was taken to [**Hospital3 **] where he was found to be unconcious, hypotensive, altered, mumbling, responding only to pain. He had right CVL placed, started on levophed, and intubated. He had a difficult intubation requiring 30 of Etomidate and 10 of Vec and 2 passes with a glide scope. A 7.0mm tube was placed. Labs returned with Cr 9.7, K of 7.7 with peaked T waves and widened QRS. He was given CaCl x2, insulin/D50, 2 amps bicarb, and 3L NS. He was started on zosyn, but this was stopped when he reached [**Hospital1 18**] as it was discovered he has an allergy to penicillin. He was initially difficult to ventilate at [**Hospital3 15402**] so was paralyzed with 2 doses of vec and was given solumedrol/albuterol for ?obstructive process. Transported via [**Location (un) **] to [**Hospital1 18**] during which time he became easier to ventilate. Labs showed K remaining elevated at 6.8 - he got Cagluconate, amp of bicarb. EKG improved, with slightly peaked T waves, QRS 78. CT Head/Neck was done and was ok. CT A/P showed RLL consolidation, confirmed on CT Chest. ABG shoed increased CO2 so his RR was increased to 28. He was given Levaquin/flagyl/vanco as well as lasix 40mg IV with 3L urine output while in ED. . On arrival to the MICU, he was intubated and sedated on pressors. . Review of systems: Unable to obtain Past Medical History: - Stroke 6 months ago per sister -HTN -DM -COPD -migraines -chronic LBP s/p low back surgery '[**86**] for spinal stenosis or sciatica, on oxycodone - muscle spasms, on valium 10 tid -tobacco -alcoholism, sober [**2083**] -remote PUD [**1-26**] etoh -insomnia on seroquel -R index finger injury [**1-26**] tablesaw, s/p fusion [**Doctor First Name **] -R broken jaw s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ~[**2091**] -CCY ~[**2089**] -appy as child -stable vision loss since accident as a child Social History: Lives at home w/ common-law wife and daughter. Disabled [**1-26**] back pain, gets SSI income. Tob [**12-26**] ppd x 35yrs. Etoh sober since [**2083**]. Remote marijuana habit, infrequent recreational cocaine use remotely, none in many yrs. From [**Doctor First Name 26692**], moved to Mass ~7-8y ago. Monogamous w/ wife. Family History: mom died metastatic cancer 59yo dad died CA unknown type 4 siblings, 1 died MVA, 1 sis diabetes/HTN 4 children healthy Physical Exam: Admission Physical Exam: General: Intubated, sedated, intermittent myoclonic jerks HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL 2-->1 Neck: supple, no LAD, difficult to appreciate JVD [**1-26**] habitus CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: right sided inspiratory wheezing with markedly decreased breath sounds at the base, CTA on left Abdomen: soft, non-distended, obese, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley in place, right femoral CVL in place - dressing c/d/i Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, trackmarks along left posteromedial calf from ankle to knee, multiple track marks and puncture wounds along both legs Neuro: Moves all 4 extremities equally . Discharge Physical Exam: Vitals: Tmax 99.0 Tc 98.8 BP 129/83 HR 83 RR 20 O2 Sat 99% on RA; patient desaturated to 91-94% on RA during ambulation; FSBG 124, 175, 175, 142 General: Sitting up in bed eating breakfast. HEENT: EOMI. MMM. Tongue midline. CV: RRR. No M/R/G. Lungs: Auscultated posteriorly. Patient diffusely wheezy throughout the lung fields posteriorly. Nml work of breathing. No accessory muscle use. Abd: Overweight. NABS+. Soft. NT/ND. Ext: WWP. Trace pitting edema bilaterally. No clubbing or cyanosis. Neuro: Patient very alert and interactive this AM. Pertinent Results: Admission labs: [**2102-4-20**] 06:15PM BLOOD WBC-22.8* RBC-3.74* Hgb-12.2* Hct-35.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-15.0 Plt Ct-173 [**2102-4-20**] 10:57PM BLOOD Neuts-97.1* Lymphs-1.4* Monos-0.9* Eos-0.5 Baso-0.1 [**2102-4-20**] 06:15PM BLOOD PT-11.3 PTT-26.8 INR(PT)-1.0 [**2102-4-20**] 10:57PM BLOOD Glucose-180* UreaN-68* Creat-6.0*# Na-138 K-7.3* Cl-100 HCO3-26 AnGap-19 [**2102-4-20**] 10:57PM BLOOD ALT-26 AST-21 LD(LDH)-158 CK(CPK)-151 AlkPhos-72 TotBili-2.3* [**2102-4-20**] 10:57PM BLOOD Calcium-9.1 Phos-6.6* Mg-1.7 UricAcd-9.7* [**Hospital3 **]: [**2102-4-20**] 06:15PM BLOOD Fibrino-540* [**2102-4-20**] 06:15PM BLOOD Lipase-36 [**2102-4-21**] 04:29PM BLOOD Lipase-15 [**2102-4-20**] 10:57PM BLOOD CK-MB-6 [**2102-4-21**] 11:30AM BLOOD Cortsol-8.1 Lactate trend: [**2102-4-20**] 11:05PM BLOOD Lactate-0.8 K-6.8* [**2102-4-21**] 08:56AM BLOOD Lactate-1.2 [**2102-4-21**] 04:01PM BLOOD Lactate-0.9 [**2102-4-22**] 04:38AM BLOOD Lactate-0.8 [**2102-4-23**] 03:01AM BLOOD Lactate-0.4* Discharge labs: [**2102-4-26**] 06:10AM BLOOD WBC-3.8* RBC-2.98* Hgb-9.1* Hct-28.3* MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-141* [**2102-4-26**] 06:10AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-137 K-3.6 Cl-103 HCO3-28 AnGap-10 [**2102-4-26**] 06:10AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6 Imaging: [**2102-4-20**] Portable CXR: FINDINGS: An endotracheal tube terminates near the thoracic inlet, approximately 7.5 cm above the carina. An orogastric tube passes beneath the left hemidiaphragm, its distal course not imaged. Opacification in the right lower hemithorax suggests a pleural effusion with volume loss including mild rightward shift of mediastinal structures most suggestive of atelectasis. An infectious causes is not excluded, however. The left lung appears clear. Although the extreme left costophrenic sulcus is partly excluded, there is no evidence for pleural effusion on the left side. Allowing for technique, the cardiac, mediastinal and hilar contours are unremarkable. IMPRESSION: 1. Endotracheal tube in a somewhat high lying position, approximately 7.5 cm above the carina. If clinically indicated, the tube could be advanced by approximately 3 cm. 2. Right basilar opacification with volume loss including suspicion for a pleural effusion. . [**2102-4-20**] Head CT: FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, shift of normally midline structures, or vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved throughout. The ventricles and sulci are normal in size and configuration. No fractures are noted. Opacification within the paranasal sinuses is likely related to recent intubation. Mastoid air cells are clear. IMPRESSION: No evidence of acute intracranial process. . [**2102-4-20**] CT Chest: FINDINGS: The right middle and lower lobe are collapsed. Bronchiectasis is mild in the segmental and subsegmental bronchi of the middle lobe, and in the subsegmental divisions of the superior and basal segments. There is no central bronchial occlusion. The constellation suggests that atelectasis may well be chronic. There is no indication of pneumonia or pleural or pericardial abnormality. A few small bronchi in the posterior segment of the right upper lobe are impacted and there is mild heterogeneity in background density of both upper lobes suggesting small airway obstruction or mild emphysema. Mediastinal lymph nodes are not pathologically enlarged. In the absence of contrast administration, I cannot say that there are no enlarged right hilar lymph nodes (there are none on the left), but even if right hilar nodes are present, they are not contributing to the atelectasis because there is no bronchial obstruction. Heart is normal size and the study is notable for the virtual absence of atherosclerotic calcification, except for small plaques at the bifurcation of the innominate artery. ET tube is in standard placement. Excretions are pooled above the inflated cuff. This study is not designed for subdiaphragmatic diagnosis except to note there is no adrenal mass. A small Bochdalek hernia in the posterior right hemidiaphragm transmits only subphrenic fat. IMPRESSION: 1. Combination of mild but diffuse bronchiectasis in collapsed right middle and lower lobes. In the absence of bronchial obstruction, this suggests that the collapse is not acute. No evidence of pneumonia. Minimal mucoid impaction in small bronchi in the upper lobe. 2. Either small airway obstruction or mild emphysema. . CT C-spine: FINDINGS: Imaged portions of the brain are better visualized on the concurrent head CT. Patient is intubated. Nasogastric and endotracheal tubes are in appropriate position. No evidence of fractures or acute alignment abnormalities. No evidence of critical spinal canal stenosis. Visualized portions of the lung bases show some scarring in the right upper lobe. Left upper lobe is unremarkable. IMPRESSION: No evidence of fracture. . CT Abdomen/pelvis: CT OF THE ABDOMEN: At the right lower lung bases consolidative processes with air bronchograms and volume loss including rightward shift. No pericardial effusion. No pleural effusion. The left lung is clear. Within the abdomen, the evaluation structures is limited without IV contrast, however, with these limitations in mind, the liver is unremarkable. The gallbladder has been surgically removed. The spleen, bilateral kidneys and pancreas are all unremarkable. There is some fat stranding of unclear significance around the left adrenal. The adrenals themselves are unremarkable. An NG tube is seen coursing into the stomach and ending at the pylorus. The remainder of the small bowel is unremarkable. Large bowel is also unremarkable. No mesenteric adenopathy is appreciated. CT OF THE PELVIS: Rectum, sigmoid colon, bladder, and prostate are all unremarkable. The patient has a Foley catheter. OSSEOUS STRUCTURES: The osseous structures are unremarkable. No concerning lytic or sclerotic lesions. IMPRESSION: 1. No evidence of acute intra-abdominal process. 2. Consolidative process in the right lower lobe consistent with pneumonia versus atelectasis; sequelae of aspiration could also be considered particularly noting historical circumstances. . [**2102-4-21**] Portable CXR: IMPRESSION: 1. Interval placement of a right internal jugular central line with its tip in the mid superior vena cava. The endotracheal tube has its tip approximately 5.5 cm above the carina, unchanged. A nasogastric tube is seen coursing below the diaphragm with the tip not identified. Patchy and linear opacity at the right base is stable suggestive of patchy and subsegmental atelectasis. Probable small layering right effusion. The lungs are otherwise clear without evidence of pulmonary edema or pneumothorax. Overall, cardiac and mediastinal contours are stable given differences in positioning. . Microbiology: [**2102-4-20**] 6:15 pm BLOOD CULTURE TRAUMA. **FINAL REPORT [**2102-4-26**]** Blood Culture, Routine (Final [**2102-4-26**]): NO GROWTH. [**2102-4-20**] 6:50 pm URINE **FINAL REPORT [**2102-4-21**]** URINE CULTURE (Final [**2102-4-21**]): NO GROWTH. [**2102-4-20**] 10:57 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2102-4-22**]** MRSA SCREEN (Final [**2102-4-22**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2102-4-21**] 1:52 am URINE Source: Catheter. **FINAL REPORT [**2102-4-21**]** Legionella Urinary Antigen (Final [**2102-4-21**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [**2102-4-21**] 1:36 am BRONCHIAL WASHINGS **FINAL REPORT [**2102-4-23**]** GRAM STAIN (Final [**2102-4-21**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2102-4-23**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. [**2102-4-23**] 3:53 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending) times 2 [**2102-4-25**] 5:54 am IMMUNOLOGY Source: Line-cvl. **FINAL REPORT [**2102-4-26**]** HCV VIRAL LOAD (Final [**2102-4-26**]): HCV-RNA NOT DETECTED. Performed using the Cobas Ampliprep / Cobas Taqman HCV Test. Linear range of quantification: 43 IU/mL - 69 million IU/mL. Limit of detection: 18 IU/mL. Rare instances of underquantification of HCV genotype 4 samples by [**Doctor Last Name **] COBAS Ampliprep/COBAS TaqMan HCV test method used in our laboratory may occur, generally in the range of 10 to 100 fold underquantitation. If your patient has HCV genotype 4 virus and if clinically appropriate, please contact the molecular diagnostics laboratory ([**Telephone/Fax (1) 6182**]) so that results can be confirmed by an alternate methodology. [**2102-4-25**] 12:15 pm IMMUNOLOGY Source: Line-PICC. HBV Viral Load (Pending): Hepatits B Ag Negative Hepatitis B Ab Negative Brief Hospital Course: 47 year old male with a past medical history significant for COPD, DM, HTN who presents after being found down with hypoxic and hypercarbic respiratory failure, RLL consolidation, hyperkalemia, and [**Last Name (un) **]. # Hypoxic and hypercarbic respiratory failure - Patient has a history of COPD, on admission had prolonged expiration phase, but no expiratory wheezing on exam. CT showed large right lower lobe consolidation concerning for pneumonia, possibly aspiration. No evidence of fluid overload on exam. Given body habitus, may have component of hypoventilation or OSA. Urgent bronchoscopy in MICU showed secretions in RLL but no mass or obstructing lesion - sample sent for culture/gram stain. He was treated for health-care acquired pneumonia with vancomycin/meropenem/levofloxacin for atypical coverage pending culture results. Legionella antigen negative. The patient self-extubated on [**4-23**] and was able to be maintained with non-invasive ventilation thereafter. # Aspiration pneumonia- Patient was started on vancomycin, meropenem and levofloxacin (for atypical coverage) in the MICU. Upon transfer to the general medicine floor, the patient was continued on broad spectrum antibiotics. As the patient clinically improved, the patient was transitioned to oral antibiotics, Levofloxacin and Clindamycin (for coverage of anaerobic bacteria). The patient remained afebrile on oral antibiotics. The patient was discharged home with another 3 days of Levofloxacin and Clindamycin to complete a 10-day course for treatment of aspiration pneumonia. Supplemental oxygen was weaned and then discontinued. The patient was saturating in the mid to high 90s at rest on room air and had ambulatory saturation of 91-94% on room air day prior to discharge. # Shock - Most likely from hypovolemia and sepsis. Bedside ultrasound showed collapse of IJ with hyperdynamic and fully contracting ventricles consistent with hypovolemia. While EKG showed low voltages, he did not have evidence of pericardial effusion or low EF on bedside U/S. Per the OMR note, he was recently on steroids for COPD so he is at risk for AI. He was treated for pneumonia, provided aggressive fluid resuscitation, and provided stress dose steroids. He was weaned off pressors after 24 hours and his pressure normalized. # Hyperkalemia - The patient exhibited persistent kyperkalemia despite adequate treatment, and despite good renal function. EKGs initially showed mild peaked T waves, but QRS remained stable. Normalized after the first 24 hours. # Acute renal failure - Likely related to hypovolemia given the patient's admission exam. CK initially flat so the patient's acute renal failure was not attributed to rhabdomyolysis. Serum creatinine improved with hydration to 1.6, although there is no clear baseline for this patient. Serum creatinine was trended through the admission, and the patient's serum creatinine normalized, ranging from 0.9 to 1.0. OUTPATIENT ISSUES: Patient will need to have renal function reassessed at his next PCP [**Name Initial (PRE) 648**]. # Pancytopenia - Upon transfer from the ICU to the floor, the patient's cell counts were noted to be falling. Thrombocytopenia initially was most pronounced. The patient did receive heparin during the admission; 4T score of 4, classifying the patient's probability of HIT as intermediate. The patient's CBC was trended daily, and his white count and hematocrit were noted to be falling as well. The differential included marrow suppression secondary to sepsis or secondary to medication. On day of discharge, the patient's blood cell lines were noted to be uptrending. OUTPATIENT ISSUES: Patient will need to have follow-up CBC at next PCP [**Name Initial (PRE) 648**]. CHRONIC ISSUES: # Hypertension - Patient with a history of hypertension; as an outpatient, patient is maintained on amlodipine 10, HCTZ 12.5mg, and lisinopril 20mg daily. These medications were initially held in light of shock. Patient's blood pressure initially ran in the 150s systolic. The patient was started on amlodipine 10mg daily initially. With a stable trend in the patient's serum creatinine, the patient's lisinopril and hydrochlorothiazide were restarted. With initiation of patient's full anti-hypertensive regimen, the patient's systolic blood pressure ranged in the 120s-130s systolic. # Chronic Obstructive Pulmonary Disease - The patient had albuterol and ipratropium inhalers available to him through his admission. The patient was also given a nicotine patch through the admission. Multiple times through the admission, the importance of smoking cessation was emphasized to the patient. He was also empirically started on Tiotropium inhaler once daily on discharge. Upon discharge, the patient was provided with a prescription for nicotine patches to aid with smoking cessation. OUTPATIENT ISSUES: PFTs as an outpatient if not already done. Smoking cessation counseling with the patient's primary care provider. # Type 2 Diabetes Mellitus - As an outpatient, the patient is on 500mg metformin [**Hospital1 **]. Upon admission, the patient was transitioned to an insulin sliding scale for hyperglycemic coverage. On the medicine floor, the patient's finger stick blood glucose ranged from 125-175, and he required minimal insulin coverage. The patient was discharged home with instructions to continue taking 500mg metformin [**Hospital1 **]. # History of muscle spasm - Patient was continued on home dose of standing Valium 10mg TID. # Chronic Low Back Pain - Oxycodone was restarted when the patient was transferred to the medicine floor. Dosing was up-titrated to original home dose and frequency on day of discharge. # History of substance abuse - Through the patient's stay in the MICU, he was placed on a CIWA scale. The patient did not score while in the ICU. On the medicine floor, the patient did not score, and CIWA scale was discontinued. Of note, the patient has been sober from alcohol for the past 17 years. OUTPATIENT ISSUES: Follow-up pending HIV serology. # Hepatitis C - Patient serology confirmed during this admission. Viral load negative. Patient has not pursued treatment in the past. Hepatitis B serology and HIV were also drawn during this admission. OUTPATIENT ISSUES: Discussion between the patient and his PCP regarding treatment for hepatitis C. Patient will need hepatitis B vaccination given hepatitis B serology. Follow-up pending HIV serology. # History of insomnia - Patient's home Seroquel was held upon admission in light of patient's serious illness. This was initially held on the medicine floors as the patient still appeared drowsy. On day of discharge, patient was instructed to continue Seroquel at home dosing. # Code: Full (presumed) # Pending studies: --Blood cultures --Hepatitis B viral load --HIV serology # PCP [**Last Name (NamePattern4) 702**]: --Repeat CBC and chemistry at patient's next PCP appointment [**Name9 (PRE) 110669**] of COPD therapy --Smoking cessation discussion Medications on Admission: lisin-HCTZ 20-12.5 amlodipine 10 metformin 500 [**Hospital1 **] fioricet prn valium 10 TID standing oxycodone 30mg 5-6x/day albuterol prn seroquel 150 qhs Discharge Medications: 1. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO three times a day as needed for Migraine Headache . 5. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*14 Patch 24 hr(s)* Refills:*0* 7. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 9. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO twice a day for 3 days. Disp:*12 Capsule(s)* Refills:*0* 10. Seroquel XR 150 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime. 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. Disp:*14 capsules* Refills:*0* 13. oxycodone 10 mg Tablet Sig: Three (3) Tablet PO every four (4) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Aspiration pneumonia Acute renal failure Secondary diagnosis: Chronic Obstructive Pulmonary Disease Hypertension Type 2 Diabetes Mellitus Chronic low back pain Pancytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your hosptalization at [**Hospital1 69**]. You were hospitalized with pneumonia and acute renal failure. Initially you were in the ICU requirining mechanical ventilation. Through your stay in the ICU, you were able to be taken off the ventilator and your kidney function improved. You were then transferred to the general medicine floor for continued treatment of your pneumonia. You initially received IV antibiotics for your pneumonia, and now you have been transitioned to oral antiobitics. You will have 3 more days of antiobitics to take once you leave the hospital. *STOP SMOKING* This is one of the best things that you can do for yourself. Discuss the options that are available for quitting smoking with your primary care physician. Take all medications as prescribed. Note the following medication changes: 1. *ADDED* Levofloxacin 750mg daily and Clindamycin 600mg every 12 hours for the next *3* days for continued treatment of your pneumonia 2. *ADDED* Nicotine patch apply daily; discontinue if you continue to have bad dreams while the patch is on you. 3. *ADDED* Prednisone 40mg for one more day 4. *ADDED* Spiriva 1 capsule daily for treatment of your underlying COPD Keep all hospital follow-up appointments. Your [**Hospital 14776**] hospital appointments are listed for you. Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2102-5-3**] at 2:40 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 25193**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2102-5-17**] at 5:20 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 25193**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2139-8-25**] Discharge Date: [**2139-9-6**] Date of Birth: [**2083-6-22**] Sex: M Service: INPATIENT MEDICINE/[**Hospital1 212**] HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with insulin dependent diabetes status post renal transplant in [**2133**] now failing, also status post right tib-fib fracture. In [**Month (only) 956**], the patient underwent an ORIF and at that time and then was removed. The patient was treated with IV Zosyn and Vancomycin for six weeks. Cultures at that time grew gram-positive cocci. Patient completed his antibiotic course a few weeks ago. The patient was recently seen by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and his Renal doctor, Dr. [**Last Name (STitle) 1860**], and was complaining of increasing discharge from the right leg two wound sites on the knee and on the ankle. A swab was taken at that time which grew gram-negative rods, which turned out to be Klebsiella that was sensitive to levofloxacin. Patient was started on 250 mg q.d. levofloxacin on [**8-19**]. Of note, the patient's rapamycin level was also decreased from 2 mg a day to 1 mg a day. Patient, hence, did not report any fever, chills, nausea, vomiting, chest pain, or shortness of breath. PAST MEDICAL HISTORY: 1. Hypertension. 2. Insulin dependent-diabetes mellitus. 3. Peripheral vascular disease diagnosed three years ago status post lower extremity bypass done by Vascular Surgery. 4. End-stage renal disease status post failing transplant since pyelonephritis one year ago. 5. Osteoarthritis. 6. Neuropathy status post right fifth toe amputation and partial left foot amputation. 7. Gastroesophageal reflux disease. 8. Depression. 9. Status post right tib-fib fracture with an ORIF with removal of infected rod in 06/[**2138**]. ALLERGIES: 1. Codeine causes swelling. 2. Prograf - Unknown reaction. SOCIAL HISTORY: Patient has a 20 pack year history of smoking. Quit six years ago. Patient used to drink heavily, but quit 11 years ago. He denies any IV drug abuse. The patient lives with his wife and daughter. MEDICATIONS ON ADMISSION: 1. Aspirin 81 q.d. 2. Atenolol 50 q.d. 3. Bupropion 100 t.i.d. 4. Calcium carbonate 500 t.i.d. 5. Celexa 40 q.d. 6. Folic acid 1 mg q.d. 7. Lasix 40 q.d. 8. Lipitor 10 q.d. 9. Multivitamin. 10. Neurontin 300 q.d. 11. OxyContin 60 b.i.d. 12. Peridex swish and swallow b.i.d. 13. Prednisone 4 mg q.d. 14. Protonix 40 mg q.d. 15. Rocaltrol 0.25 mcg q.d. 16. Roxicet for breakthrough pain. 17. Trazodone 50 prn. 18. Viokase two tablets with meals, one tablet with snacks. 19. Erythropoietin 10,000 units one time per week. 20. Lovenox 40 q.d. 21. Rapamune 1 mg q.d. 22. Insulin NPH 22 units in the a.m. and 6 units in the p.m. with a sliding scale. 23. Levaquin 250 mg p.o. q.d. x7 days. 24. CellCept [**Pager number **] mg q.d. PHYSICAL EXAM: Temperature 96.5, blood pressure 170/90, pulse 58, respiratory rate 16, O2 saturation 99% on room air. In general, the patient is a thin male in no acute distress. Cardiovascular system: Regular, rate, and rhythm. Lungs are clear to auscultation bilaterally with no rales or rhonchi. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities: Fifth digit on the right foot is amputated. Left foot has partial amputation. Patient has an external fixator in place in the right lower extremity with foul smelling purulent discharge from the wound in the right ankle and the right knee. LABORATORIES ON [**8-19**]: Patient has a wound culture that grew Klebsiella sensitive to levofloxacin. White count of 12.8 with no left shift. Sodium 141, potassium 5.2, bicarb of 11, BUN of 51, creatinine is 7.2, glucose of 189. Patient has an albumin of 3.7, calcium 9.1, and a phosphorus of 5.9. Rapamycin level of 3.4. HOSPITAL COURSE: 1. Right leg infection: Patient was continued on p.o. levofloxacin. Blood cultures were drawn and ID was consulted. Ortho was also consulted. Patient was followed by Vascular Surgery as well. On hospital day two, Vascular Surgery debrided the wound at the bedside and sent repeat cultures. Repeat cultures eventually grew back just gram-negative rods and so patient was continued on levofloxacin. On [**8-28**], the Ortho attending, Dr. [**First Name (STitle) **] came to see the patient and presented the option of amputation versus debridement. The patient expressed desire to go the conservative route, and attempt debridement surgery. On [**8-29**], the patient went to the OR and debridement was done with intraoperative tissue and bone cultures sent. Tissue and bone cultures grew out gram-positive cocci, coag-negative gram-positive cocci, and gram-negative rods not Pseudomonas. The patient was then started on IV Vancomycin 1 gram dose for levels less than 15. Patient is to be followed by Ortho. Upon discharge, he will follow up with Dr. [**First Name (STitle) **] in clinic. 2. Renal: The patient has a failing kidney transplant. The Renal Service decided to discontinue the CellCept and increase prednisone to 5 mg q.d. and continue the rapamycin at 1 mg q.d. Renal service discussed with Transplant Surgery the need for hemodialysis access. He was assessed by Transplant Surgery and will follow up with them as an outpatient for likely hemodialysis access. Patient's renal function, BUN and creatinine remained stable throughout the hospitalization. He will follow up with Dr. [**Last Name (STitle) 1860**] as an outpatient. 3. Hyperphosphatemia: On admission, patient had a phosphate of 5.9. His Rocaltrol was increased to 0.5 q.d. and then further increased later due to continual increased phosphate to 1 mcg q.d. Patient's phosphate then dropped to normal levels and remained there throughout the hospitalization. 4. Hypocalcemia: Patient's calcium level on admission was within normal limits. Patient's calcium carbonate was continued at 1,000 mg t.i.d. 5. Acidosis: On admission, patient had a bicarb level of 11. He was started on sodium bicarb 650 b.i.d. By [**8-31**], patient's bicarb level was within normal limits and sodium bicarb was discontinued. Patient's bicarb level remained within normal limits throughout the hospitalization. 6. Hyperkalemia: Throughout the hospitalization, patient required multiple doses of Kayexalate to maintain his potassium less than 5. Patient's potassium stabilized at 4.6 and remained normal throughout the hospitalization. 7. Diabetes: Patient's diabetes is very difficult to control and fluctuates widely between very hyperglycemic in the 300s to hypoglycemic down to the 50s with mental status changes and confusion. [**Last Name (un) **] was consulted to follow the patient. On [**8-28**], patient had an episode of low blood sugar down to 40 with shaking and unresponsiveness. This was treated with D50 and a decrease in his sliding scale. Patient continued to have episodes of mild hypoglycemia until [**9-4**], at which point the adjustments in his NPH insulin, regular insulin-sliding scale were such that he no longer had episodes of severe hypoglycemia. The patient is to followup with his [**Last Name (un) **] physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] as an outpatient for further diabetic control. 8. Vomiting: Patient had occasional episodes of vomiting throughout the hospitalization with immediate relief after vomiting. Patient's vomiting is likely due to mild degree of gastroparesis. On [**9-4**], the patient had an episode of vomiting in the evening and was given Phenergan. Patient then became agitated and aggressive. The patient was seen by Psychiatry. Was placed on one-to-one sitter and required restraints. Patient was also given Haldol with good affect. The day following this episode, the patient was back to baseline mental status with no further episodes of aggression or agitation. The agitation was likely secondary to Phenergan and Phenergan was avoided for the remainder of the hospitalization. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. Dictated By:[**Last Name (NamePattern1) 7586**] MEDQUIST36 D: [**2139-9-6**] 12:11 T: [**2139-9-8**] 08:01 JOB#: [**Job Number 106441**]

Admission Date: [**2200-11-10**] Discharge Date: [**2200-11-18**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10593**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Thoracentesis [**2200-11-10**] History of Present Illness: [**Age over 90 **] year old female that was brought to the ED tonight for shortness of breath. The family noticed that the patient appeared to be quite dyspnic this AM. The shortness of breath was exacerbated by exertion. The patient has not had fever or cough. No N/V/D. no abdominal complaints. The patient denied any chest discomfort. The family has also noted cyanotic fingers and toes that are new for the patient. She denies any associated pain. In the ED the patient had a chest x-ray that was consistent with a significant left pleural effusion. A thoracentesis was performed and removed 1.5L. Post procedure chest x-ray showed improvement. The patient symptomatically improved and required lower oxygen requirements. She was found to have a lactic acidosis that improved after 1L of crystalloid. She was given IV vancomycin and cefepime for empiric antimicrobial coverage. In the ED, initial VS were: Sinus tachycardia, 108, 125/76, 29, 5L NC . On arrival to the MICU, the patient was awake and mildly confused. Patient aware of her location and self but confused to time. She was not in any acute distress. She reports that her breathing is much better than when she initially presented to the ED. Denies any current chest pain or abdominal pain. Patient is still somewhat tachypnic but appears comfortable. Past Medical History: hyperlipidemia, dementia, osteoperosis Social History: Denies any tobacco, EtOH, or recreational drug use Family History: Non-contributory Physical Exam: On admission: Vitals: T:97.3 BP:154/73 P:110 R:28 O2: 94% 4L NC General: Alert, confused to place, but does not appear to be in distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles in the left lobes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: cyanotic digits in the hands and feet, +radial pulses bilaterally, +DP/PT in left, right foot difficult to obtain Doppler pulses Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred On discharge: Vitals: 98.6 150/90 103 21 92%1L NC GEN: Frail elderly female, No acute distress. HEENT: Dry mucous membranes, no lesions noted. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP not elevated. No lympadenopathy. CV: Regular rate and rhythm, no murmurs, rubs or [**Last Name (un) 549**] PULM: Bibasilar crackles, diminished breath sounds at left base. Resp unlabored, no accessory muscle use. ABD: Soft, non-tender, non distended, bowel sounds present. No hepatosplenomegaly EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally. NEURO: A & O x 1. Moving all extremities, following commands SKIN: No ulcerations or rashes noted. Pertinent Results: On admission: [**2200-11-10**] 07:05PM BLOOD WBC-15.6* RBC-5.88* Hgb-16.9* Hct-52.7* MCV-90 MCH-28.7 MCHC-32.0 RDW-14.0 Plt Ct-131* [**2200-11-10**] 07:05PM BLOOD Neuts-89.2* Lymphs-5.9* Monos-3.7 Eos-0.9 Baso-0.3 [**2200-11-10**] 07:05PM BLOOD PT-17.8* PTT-22.4 INR(PT)-1.6* [**2200-11-10**] 07:05PM BLOOD Glucose-394* UreaN-59* Creat-1.5* Na-138 K-5.5* Cl-95* HCO3-20* AnGap-29* [**2200-11-10**] 07:05PM BLOOD LD(LDH)-523* [**2200-11-10**] 07:05PM BLOOD proBNP-[**Numeric Identifier 1199**]* [**2200-11-10**] 07:05PM BLOOD cTropnT-0.03* [**2200-11-10**] 07:05PM BLOOD Calcium-9.6 Phos-6.2* Mg-2.2 [**2200-11-12**] 07:08AM BLOOD %HbA1c-10.8* eAG-263* [**2200-11-11**] 04:41AM BLOOD TSH-5.7* [**2200-11-11**] 08:25PM BLOOD Vanco-9.8* [**2200-11-10**] 07:25PM BLOOD Type-ART pO2-77* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 [**2200-11-10**] 07:13PM BLOOD Glucose-339* Lactate-5.3* [**2200-11-11**] 12:18AM BLOOD O2 Sat-95 [**2200-11-11**] 12:18AM BLOOD freeCa-1.10* [**2200-11-11**] 01:15AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2200-11-11**] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-NEG [**2200-11-11**] 01:15AM URINE RBC-5* WBC-3 Bacteri-FEW Yeast-NONE Epi-1 [**2200-11-11**] 01:15AM URINE CastHy-64* [**2200-11-11**] 01:15AM URINE Hours-RANDOM UreaN-897 Creat-159 Na-10 K-74 On discharge: [**2200-11-17**] 07:00AM BLOOD WBC-11.7* RBC-4.65 Hgb-13.5 Hct-42.3 MCV-91 MCH-29.0 MCHC-31.9 RDW-14.6 Plt Ct-211 [**2200-11-14**] 08:30AM BLOOD PT-13.2* PTT-26.7 INR(PT)-1.2* [**2200-11-17**] 07:00AM BLOOD Glucose-157* UreaN-11 Creat-0.6 Na-138 K-4.3 Cl-100 HCO3-26 AnGap-16 [**2200-11-12**] 07:08AM BLOOD proBNP-3694* [**2200-11-17**] 07:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.7 [**2200-11-16**] 06:30AM BLOOD Triglyc-183* HDL-29 CHOL/HD-6.0 LDLcalc-108 [**2200-11-12**] 06:51AM BLOOD Lactate-1.6 Pleural Fluid: [**2200-11-10**] 09:37PM PLEURAL WBC-299* RBC-179* Polys-34* Lymphs-16* Monos-0 Meso-2* Macro-18* Other-30* [**2200-11-10**] 09:37PM PLEURAL TotProt-3.8 LD(LDH)-115 Cholest-119 GRAM STAIN (Final [**2200-11-10**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2200-11-13**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2200-11-16**]): NO GROWTH. Cytology: POSITIVE FOR MALIGNANT CELLS, Consistent with metastatic adenocarcinoma. Immunohistochemical stains show that tumor cells stain positive for B72.3, [**Last Name (un) **]-31 (weak) and cytokeratin 7; cells are negative for CD15 (LeuM1), cytokeratin 20, TTF-1, mammoglobin, GCDFP, ER, PR and CDX2. Immunostains for calretinin and WT-1 highlight background mesothelial cells. The immunophenotype is non-specific. Possibilities include (but are not limited to) lung, breast and gynecologic primary malignancies. Microbiology: Blood Culture, Routine (Final [**2200-11-16**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2200-11-11**]): GRAM POSITIVE COCCI IN CLUSTERS URINE CULTURE (Final [**2200-11-12**]): NO GROWTH. Blood Culture, Routine (Final [**2200-11-17**]): NO GROWTH. Blood Culture, Routine (Final [**2200-11-18**]): NO GROWTH. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2200-11-16**]): Feces negative for C.difficile toxin A & B by EIA. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2200-11-18**]): Feces negative for C.difficile toxin A & B by EIA. Portable CXR [**2200-11-10**]: IMPRESSION: Large left pleural effusion with associated lower lung atelectasis. Please note underlying pneumonia cannot be excluded. Recommend followup to resolution. Portable CXR [**2200-11-10**]: Previous left pleural effusion has nearly resolved following thoracentesis. No obvious pneumothorax. Heterogeneous opacification in the left lung could be residual atelectasis or reexpansion edema and should be followed. Mild interstitial abnormality and possible bronchiectasis noted in the right lung, but nothing acute. The heart is moderately enlarged. TTE [**2200-11-11**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. CT chest w/o contrast [**2200-11-11**]: FINDINGS: Extensive calcifications of the aorta are noted. Mediastinal lymph nodes are not pathologically enlarged based on the size criteria. There is normal diameter of the pulmonary arteries. There is left lower lobe extensive consolidation associated with pleural effusion. In addition there are multiple pulmonary nodules with ill-defined margins noted throughout the lungs bilaterally. Multiple pulmonary nodules are bilateral, ranging up to 15 mm in the left upper lobe, 10.5 mm in the right upper lobe. Some of the nodules are cavitated. No definite dominant lesion is noted in the lungs, but it potentially could be obscured by extensive consolidation in the lingula and left lower lobe. Small amount of pleural effusion on the current study appears to be decreased as compared to [**2200-11-10**] and most likely unchanged since chest radiograph obtained after thoracocentesis. Airways are patent to the level of subsegmental bronchi bilaterally. No bone abnormalities to suggest lytic or sclerotic lesions worrisome for neoplasm or infectious process demonstrated. The imaged portion of the upper abdomen demonstrates sludge in the gallbladder and otherwise is unremarkable within the limitations of this study technique. IMPRESSION: 1. Substantial consolidation in the left lower lobe and lingula with some degree of volume loss associated currently with minimal amount of pleural effusion. Infectious etiology would be the first choice, although underlying neoplasm or vasculitis cannot be excluded. All those etiologies may potentially explain the presence of multiple ill-defined pulmonary nodules seen in both lungs as well as consolidation, correlation with clinical symptoms and tissue diagnosis is required. 2. The extensive consolidations might potentially obscure pulmonary lesions being dominant in the case of malignancy. Portable CXR [**2200-11-13**]: FINDINGS: Since the most recent examination, there has been interval increase in now a small-to-moderate left layering pleural effusion. There is mild improvement in ill-defined nodular opacification scattered throughout all lung fields as better characterized on recent CT. There is no evidence of pneumothorax. There is no right-sided effusion. The cardiomediastinal and hilar contours are stable, demonstrating borderline enlarged heart size. Pulmonary vascularity is not increased. IMPRESSION: 1. Mild interval increase in now small-to-moderate left layering pleural effusion since most recent examination. 2. Mild improvement in multifocal ill-defined nodular opacification, as better characterized on CT from [**2200-11-11**]. MRI head w and w/o contrast [**2200-11-14**]: FINDINGS: Diffusion images demonstrate a small area of high signal in the right occipital lobe near the midline without corresponding enhancement. Subtle T2-hyperintensity is also seen in this region. Additionally, there is a focus of hyperintensity in the left centrum semiovale, which demonstrates an area of enhancement. There are no other areas of abnormal enhancement seen. There is moderate-to-severe brain atrophy seen with prominence of temporal horns indicating temporal lobe atrophy. Mild-to-moderate changes of small vessel disease are seen. IMPRESSION: A focus of hyperintensity on diffusion images in the right occipital lobe without corresponding enhancement is too small to characterize on ADC map, but could represent a small acute infarct. An abnormality in the left centrum semiovale demonstrates T2 abnormality with subtle enhancement. Given the faint enhancement and T2 abnormality, the differential diagnosis includes a small deep white matter subacute infarct versus a metastatic lesion. A followup study in two weeks would help for further assessment. No other areas of abnormal enhancement seen. No territorial infarcts are identified. Brain atrophy is seen. Brief Hospital Course: [**Age over 90 **]yo F with dementia, HL, and osteoporosis who presented with SOB and was found to have large left sided pleural effusion on CXR. #Pleural Effusion, malignant: Patient presented to the ED with shortness of breath, tachypnea and hypoxia. Chest x-ray was significant for a large left pleural effusion. Thoracentesis was performed that removed 1.5L of fluid. Analysis showed 300 WBC with 33% PMN. Light criteria negative for exudate. Gram stain was negative. Differential is broad but based on history, physical, and labs question parapneumonic effusion vs malignancy. Less likely to be CHF, PE. TTE was performed that showed EF >75%. BNP was [**Numeric Identifier 1199**] on admission but dramatically decreased to 3694 after thoracentesis. Patient was transitioned to ceftriaxone and azithromycin for empiric coverage for CAP and treated with 7 days of antibiotics. Repeat chest x-ray was consistent with intersitial edema and questionable consolidation in the left lower lobe. Oxygen requirements were weaned and the patient was transferred on 2L on nasal cannula. She remained mostly on room air, intermittently on 1-2L oxygen, throughout remainder of hospital course on the floor. Repeat CXRs showed slow re-accumulation of left pleural effusion. Cytology of the pleural fluid returned positive for malignant cells, showing metastatic adenocarcinoma. Interventional pulmonary continued to follow the patient on the floor. Discussion of therapeutic options for the pleural effusion was held, including possible options of chest tube drain and pleurodesis. Prior to discharge, the option of performing a repeat thoracentesis to drain remaining fluid was discussed with the family. Given the risks of the procedure, the family declined further interventions. The palliative care team was consulted for further guidance on end of life care. On [**2200-11-17**], family meeting was held with the palliative care team to discuss goals of care and options for care at home vs extended care facility. The family decided to home hospice and the patient was discharged on [**2200-11-18**] with home hospice service in place. She will need 24 hour care at home, home oxygen at home for oxygen saturation below 90%, and a wheelchair. She will also be provided with medications to help with comfort, including morphine. # Somnolence/Encephalopathy: Pt exhibited waxing and [**Doctor Last Name 688**] levels of somnolence during her hospital stay. Per family report, she had also been increasingly sleep at home prior to admission to hospital. Because of the likelihood of malignancy and possibility of metastatic spread, MRI of the head was pursued after discussion with the family about risks and benefits of head imaging. The MRI showed a focus of hyperintensity in right occipital lobe that could represent small acute infarct as well as abnormality in left centrum semiovale consistent with either subacute infarct vs metastatic lesion. Patient was started on a baby aspirin and will remain on her simvastatin. Her LDL was 108. #Lactic acidosis: Patient presented with a lactate of 5.3. After thoracentesis and fluid resuscitation lactate improved to 4.1. Etiology includes hypovolemia and hypoperfusion vs sepsis vs hypoxia. Patient does have an elevated WBC to 15.6 with a left shift. Patient was hemodynamically stable. Received IV vancomycin and cefepime in the ED and was transitioned to ceftriaxone/azithromycin. Lactate normalized to 1.6 prior to transfer to the floor. #Acute Kidney Injury: On admission, patient had acute elevation in her Cr from 0.8 to 1.5 with an elevated BUN to 59. Pre-renal azotemia most likely secondary to hypovolemia. Differential also includes ATN. FeNa <1%. Most likely secondary to hypovolemia. Cr improved with fluid resusciation. Cr was at baseline 0.6 by time of discharge. She was given conservative IV fluids prn for signs of volume depletion, including tachycardia to low 100s and low urine output. #Hyperglycemia/DM type 2, uncontrolled, without complications: Patient with a history of diabetes and on glimepiride at home presenting with serum glucose of 394. Patient was started on sliding scale insulin. Prior to discharge home, fingersticks remained 100s-200s without insulin. Hemoglobin A1c was 10.8. Risks and benefits of oral agents for diabetes were discussed with family. Because of the risks of hypoglycemia and her minimal po intake, the patient was not discharged on home oral hypoglycemics. #Cyanotic Digits: Patient has cyanosis of fingers and toes. Not associated with any pain. Positive radial pulses. Left DP/PT present on Doppler but was not able to be obtained on the right. Currently does not appear to be ischemic but more likely to be chronic PVD. After re-examining the patient during HD 1 morning rounds the extremity cyanosis resolved and pulses were present in all extremities. ABI showed bilateral aortoiliac and likely infrainguinal arterial occlusive disease . ABIs were 0.7 on the right and 0.6 on the left. Given overall limited life expectancy, further work-up for PVD was not pursued. # Bacteremia: Blood culture on arrival to ED [**2200-11-10**] grew GPCs in clusters; she was started on vancomycin empirically. Speciation returned as coag negative staph. It was felt that this one positive blood culture was most likely contaminant as pt was afebrile and with downtrending WBC. Subsequent blood cultures showed no growth. Vancomycin was discontinued after one day. #Diarrhea: Two days prior to discharge, pt developed increased frequency of loose stools. C.diff was negative x 2. She may find symptomatic relief with anti-diarrheal agents such as loperamide. She was given conservative IV fluids prn for volume depletion. She did not have diarrhea on day of discharge. #Poor po intake: Family was concerned with pt's minimal oral intake, which had been an ongoing problem prior to admission. She was seen by swallow therapist who performed a bedside evaluation and found no risk of aspiration. Although swallow therapist felt that there were no restrictions on her diet, she was kept on a soft dysphagia diet because the family requested it. Medications on Admission: ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly DONEPEZIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day glimepiride 1 mg tab QD SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Wheelchair Please provide 1 wheelchair 3. Compression stockings Provide 1 pair of compression stockings 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Hospice of the [**Location (un) 1121**] Discharge Diagnosis: Primary: Pleural effusion Adenocarcinoma Acute/subacute infarct Secondary: Diabetes mellitus type II Peripheral vascular disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted with shortness of breath. You were found to have a large fluid collection around your lungs; this fluid was removed. This fluid showed cancer cells. An MRI of the head also showed a possible stroke and possibly spread of cancer to the brain. Your family met with the palliative care team and it was decided that you would go home with hospice care. The hospice team will provide your family with medications to keep you comfortable. The following medication changes were made: 1) STOP glimepride 2) START aspirin 81mg daily 3) You may continue to take simvastatin 10mg daily 4) STOP alendronate Followup Instructions: You will be cared for by a hospice team at home. Completed by:[**2200-11-18**]

Admission Date: [**2102-6-3**] Discharge Date: [**2102-6-5**] Date of Birth: [**2079-7-19**] Sex: F Service: MEDICINE Allergies: Levaquin / Metronidazole Attending:[**First Name3 (LF) 30**] Chief Complaint: TCA Overdose, Depression Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 22F with a history of polysubstance abuse and depression who now presents after an ingestion of pills. The history was gathered from her father and cousin. [**Name (NI) **] was in her usual state of health at 7am on morning of admission and when she reported to family that she had just ingested 14 Doxepin pills. She became nauseated and mentioned she needed to vomit. She had a change in mental status, becoming confused and the father carried her into the car and drove her to the emergency department at [**Hospital6 **]. Initial vitals were t99.1 111/67 130 14 100 RA. ECG was noted to be without signs of TCA toxicity and she was transferred to [**Hospital1 18**] for further evaluation. At [**Hospital1 18**], vitals initially p 110 bp 130/70 28 98 4L. She was noted to be somnolent and was intubated for airway protection and to get head CT. Toxicology consultant evaluated the patient in the ED and recommended serial ECGs and monitoring in MICU. . In the MICU ([**2102-6-3**]), the patient was sedated with propofol 20-100 mcg/kg/min IV drip and was unresponsive. On the floor, initial MICU vitals were 97.1, 121/84, 81, 100% (intubated). Toxicology screen was positive for cocaine, methadone, and tricyclics. EKGs were monitored Q1 hr; no abnormalities including QT or QRS elongation were seen. No intracranial process was seen on CT, and CXR was within normal limits. She remained stable overnight. On morning of HD #2, patient was extubated and EKGs remained WNL. Potassium (2.8) was repleted. Psychiatry was consulted and diagnosed polysubstance abuse, major depression (r/o PTSD), and believe that it is still unsafe for her to be discharged. They started patient on Valium 5 mg PO tid/prn for anxiety and Seroquel 25-50mg po tid/prn for agitation; in addition, they recommended a 1:1 sitter. At this time, she was transferred to SIRS service. On the floor, she denied any chest pains, shortness of breath, palpatations, suicidal or homicidal ideations, and reports that she did not intend to kill herself, but was trying to use them for sleep. Past Medical History: -Asthma as a child, and has a home nebulizer which she never uses. She does not use inhalers -Polysubtance abuse. Social History: Polysubtance abuse including heroin, cocaine. +tobacco use 1 PPD x 5 years, per father no history of significant etoh use. Family History: No significant family history. Father is healthy. Physical Exam: VS: Temp: 100.4, ST 114, 109/54, 94% RA GEN: awake, alert, anxious to leave hospital, crying occasionally HEENT: NC/AT, EOMI, pupils 4mm equal, reactive, no LAD RESP: clear bilaterally with good aeration CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, WWP Neuro: A&O x3, CN II-XII intact, good motor strength and no atrophy, no gait abnormalities, FNF test WNL Pertinent Results: [**2102-6-4**] WBC-21.0*# RBC-4.84 Hgb-9.7* Hct-31.5* MCV-65* MCH-20.1* MCHC-30.8* RDW-13.9 Plt Ct-325 [**2102-6-5**] WBC-12.1* RBC-4.63 Hgb-9.1* Hct-30.9* MCV-67* MCH-19.6* MCHC-29.4* RDW-14.0 Plt Ct-300 [**2102-6-3**] Neuts-82.6* Lymphs-14.7* Monos-2.2 Eos-0.3 Baso-0.2 [**2102-6-5**] Neuts-70.4* Lymphs-23.9 Monos-2.3 Eos-3.2 Baso-0.2 [**2102-6-4**] Glucose-82 UreaN-8 Creat-0.5 Na-140 K-2.8* Cl-107 HCO3-25 AnGap-11 [**2102-6-5**] Glucose-135* UreaN-13 Creat-0.5 Na-143 K-4.2 Cl-110* HCO3-24 AnGap-13 [**2102-6-4**] ALT-51* AST-39 LD(LDH)-211 AlkPhos-79 TotBili-1.1 [**2102-6-5**] ALT-41* AST-35 AlkPhos-89 [**2102-6-3**] Lipase-20 [**2102-6-5**] Calcium-8.5 Phos-2.7 Mg-1.7 [**2102-6-4**] Albumin-3.6 Mg-1.8 Iron-20* [**2102-6-4**] calTIBC-257* Ferritn-136 TRF-198* [**2102-6-3**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2102-6-3**] Type-ART Temp-37.1 Tidal V-500 pO2-402* pCO2-41 pH-7.40 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2102-6-3**] Lactate-.6 [**2102-6-4**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-SM Urobiln-2* pH-7.0 Leuks-NEG TECHNIQUE: Non-contrast head CT. FINDINGS: Evaluation is slightly limited by patient motion artifact. There is no evidence of hemorrhage, edema, mass, mass effect or infarction. Ventricles and sulci are normal in size and configuration. There is no fracture. Inspissated secretions in the posterior nasopharynx likely reflect the patient's intubated status. IMPRESSION: No acute intracranial process. CHEST, SINGLE VIEW: An ET tube tip terminates 4.4 cm above the carina. An NG tube and sidehole projects below the diaphragm in the left upper quadrant. Heart size and cardiomediastinal contours are normal. There is no focal airspace opacification. Pulmonary vasculature is normal. No gross osseous abnormalities. IMPRESSION: No acute intrathoracic process. ETT and NGT in appropriate position. Brief Hospital Course: # TCA overdose: Patient presents with intoxication of doxepin; toxicology screen was positive for methadone, TCAs, and cocaine. Patient states that last methadone dose was x2 weeks ago and she took suboxone x2 days prior to admission. Patient was initially admitted to the medical ICU where she was intubated to secure the airway, serial EKGs were done (all showed NSR without abnormalities), and patient was monitored. On HD #2, patient was extubated, and was monitored for symptoms of hypotension, palpatations, chest pain, or any other symptoms of TCA intoxication. EKGs remained normal throughout MICU course without arrythmias. She was then transferred to the medicine services after patient's peak for toxic symptoms were over (active metabolites 12-24 hours), EKGs remained normal throughout the course, and she exhibited no symptoms upon discharge. . # Psychiatric Status: Patient was seen by psychiatric in the MICU for questionable suicidal ideation. The patient denied any suicidal or homicidal ideation, and repeatedly wanted to go home. Psychiatry reported that she has polysubstance abuse, depression, and borderline personality. She was given Valium, Seroquel, and Ibuprofen PRN for anxiety, agitation, and possible opiate withdrawal. She had 1:1 sitter throughout her hospital stay. Upon discharge, she was counseled on depression and an appointment was made for outpatient psychiatric care near her home. . #Anemia: Patient presented with hematocrit of 31.5 (baseline unknown), with microcytic features and wide RDW. Iron levels are low (20) with low TIBC (257), and her low MCV (68) do not suggest a complete iron deficiency picture. Iron deficiency alone is unlikely to cause such a microcytosis picture, therefore her anemia could be secondary to a mixed etiology of minor thalassemia (microcytosis of 68) and iron deficiency. She was started on iron supplementation and outpatient care for follow-up for her anemia. . #Elevated WBC and fever: The patient had elevated WBC (20) and low-grade fever 100.4 in the MICU, but trended down while admitted to the medicine floor (WBC 12, temp 98.2). She has no indication of infection as she clinically has no syptoms of fevers/chills and does not feel overall unwell; in addition, CXR shows no abnormalities. The most likely etiology was s/p MICU extubation and stress response. Medications on Admission: None. Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Home Discharge Diagnosis: Tricyclic overdose. Discharge Condition: Good. Discharge Instructions: You were treated for a tricyclic overdose and were admitted to the Medical ICU. Your laboratory values and EKG were stable, and you were then transferred to the medicine floor. Please follow-up with your primary care physician and with outpatient pscyhicatric services ([**6-10**], 9:30 am at the Psychologic Services of [**Hospital1 487**]). If you feel unsafe, feel like hurting yourself or other people, or feel symptoms such as shortness of breath, weakness, fevers, or chills, please report to your primary care physician or return to the hospital. . Please change your Mass Health insurance from [**Hospital1 189**] to [**Hospital 61**]. It is important you do this for your primary care appointment or you will be billed. Followup Instructions: Please follow-up with your primary care physician on Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29932**] on [**6-30**] at 1:30pm [**Hospital6 733**] ([**Telephone/Fax (1) 69622**] to change or cancel appointment). Please follow-up with your psychiatric outpatient appointment on [**6-10**], Saturday, 9:30 am at the Pscyhological Services in [**Hospital1 487**], MA. Completed by:[**2102-6-8**]

Admission Date: [**2176-1-12**] Discharge Date: [**2176-1-16**] Service: HISTORY OF PRESENT ILLNESS: This is a 79-year-old Russian speaking woman resident of [**Hospital 100**] Rehab who presented on the day of admission with a one week history of epigastric and right upper quadrant pain, nausea and vomiting that is worse with eating, increased fatigue and dyspnea on exertion. Four days prior to admission, the patient also started having altered mental status. The day of admission, the patient's daughter fed her and this was followed by the patient vomiting up her cereal. Follows this she vomited up about a cup full of blood clots. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Insulin dependent diabetes type 2. 3. Hypertension. 4. Cirrhosis secondary to chemical exposure in the [**Location (un) 3156**]. 5. Gastroesophageal reflux disease. 6. History of pulmonary embolus on Coumadin. 7. Status post right femoral fracture in [**2174**]. 8. Atrial fibrillation. ALLERGIES: 1. Sulfa. 2. Nafcillin. 3. She also has positive HIT antibodies to heparin. MEDICATIONS ON ADMISSION: 1. Coumadin, unclear dose. 2. TUMs 650 mg b.i.d. 3. Colace 250 mg p.o. q. day. 4. Iron Sulfate 325 mg p.o. b.i.d. 5. Lasix 80 mg p.o. q. day. 6. Prevacid 30 mg p.o. q. day. 7. Tylenol 650 p.o. b.i.d. p.r.n. 8. NPH insulin 18 units subcu q. AM. 9. Regular insulin 6 units subcu b.i.d. 10. Metolazone 2.5 mg q. Monday and Friday. 11. Multivitamin one tablet p.o. q. day. 12. Nadolol 20 mg p.o. q. day. 13. Senokot two tablets p.o. q. day. SOCIAL HISTORY: The patient is a resident of [**Hospital 100**] Rehab. She has family in the area including two daughters and two grandson. [**Name (NI) 440**], her daughter, phone # [**Telephone/Fax (1) 42214**]. PHYSICAL EXAMINATION: On admission temperature of 98.4 F, pulse 62, blood pressure 164/47, respiratory rate 16, oxygen saturations 95% on room air. In general the patient was awake and opened eyes to command. Unable to follow commands, though and generally nonverbal. She responded to noxious stimuli. Head, eyes, ears, nose and throat: Extraocular muscles are intact. Pupils are equal, round and reactive to light. The sclerae were anicteric. Neck was supple. No significant jugular venous pressure. Mucous membranes were moist. Lungs: Decreased breath sounds bilaterally at the bases with faint crackles. Heart exam: Regular rate and rhythm with a III/VI systolic ejection murmur at the left and right upper sternal border and the left lower sternal border. Abdomen: Patient had mild diffuse abdominal pain mostly in the right upper quadrant, no rebound or guarding. Normoactive bowel sounds. It was obese with positive fluid air level. Extremities: She had positive DP pulses. She was moving all four extremities spontaneously. Rectal exam revealed bright red blood. LABORATORY DATA ON ADMISSION: White count 6.5, hematocrit 26.7, platelets 158. She had a Chem-7 with a sodium of 139, potassium 4.0, chloride 106, bicarbonate 24, BUN 17, creatinine 0.8, glucose 190. Her prothrombin time 22.3, partial thromboplastin time 38.4, INR 3.3. LFTs: ALT 9, AST 21, alkaline phosphatase 99, T. Bilirubin 0.9. EKG: Normal sinus rhythm, normal axis, T wave flattening in F, T wave inversion in V1, Slight ST depression less than 1 mm in V3. No significant change from [**2175-5-24**]. HOSPITAL COURSE: In the emergency room, the GI Service was consulted. There was initial concern for a variceal bleed given her manifestations and her history of cirrhosis. The patient was electively intubated for airway protection. She was put on a Nitrate drip for her potential esophageal varices and her coagulopathy was reversed with 10 mg of subcu vitamin K, four units of FFP. She was also transfused initially with two units of packed red blood cells. She was brought to the Medical Intensive Care Unit for observation as well as esophagogastroduodinoscopy. The EEG which was performed on the day of admission, did show varices of the lower third of the esophagus. These were nonbleeding. The stomach was normal. In the duodenum there was a large necrotic ulcer involving the entire bulb extending to the second portion of the duodenum. This was unable to be passed due to necrosis and clots. It was felt that this necrotic mass most likely represented an ulcer which had perforated posteriorly possibly into the pancreas or into the lesser sac and that this was likely the source of her bleeding. At this point in her care, decision point was reached with regards to the aggressiveness of her care. Her family was informed that the nature of her ulcer would likely require surgical intervention and that the prognosis, even if operated on, was most likely very poor. The patient who had been a DNR, DNI prior to this hospitalization which was reversed temporarily for the EGD, elected to pursue comfort measures only as to the philosophy of her care. The patient was extubated and transferred out of the Medical Intensive Care Unit to the Medical floor. Her course on the floor has been otherwise been unremarkable. The patient has been under very good pain control now only requiring sublingual Morphine Sulfate every two hours. She has been maintained on intravenous Protonix 40 units q. 24 hours. She is also continuing to receive antibiotics for a concomitant urinary tract infection. The Geriatric Service advised giving her two units of packed red blood cells on the day of admission to the Medical floor which was carried out. The rest of her course on the Medical floor has been otherwise unremarkable. Her mental status actually has improved to some extent while being here and her pain has been under very tight control. DISCHARGE DISPOSITION: The patient is being transferred to the [**Hospital 100**] Rehab where she will have Hospice care. The patient will be sent out on the following medications: 1. Protonix 40 mg IV q. 24 hours 2. Levofloxacin 500 mg IV q. 24 times five more days. 3. Morphine Sulfate sublingual 5 mg q. two hours p.r.n. to be adjusted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Hospital 100**] Rehab. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 16075**] MEDQUIST36 D: [**2176-1-16**] 11:46 T: [**2176-1-16**] 13:11 JOB#: [**Job Number 42215**]

Admission Date: [**2140-4-14**] Discharge Date: [**2140-4-18**] Date of Birth: [**2080-8-27**] Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:[**First Name3 (LF) 1854**] Chief Complaint: mental status change Major Surgical or Invasive Procedure: steriotactic brain biopsy History of Present Illness: The patient is a 59 y/o female who presented today to an outside hospital after experiencing an increasingly severe headache for the past 4 days. The patient has had two syncopal events over the past year (most recent episode in early [**Month (only) 958**]). The patient had an episode of vomiting 4 days ago and has had worsening headache since that time. The headache has caused the patient to remain in bed for most of the day. The patient's husband notes that the patient has been more somnolent over the past couple days in addition to some gait unsteadiness. Head CT at the outside hospital demonstrated a significant right frontal brain mass associated with mass effect and shift. She was given 10 mg of IV decadron and 1 gram of dilantin at the outside hospital and was transeferred to [**Hospital1 18**] for further management. Past Medical History: hypothyroidism, s/p tubal ligation Social History: works part-time as a hairdresser Family History: no family history of intracranial malignancy Physical Exam: A&O x 3. EOMs intact. Face symmetric. Motor [**4-18**] throughout. Sensation intact throughout. Toes downgoing bilaterally. Pertinent Results: CT head [**4-15**]: FINDINGS: Patient is status post stereotactic brain biopsy of right frontal cystic lesion, and Ommaya shunt device is now seen in place, with reservoir in the right frontal subcutaneous tissues, and catheter extending into the lesion, with tip seen just lateral to the frontal [**Doctor Last Name 534**] of the right lateral ventricle. There is a small amount of expected post-surgical pneumocephalus. There is a tiny amount of curvilinear density seen anterior to the frontal [**Doctor Last Name 534**] of the right lateral ventricle, which likely represents a small amount of post-procedural hemorrhage. There is no sign of new or large intracranial hemorrhage. Vasogenic edema in the right frontal lobe is unchanged. 8-mm leftward subfalcine herniation is largely unchanged. Right uncal herniation is unchanged. IMPRESSION: 1. Status post stereotactic brain biopsy and placement of Ommaya shunt in large cystic lesion in the right frontal lobe. Unchanged vasogenic edema, leftward subfalcine herniation, and right uncal herniation. 2. Expected post-procedural pneumocephalus. Tiny amount of blood anterior to right lateral ventricle, but no new large intracranial hemorrhage. MRI head [**4-14**]: FINDINGS: When compared with a prior study, again there is evidence of a large approximately 4 x 5 cm right frontal cystic mass lesion associated with vasogenic edema and subfalcine herniation to the left (approximately 1.2 cm of shifting is noted). After the administration of gadolinium contrast, there is evidence of ring-enhancing pattern in this lesion with some irregular areas and possible septations. On the magnetic susceptibility, there are low signal areas suggesting calcifications or blood products. On FLAIR sequence, there is evidence of some scattered hyperintense foci and possible transependymal migration of CSF on the left occipital ventricular [**Doctor Last Name 534**]. There is also evidence of effacement of the right perimesencephalic cisterns and right uncal herniation. Normal flow void signal is identified on the vascular structures. The orbits, the paranasal sinuses appear within normal limits, patchy hyperintensity signal is identified on the mastoid air cells bilaterally, more evident on the left. IMPRESSION: Large cystic mass lesion is identified on the right frontal lobe with evidence of ring-enhancing pattern at irregular contour in the base of the lesion with septations and possible hemorrhagic blood products or calcifications. The possibility of a primary cystic lesion is a consideration, a metastatic lesion cannot be completely ruled out. Brief Hospital Course: The patient was started on mannitol and decadron upon admission. Her neuro status improved slightly after the mannitol was started. On [**4-15**] she had a steriotactic brain biopsy, drainage of cystic mass, and placement of Ommaya shunt. Her post-op CT scan was stable. On [**4-16**] she was transferred to the floor. Due to her improved mental status, the mannitol was weaned off. The patient was eating, drinking, and ambulating on her own prior to discharge. She was sent home on [**2140-4-18**] after her MRI. Medications on Admission: [**Last Name (LF) **], [**First Name3 (LF) **], MVI, lutein, b12, vitamin E Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed: No driving while on narcotics. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: brain mass Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow-up in the Brain [**Hospital 341**] Clinic. You should have your sutures removed at that time. Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2140-5-3**] 9:00. This is on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. Completed by:[**2140-4-18**]

Admission Date: [**2103-2-19**] Discharge Date: [**2103-3-6**] Date of Birth: [**2039-10-29**] Sex: F Service: CARDIOTHORACIC Allergies: Gabapentin / Phenobarbital / adhesive tape Attending:[**First Name3 (LF) 4679**] Chief Complaint: right upper lobe lung nodule Major Surgical or Invasive Procedure: [**2103-2-20**]: 1. Right thoracotomy, right upper lobectomy. 2. Wedge resection of superior segment of right lower lobe. 3. Mediastinal lymph node dissection. History of Present Illness: The patient is a 63-year-old woman with a 4-cm lung cancer arising from the right upper lobe. Preoperative imaging suggested that the lesion crossed the major fissure into the right lower lobe. Given this and the tumor size, we elected to perform the lobectomy through a right thoracotomy. Past Medical History: Metastatic Breast Cancer Hypertension Hyperlipidemia Gout Pancreatitis Parotitis Diverticulitis Lumbar disc disease Anxiety Stress fracture of fibula Past Surgical History: Vaginal hysterectomy multiple D&Cs left foot surgery Social History: former smoker (20+pk yrs, quit x20yrs). Occ EtOH. Had a significant other. Family History: FAMILY HISTORY: BRCA [**1-28**] negative Mother: Died of stomach CA at age 73 Father: Died of renal CA at age 39 (possible related to radiation exposure in WWII) Siblings Offspring Other: Niece with breast CA in 40's Physical Exam: Discharge vital signs: T 98.2, HR 67, BP 114/64 RR 20 O2 sats 94% RA Discharge Physical exam: General: pleasant in NAD Lungs: clear t/o chest: right thoracotomy healed. right chest tube site with suture intact. CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm without edema Pertinent Results: [**2103-3-1**] 07:30AM BLOOD WBC-13.9* RBC-3.86* Hgb-12.3 Hct-35.0* MCV-91 MCH-31.9 MCHC-35.2* RDW-16.7* Plt Ct-298 [**2103-2-28**] 07:10AM BLOOD WBC-16.7* RBC-3.91* Hgb-12.1 Hct-35.5* MCV-91 MCH-30.9 MCHC-34.1 RDW-17.2* Plt Ct-256 [**2103-2-22**] 01:43AM BLOOD PT-17.8* PTT-33.6 INR(PT)-1.6* [**2103-3-2**] 07:15AM BLOOD Glucose-135* UreaN-15 Creat-0.6 Na-136 K-4.1 Cl-102 HCO3-26 AnGap-12 [**2103-3-1**] 07:30AM BLOOD Glucose-148* UreaN-21* Creat-0.7 Na-135 K-4.0 Cl-102 HCO3-24 AnGap-13 [**2103-2-28**] 07:10AM BLOOD Glucose-104* UreaN-44* Creat-1.4* Na-137 K-4.9 Cl-102 HCO3-24 AnGap-16 [**2103-2-27**] 11:10AM BLOOD Glucose-120* UreaN-36* Creat-2.2* Na-138 K-4.5 Cl-101 HCO3-25 AnGap-17 [**2103-2-24**] 08:10AM BLOOD ALT-26 AST-37 LD(LDH)-377* AlkPhos-86 TotBili-2.0* [**2103-3-2**] 07:15AM BLOOD Calcium-8.4 Phos-2.0* Mg-1.8 CXR on discharge [**2103-3-6**]: Stable right apical pneumothorax. [**2103-2-27**] Renal US Normal renal ultrasound. [**2103-2-26**] IMPRESSION: Suboptimal image quality. Grossly normal cavity sizes and biventricular systolic function. No definite pathologic valvular flow identified. Brief Hospital Course: Ms. [**Known lastname 96189**] was taken to the operating room by Dr. [**First Name (STitle) **] on [**2103-2-19**] where she underwent a right open thoractomy with right upper lobectomy and lymph node dissection (see operative report for full details). She remained intubated postoperatively and transfered to the ICU. Below is a systems review of her hospital stay. Neuro: The patient remained neurologically intact throughout her stay. Dilaudid IV was used in the immediate postoperative period, then switched to ibuprofen, tylenol, lidocaine patch and oxycodone, with prn cyclobenzaprine which was effective in pain relief. Pulmonary: The patient was keep intubated postoperatively, and extubated POD 1. Aggressive pulmonary toilet was continued to incentive spirometry, ambulation, nebulizers and mucolytics. Home lasix was continued with spot dosing of IV lasix to diurese. She had a right chest tube which was discontinued initially on [**2103-2-24**], however developed increasing pneumothorax, and subcutaneous air necesitating right pigtail placement with Dr. [**Last Name (STitle) **] of interventional pulmonology on [**2103-2-26**]. Leak continued, therefore a talc 5gram pleurodiesis was done on [**2103-3-2**]. The chesttube was kept for 48hours on suction. It was eventually removed on [**2103-3-6**] after successful clamp trial, with stable right small pneumothorax on postpull film. CV: The patient went into atrial fibrillation on POD 1 after extubation. This resolved initially on home dose of nadolol and IV diltiazem. After transfer to the floor on [**2103-2-22**] she developed atrial fibrillation [**2103-2-23**]. At this time IV lopressor was unsuccessfull, therefore she received IV amiodarone 10g load with oral amio plus nadolol as recommended by cardiology thereafter. We did consult cardiology who recommended echo and the above described antiarrhythmic agents. The patient had afib on [**2-26**], but converted midday and has maintained SR since with occasional tachycardia with ECG evidence of SR with PAC's. It was felt she did not need coumadin, but a full strength aspirin was started. The patient remained hemodynamically stable throughout. Her nadolol was cut in half on [**2-27**] after acute renal insufficiency as described below. Echo was done on [**2103-2-26**] and essentially normal with normal LVEF. She was set up with Dr. [**First Name (STitle) **] in a month for followup and weaning off amiodarone. Abd: Her diet was advanced and tolerated. Stool softeners were given to prevent constipation. Renal: Foley was removed POD 1, but replaced for retention, and dc'd on [**2-24**], with minimal but adequate urine output. She required IV lasix for volume overload. Daily weights were followed. Electrolytes were watched and replaced. On [**2-27**] the patient's creatinine acutely rose to 2.0 then later 2.2. Renal US was performed and normal. NSAIDS were dc'd and metformin held. Amiodarone was decreased to [**Hospital1 **] and nadolol home dosing halved to increase renal perfusion pressures. Urine lytes were done. She was felt to be dry, therefore a liter of fluid was given. The patient's creatinine was closely watched and two days later normalized, with auto diuresing. Endo: Sliding scale insulin was initially given for hyperglycemia. Her home metformin was restarted with improved blood sugars in the low 100's. This was held during her renal insufficiency, and resumed [**2103-3-1**] with improved glucose. Insulin sliding scale was utilized as well. ID: The patient remained afebrile, and CBC trends watched. On [**2-27**] she spiked w WBC count 23, UA was sent and positive, cipro was started and continued x 3 days. Urine culture was sent and final was mixed bacteria consistent with fecal contaminant. After the cipro started her WBC trended downward. The patient noted that during past colon infections she has never mounted a fever. Proph: SCD's and SQ heparin were given for VTE prophylaxis. Dispo: Physical therapy evaluation was made. The patient was deemed appropriate for home with PT. She left with a walker for stabilization. On [**2103-3-6**] the patient was ambulating with adequate pain control, with room air saturations of 92-94%. The patient will see Dr. [**First Name (STitle) **] on [**3-13**] with a chest xray in clinic. Medications on Admission: Aspirin 325 mg daily Clonazepam 0.5 1/2-1 tablet daily Potassium daily Zometa IV Prilosec 20 mg daily Lasix 40 mg prn leg swelling Cyclobenzaprine 10 mg tid prn Metformin 1000mg [**Hospital1 **] Oxycodone 5 mg q3-4 hrs prn pain Nadolol 40mg [**Hospital1 **] Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 2. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for muscle spasm. Disp:*90 Tablet(s)* Refills:*0* 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on during day, 12 hours off at night. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1* 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 9. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for HTN: note that this is half the dose you were taking at home. 10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 2 weeks until [**2103-3-18**] then take 1 tabs by mouth daily x a month and followup with your cardiologist about future dosing. Disp:*75 Tablet(s)* Refills:*0* 11. exemestane 25 mg Tablet Sig: One (1) Tablet PO daily (). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right upper lobe mass s/p right upper lobectomy positive for adenocarcinoma Postoperative atrial fibrillation Postoperative acute kidney injury, resolved Postoperative urinary tract infection, resolved Metastatic Breast Cancer Hypertension Hyperlipidemia Gout Pancreatitis Parotitis Diverticulitis Lumbar disc disease Anxiety Stress fracture of fibula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough, or chest pain (It is normal to cough up small amounts of blood tinge sputum) -Incision develops drainage -Chest tube site: remove dressing on Wednesday evening and cover site with a bandaid until healed -Should site have drainage cover with a clean, dry dressing, change as needed to keep site clean and dry. -Shower daily starting Wednesday night. Wash incisions with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs -No driving while taking narcotics. Take stool softners with narcotics -Walk 4-5 times a day day for 10-15 minutes increase to a Goal of 30 minutes daily -Daily weight. If up 2 # or more in a day, or 3# or more in a week take lasix 40mg and followup with your PCP. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2103-3-13**] 9:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray 30 minutes before your appointment [**Location (un) 861**] Radiology Followup with your primary care doctor Dr. [**First Name (STitle) 1022**] on [**2102-3-14**] at 2:40pm [**Telephone/Fax (1) 17794**] Follow up with Dr. [**First Name (STitle) **] (Cardiologist) on [**Telephone/Fax (1) 2258**] on [**4-4**] at 1050am [**Location (un) 4363**] [**Location (un) **] Office, [**Location (un) 86**] [**Numeric Identifier 6425**] fax [**Telephone/Fax (1) 79385**] Completed by:[**2103-3-6**]

Admission Date: [**2162-7-28**] Discharge Date: [**2162-7-31**] Date of Birth: [**2080-3-22**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3190**] Chief Complaint: ?Guillain-[**Location (un) **] Major Surgical or Invasive Procedure: Bronchoscopy and bronchial lavage: 8/3 [**2162-7-29**] 1. Total laminectomy of C3, 4, 5, 6 and 7. 2. Fusion C3 to 7. 3. Autograft and allograft. History of Present Illness: 82 y/o male with PMHx breast CA s/p mastectomy in [**5-/2162**] c/b right frozen shoulder, squamous cell CA of the penis s/p resection, glaucoma who is being transferred for concern of Guillain-[**Location (un) **] syndrome. Per the pt's niece, he was in his usual state of health until [**7-24**], when he fell while unloading a piece of furniture from his car. Per OSH notes, he did not lose conciousness nor complain of any cardiac prodrome - he felt this was a mechanical fall. He was too weak to get up on his own and was on the ground for ~2 hours prior to being found by his neighbor. [**Name (NI) **] was taken to [**Hospital3 **] and admitted to a telemetry unit. He was noted to have elevated CK, which peaked at 3320, then trended down with IVF. Cardiology was consulted but felt this was a mechanical fall and had planned to obtain an echocardiogram. On [**7-25**], the patient was noted to have increased weakness and progressed to a feeling of an inability to move his extremities on [**7-26**]. Shortly after this, he became bradycardic and hypotensive and went into respiratory failure. He was intubated, had CPR performed, then was transferred to the CCU. He was intermittently on pressors and was felt to have developed an aspiration pneumonia. He was initially on clindamycin, then broadened to vancomycin and cefepime. His O2 requirement improved and there were plans to extubate him on [**7-28**], however a NIF was noted to be -10 and the patient was noted to have complete paralysis of bilateral extremities. CT was negative, neuro consulted and felt he may have an ascending paralysis such as GBS and recommended transfer to a tertiary care facility. . In the ICU, the patient is intubated. He is able to shake his head yes and no to questions. Past Medical History: Breast CA s/p mastectomy [**5-/2162**] penile Squamous cell CA s/p resection Glaucoma Social History: - Tobacco: none - Alcohol: none - Illicits: none Family History: Unknown Physical Exam: Vitals: T: BP: P: RR: SpO2: General: Intubated HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Decreased breath sounds on the left, coarse breath sounds on right CV: RRR, normal S1 + S2, tachycardic Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: able to shake head yes and no to simple questions, Pupils track across midline. Right hand with minimal movement when asked to squeeze, no movement in rest of extremities - sensation unable to be assessed - no reflexes noted on exam Rectal exam deferred until collar able to be placed Pertinent Results: Admission Labs: [**2162-7-28**] 07:40PM WBC-7.1 RBC-4.07* HGB-12.9* HCT-35.6* MCV-87 MCH-31.7 MCHC-36.3* RDW-13.0 [**2162-7-28**] 07:40PM NEUTS-83* BANDS-3 LYMPHS-5* MONOS-8 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2162-7-28**] 07:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2162-7-28**] 07:40PM PT-13.3 PTT-30.0 INR(PT)-1.1 [**2162-7-28**] 07:40PM GLUCOSE-147* UREA N-16 CREAT-0.6 SODIUM-139 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10 [**2162-7-28**] 07:40PM ALT(SGPT)-67* AST(SGOT)-52* LD(LDH)-219 CK(CPK)-629* ALK PHOS-43 TOT BILI-0.8 [**2162-7-28**] 07:40PM CK-MB-4 cTropnT-<0.01 [**2162-7-28**] 07:40PM ALBUMIN-3.2* CALCIUM-7.6* PHOSPHATE-2.7 MAGNESIUM-2.2 [**2162-7-28**] 08:00PM TYPE-ART TEMP-37.2 RATES-14/6 TIDAL VOL-500 PEEP-5 O2-100 PO2-65* PCO2-40 PH-7.45 TOTAL CO2-29 BASE XS-3 AADO2-617 REQ O2-99 INTUBATED-INTUBATED . Microbiology: Bronchial lavage ([**7-28**]): [**2162-7-28**] 10:37PM OTHER BODY FLUID POLYS-86* LYMPHS-1* MONOS-13* . Imaging: CXR ([**7-28**]): MR [**Name13 (STitle) **] ([**8-24**]: FINDINGS: There is exaggerated lordosis of the cervical spine. There is minimal retrolisthesis of C4 over C5 vertebra by 4 mm. The vertebral bodies are normal in height and marrow signal intensity. There is no evidence of acute fracture. Prevertebral soft tissue is noted from C1 to C5 level. Hyperintensity is noted in posterior paraspinal muscles and soft tissues from C1 to C6 levels. A small hypointense area is noted in right paraspinal muscles at the C7-T1 level measuring 1.8 x 1.4 x 1.7 cm in craniocaudad, AP, and transverse dimensions. This likely represents calcification. There is multilevel disc degenerative disease. There is desiccation of all cervical intervertebral discs. At C2-C3 level, there is no significant spinal canal or neural foraminal narrowing. At C3-C4 level, there is a broad-based posterior disc protrusion causing indentation and compression of spinal cord. There is severe spinal canal stenosis. The disc with uncovertebral and facet osteophytes causes moderate bilateral foraminal stenosis. At C4-C5, there is posterior disc protrusion causing indentation and compression of the spinal cord and severe spinal canal narrowing. The disc with uncovertebral and facet osteophytes causes moderate right and mild left foraminal narrowing. At C5-C6, there is diffuse posterior disc bulge causing indentation of the anterior subarachnoid space. There is no evidence of significant spinal canal or neural foraminal narrowing. At C6-C7 level, there is diffuse posterior disc bulge without significant spinal canal or neural foraminal narrowing. Hyperintense signal is noted in cervical spinal cord from C2 to C7 level. This likely represents combination of compressive edema and contusion secondary to fall. Brief Hospital Course: 82 y/o male with PMHx breast CA s/p mastectomy in [**5-/2162**] c/b right frozen shoulder, squamous cell CA of the penis s/p resection, glaucoma with neurologic signs concerning for cervical spine injury vs GBS vs myositis. . # Weakness/paralysis - Concerning for cervical spine injury (may have occurred during intubation) vs ascending paralysis such as GBS vs myositis/myopathy given elevated CK on admission. Patient has no clear history of prodromal illness for GBS, but this is not necessary for the diagnosis. CK trending down without any intervention for myositis making it less likely. MR [**Name13 (STitle) 2853**] performed early [**7-29**] showed chronic DJD of C-spine with significant narrowing of spinal canal, compression of spinal cord, and associated edema from C3-T1. Spine surgery was consulted and felt that the paralaysis is secondary to spinal cord compression with poor prognosis if patient taken to the OR and very low probability of recovery of any function. Spine surgery had a discussion with family who chose to pursue surgical repair. . # Hypoxemic respiratory failure - [**1-27**] diaphragmatic weakness and pneumonia/mucus plugging. CXR on presentation showed complete whiteout of left lung - bronchoscopy the evening of [**7-28**] showed copious amounts of mucus plugging that was suctioned out. Post bronch, has been able to be weaned to 60% FiO2. A repeat CXR on [**7-29**] showed substantial improvement, with possible consolidation in the LLL. Due to neuromuscular dysfunction, he was continued on ventilation. . # HCAP - Signs of LLL PNA seen on bronchoscopy with edematous, red airways. Was thought to have aspirated at OSH and covered with vanco/cefepime. Has been in hospital > 48 hours so needs to be covered for HCAP. Plan to continue coverage and request sputum culture results from OSH. . # Thrombocytopenia - Platelets of 114 on [**7-28**], down from 147 on admission to OSH. No signs of spontaneous bleeding at this time. Differential includes med effect vs decreased production. . # Anemia - Mild normocytic anemia. On admission Hgb was 14.7. [**Month (only) 116**] be [**1-27**] dilution vs decreased production vs bleed (although no evidence). Plan to follow CBC. . # Elevated AST/ALT - mildly elevated, other LFTs are normal including bili. [**Month (only) 116**] be related to periods of hypotension. Plan to trend LFTs. . # Bradycardia - Bradycardic at OSH, has been stable here. [**Month (only) 116**] be secondary to [**Last Name (un) 4584**]-[**Location (un) **] or other neuro problem affecting autonomic nervous system. Presumably, was ruled out for MI after this happened but unknown if this did happen. EKG shows no evidence of infarct. Echo planned for [**7-29**], may be deferred given emergent surgical intervention. . # Elevated CK - Likely secondary to rhabdo from fall, CK's have been trending down without acute intervention and renal function is stable. . # FEN: IVF as needed, replete electrolytes, NPO for now # Prophylaxis: Pneumoboots and subQ heparin # Access: peripherals # Communication: Patient # Disposition: Patient was transferred to [**Hospital Ward Name **] trauma ICU for possible surgical intervention per Spine surgery In the evening of [**2162-7-30**], after discussion with patient and family members, the patient's code status was changed to Comfort Measures Only. His pain was controlled with IV morphine. At 1030pm, the patient was noted to have no respiratory drive, no pulse and no heart/lung sounds. The on call resident was called to evaluate the patient, and the patient was pronounced dead at 1040pm on [**2162-7-30**]. Medications on Admission: Home Medications: Xalatan Combivent MVI Advil Discharge Disposition: Expired Discharge Diagnosis: Cervical stenosis/spondylosis Quadraplegia Pneumonia Discharge Condition: Expired Completed by:[**2162-8-16**]

Admission Date: [**2103-5-24**] Discharge Date: [**2103-5-27**] Service: [**Location (un) **] NOTE: This is a partial dictation. The rest of the dictation will be done in the Internal Service. CHIEF COMPLAINT: Explosive diarrhea. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female with a past medical history significant for coronary artery disease, atrial fibrillation (on Coumadin), and congestive heart failure who now presents with severe explosive diarrhea. The patient was recently hospitalized at the [**Hospital1 346**] and was discharged on [**2103-5-24**]; the same day that she re-presented to the Emergency Room with explosive diarrhea. During her prior hospitalization, she was noted to have a pneumonia and was started on antibiotic therapy. She was discharged on levofloxacin. She was reportedly discharged in good condition; however, during the ambulance ride to the nursing home she developed explosive diarrhea and became tachycardic. Upon arrival to the nursing home she was redirected to the [**Hospital1 69**] for further management. In the Emergency Department, she was noted to be tachycardic to 140 and dehydrated. She was treated with one liter of intravenous fluids and 5 mg of intravenously Lopressor times two. She was also started on Flagyl for empiric coverage of Clostridium difficile. A chest x-ray was obtained and revealed stable cardiomegaly with a tortuous and calcified aorta. She was noted to have upper zone redistribution of the pulmonary vasculature. This was consistent with congestive heart failure. There were also bibasilar effusions and consolidation at the left lung base. An underlying pneumonia could not be excluded. The overall impression was that this chest x-ray revealed improvement of her underlying congestive heart failure. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Coronary artery disease; status post non-ST-elevation segment myocardial infarction. 3. History of peptic ulcer disease. 4. Status post cataract surgery. 5. History of gastrointestinal bleed. 6. History of carotid stenosis. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg by mouth once per day. 2. Atorvastatin 10 mg by mouth once per day. 3. Ipratropium nebulizers as needed. 4. Levofloxacin 250 mg by mouth q.24h. 5. Metoprolol 50 mg by mouth three times per day. 6. Sublingual nitroglycerin. 7. Pantoprazole 40 mg by mouth once per day. 8. Psyllium by mouth as needed. 9. Warfarin 3 mg by mouth at hour of sleep. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient denies a history of tobacco. The patient does not consume alcohol. No history of intravenous drug use. PHYSICAL EXAMINATION ON PRESENTATION: The patient's temperature was 98.6 degrees Fahrenheit, her blood pressure was 138/72, her heart rate was 93, her respiratory rate was 90, and she was saturating 94% on room air. In general, the patient was an elderly female sitting comfortably in bed in no apparent distress. Head, eyes, ears, nose, and throat examination revealed the extraocular movements were intact. The pupils were equal, round, and reactive to light. The mucous membranes were dry. Neck revealed jugular venous distention approximately 9 cm. There was no lymphadenopathy appreciated on examination. Pulmonary examination revealed diffuse crackles throughout and mild expiratory wheezes. Cardiovascular examination revealed an irregularly irregular rhythm. Normal first heart sounds and second heart sounds. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds. Extremities revealed no clubbing, cyanosis, or edema. There was no calf tenderness. BRIEF SUMMARY OF HOSPITAL COURSE: In the setting of explosive diarrhea and tachycardic, it was felt that the patient was mildly volume depleted. In addition, she had dry mucous membranes. She was resuscitated with approximately one liter of normal saline. It was also felt that due to her recent antibiotic therapy for pneumonia, a likely etiology of her diarrhea could be Clostridium difficile. She was started on empiric antibiotics with Flagyl. She reported subjective improvement with intravenous hydration; however, she remained tachycardic. She was then given 5 mg of intravenous Lopressor times two 15 minutes apart. Her heart rate stabilized to the middle 90s; which was down from 160 to 140. The following day a cardiac echocardiogram was obtained which showed mild left ventricular hypertrophy. The left ventricular cavity size was normal and the left ventricular ejection fraction was greater than 55%. There was mild aortic valve stenosis and trace aortic regurgitation. There was 1 to 2+ mitral regurgitation. There was moderate pulmonary artery systolic hypertension. An electrocardiogram was also obtained which demonstrated atrial fibrillation with a rapid ventricular response. There was mild left axis deviation. There were some nonspecific extensive ST segment changes. Cardiac enzymes were cycled. The patient was noted to have an elevated troponin. However, this was believed to be secondary to her non-ST-segment elevation myocardial infarction which she reportedly had during her [**Hospital Ward Name 332**] Intensive Care Unit stay. Her creatine kinase and CK/MB remained within normal limits during her hospitalization. The patient continued to support subjective improvement. She was not discharged back to the nursing home, however, because her white blood cell count remained elevated. At the time of this dictation, the Clostridium difficile toxin assay was still pending. The plan was to discharge the patient if her white blood cell count improved on Flagyl therapy and if the Clostridium difficile toxin assay was positive. DR [**First Name8 (NamePattern2) 312**] [**Last Name (NamePattern1) 5408**] 12.766 Dictated By:[**Last Name (NamePattern1) 9725**] MEDQUIST36 D: [**2103-5-26**] 09:54 T: [**2103-5-26**] 10:13 JOB#: [**Job Number 106490**]

Admission Date: [**2136-2-9**] Discharge Date: [**2136-3-6**] Date of Birth: [**2061-6-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: CC: Fever, altered mental status, hypotension, sepsis Major Surgical or Invasive Procedure: [**2136-3-2**]-Open tracheostomy [**2136-3-2**]-percutaneous endoscopic gastrostomy tube History of Present Illness: . PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45938**] office [**Telephone/Fax (1) 45939**], [**Hospital **] Hospital ED ([**Telephone/Fax (1) 77108**]. . HPI: 74yoF with PMH of tobacco use and glaucoma (no regular medical care with last PCP [**Name Initial (PRE) **] 6 years ago) who developed fever and body aches [**2136-2-1**] and progressively worsening confusion since then presented to her PCP's office today with complaints of generalized malaise and feeling unwell. She specifically complained of inability to sleep and requested sleep medication however also endorsed generalized weakness and perhaps some dizziness. Her PCP referred her to [**Hospital **] Hospital ED given her symptoms and she reportedly looked "overall unwell". She (and family) report that her symptoms began on [**2136-2-1**] at which time she developed "body aches" and subjective fevers/chills. She also had a very mild dry cough. Her daughter reports progressive confusion mainly over the past few days. She has also had poor PO intake (food and fluid) [**3-10**] poor appetite. She denies sore throat, runny nose, N/V/diarrhea/abdominal pain, dysuria/hematuria. She further denies night sweats, signifiant weight loss. She also denies HA, changes in vision, neck stiffness. . At the OSH ED, noted peripheral blood WBC >60K with a reported "left shift". RUL infiltrate was noted on CXR and she received 1 dose levofloxacin IV. ABG initially showed pCO2=59 however she became increasingly lethargic and repeat ABG showed pCO2=78. She was simultaneously noted to be hypoxemic (paO2 not clear), but SaO2 70% on NRB prior to intubation. She was intubated and was noted to be hypotensive with nadir 65/40 (? post sedation vs. before) and was started on dopamine via peripheral IV initially at 20mcg/kg/min. Dopamine was decreased to 5mcg/kg/min prior to transfer with maintenance of SBPs 90s. She became tachycardic to the 140s on dopamine so was changed to levophed without tachycardia and maintenance of MAPS approximately 50-60. . Transferred to MICU for presumed sepsis. . ROS: As above, also denies rashes. + DOE when walking up stairs, no PND, orthopnea (per family history). No melena/hematochezia. Medications: Glaucoma eye gtts . Allergies: NKDA Past Medical History: Past Medical History: Tobacco use, ? COPD Glaucoma Social History: Social History: Quit tobacco 15years ago, previously has approximately 20-30packyear history. No EtOH nor other illicits. Formerly worked in parking permit department at the police dept. Has 9 children (7 daughters, 2 sons). Family History: Family History: non-contributory Physical Exam: Physical Exam: VS: Temp: 97.0 BP: 96/61 HR: 101 ST RR: 12 O2sat 95-96% AC 500/12 PEEP 10 FiO2 0.60 GEN: intubated HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, superior lip with mild blood oozing under ETT tape NECK: no supraclavicular or cervical lymphadenopathy appreciated, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Rhonchorus anteriorly CV: RRR, S1 and S2 wnl, systolic murmur heard greatest LUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: trace to 1+ edema b/l feet, warm, good pulses SKIN: no rashes/no jaundice NEURO: Somnolent on sedation, but arousable and able to answer yes/no to questions, nods appropriately. Able to cooperate with strength exam/follow commands. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: EKG: Sinus tachy rate 103, normal access, q II, III, aVF, 1mm ST depression II and aVF, 1mm ST depression V5, 1mm ST elevation V2. Isolated biphasic TW in aVL. . Imaging: . [**2136-2-9**] OSH CXR: Per verbal report showed opacity upper portion of RLL. (Need to review CD) . [**2136-2-9**] CXR on presentation to ICU (WET): Opacity superior portion of right lower lobe, left upper lobe opacity and hiatal hernia vs. left hemidiaphragm elevation. Hilar fullness likely representing LAD. . ADMISSION LABS: [**2136-2-9**] . [**2136-2-9**] 08:55PM BLOOD Neuts-91* Bands-3 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2136-2-9**] 08:55PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL [**2136-2-9**] 08:55PM BLOOD Plt Smr-HIGH Plt Ct-538* [**2136-2-9**] 10:55PM BLOOD PT-12.5 PTT-23.4 INR(PT)-1.1 [**2136-2-9**] 05:58PM BLOOD Glucose-188* UreaN-63* Creat-1.3* Na-136 K-3.5 Cl-98 HCO3-28 AnGap-14 [**2136-2-9**] 05:58PM BLOOD estGFR-Using this [**2136-2-9**] 05:58PM BLOOD ALT-33 AST-37 LD(LDH)-311* AlkPhos-235* TotBili-1.2 [**2136-2-9**] 05:58PM BLOOD Albumin-2.2* Calcium-7.4* Phos-4.5 Mg-2.5 [**2136-2-9**] 05:58PM BLOOD Cortsol-59.3* [**2136-2-9**] 08:05PM BLOOD Type-ART pO2-62* pCO2-70* pH-7.26* calTCO2-33* Base XS-1 [**2136-2-9**] 09:34PM BLOOD Type-MIX Temp-36.7 [**2136-2-9**] 08:05PM BLOOD Lactate-1.3 K-3.3* [**2136-2-9**] 09:34PM BLOOD Hgb-10.9* calcHCT-33 O2 Sat-74 [**2136-2-9**] 08:05PM BLOOD freeCa-0.99* . . MICRO DATA [**2136-3-2**] 11:42 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. ASPERGILLUS FUMIGATUS. IDENTIFICATION PERFORMED ON CULTURE # 244-2449B ([**2136-2-26**]). . [**2136-2-9**] 9:31 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2136-2-12**]** GRAM STAIN (Final [**2136-2-10**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS IN SHORT CHAINS. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2136-2-12**]): OROPHARYNGEAL FLORA ABSENT. STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH. PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | PENICILLIN------------ S . [**2136-2-10**] 10:33 am URINE Site: CATHETER **FINAL REPORT [**2136-2-11**]** Legionella Urinary Antigen (Final [**2136-2-11**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. . [**2136-2-14**] 2:24 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2136-2-20**]** GRAM STAIN (Final [**2136-2-16**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2136-2-18**]): NO GROWTH, <1000 CFU/ml. VIRAL CULTURE (Final [**2136-2-20**]): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. . [**2136-2-17**] 3:05 pm SKIN SCRAPINGS **FINAL REPORT [**2136-3-2**]** VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2136-3-2**]): NO VIRUS ISOLATED. . [**2136-2-17**] 2:40 pm EAR LEFT EAR. SITE CONFIRMED BY [**Numeric Identifier 77109**] DR [**Last Name (STitle) **] [**2136-2-21**]. **FINAL REPORT [**2136-2-21**]** GRAM STAIN (Final [**2136-2-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2136-2-19**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. YEAST. MODERATE GROWTH. . [**2136-2-17**] 2:40 pm SWAB Site: EAR RIGHT EAR. SITE CONFIRMED BY DR [**Last Name (STitle) **] [**Numeric Identifier 77109**] [**2136-2-21**]. **FINAL REPORT [**2136-2-21**]** GRAM STAIN (Final [**2136-2-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2136-2-21**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. 2ND TYPE. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH . [**2136-3-1**] 5:29 pm ASPIRATE Site: SINUS Source: Sinus. GRAM STAIN (Final [**2136-3-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2136-3-3**]): NO GROWTH. POTASSIUM HYDROXIDE PREPARATION (Final [**2136-3-1**]): Test cancelled by laboratory. PATIENT CREDITED. Inappropriate specimen for Fungal Smear (KOH). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. RELEVANT IMAGING Echo [**3-2**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No definite aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 7 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2136-2-10**], the findings are similar. . [**3-1**] CT sinuses IMPRESSION: 1. Improvement of the mucosal thickening in the paranasal sinuses as described above. Resolution of the fluid within the middle ear cavities bilaterally. 2. Persistent partial opacification of mastoid air cells bilaterally. . [**2-29**] chest CT IMPRESSION: 1) Persisting multifocal consolidation, not significantly changed. 2) Interval development of underlying pulmonary edema with increasing, now moderate, bilateral pleural effusions. 3) Enlarged mediastinal lymph nodes likely reactive to the underlying infectious process and/or CHF. 4) Lobulated, hypodense hepatic dome lesion, likely a cyst. 5) Left adrenal mass with Hounsfield Units between 5 and 15, most likely an adenoma. . [**2-17**]-CT orbit, sella, IAC IMPRESSION: 1. Paranasal sinus opacification as described above. 2. Soft/fluid density within the bilateral mastoid air cells and right middle ear cavity without bony erosions or other destructive changes. Findings may represent effusions of the mastoid air cells and right middle ear cavity, versus otomastoiditis. 3. 7-mm well-circumscribed lytic area within the left occipital lobe, likely an arachnoid granulation. If there is clinical concern or previous history of malignancy, a bone scan could be considered for further characterization. . [**2136-2-11**] CT Torso 1. Extensive bilateral pulmonary consolidations that are most consistent with pneumonia. 2. Small bilateral pleural effusions. 3. Suboptimal position of the right internal jugular central line with its tip in the inferior vena cava. 4. Ascites. 5. Cholelithiasis. 6. Left adrenal mass, which cannot be further characterized on this study. Further evaluation with MRI may be obtained when clinically feasible . echo [**2136-2-10**] The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 70-80%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Mrs. [**Known lastname **] was admitted to [**Hospital1 18**] MICU. 74F h/o tobacco use, glaucoma (no past regular medical care) developed fever and body aches [**2136-2-1**], with progressively worsening confusion since then, presented to OSH ED and was found to have WBC 60+, RUL and hypotension requiring pressors, intubated and was transferred for further management of septic shock [**3-10**] pneumococcal RUL PNA. Now with resolved WBC but continued respiratory failure and ventilator dependancy; Now s/p Trach/PEG. Also now with new growth of mold out of [**2-26**] sputum culture, and staph coag (-) off the CVL tip on [**2-28**], completed treatment for pneumococcal pneumonia, as well as herpes lung infection, still being treated for mold in sputum-aspergillus infection. . Problems: . RESPIRATORY FAILURE: She presented with a hypercarbic and hypoxic respiratory failure with an acute on chronic respiratory acidosis secondary to pneumonia which developed into ARDS. A chest CT showed multifocal pneumonia, sputum culture showed penicillin resistant strep pneumonia. Empirical Vancomycin and Flagyl were discontinued, and levofloxacin and zosyn were continued for a completed course. There was also a component of underlying COPD exacerbation for which she was on albuterol and atrovent. Diuresis was initiated for a component of volume overload that was felt to be present. However she was allowed to self diurese after she became euvolemic. She was also found to have a herpetic pulmonary infection (tracheobronchitis). BAL washings ([**2-14**])confirmed HSV-positive herpetic lesions in trachea. Acyclovir was started [**2-21**], ending [**3-6**] (2 week course); liver (AST 13. ALT 17), renal function were monitored. She had previously had aspergillus in her sputum but negative beta-glucan and galactomannan. Whether this was a pathogen or a contaminant was not clear. She was started voriconazole [**2-29**], CT sinus and CT chest did not show invasive disease. She should continue on this for two weeks and have LFTs monitored weekly. She should also have a follow up sputum for KOH and fungal culture in [**3-12**] weeks after stopping voriconazole. . Vent settings at d/c ventilator settings: CPAP 46% FiO2 PEEP 5 Pt averaging tidal volumes of 20 respiratory rate 30 . She was in chronic respiratory failure and did not tolerate weaning of vent given need for high PEEP & FIO2. Thus, she had a tracheostomy placed and is now being slowly weaning from vent. Trach: Dead space:tidal volume 78%. She needs PRN decreases in FiO2, PEEP. . HYPOTENSION: On admission she had leukocytosis WBC 60, fever, tachycardia c/w SIRS and since she had pneumonia and hypotension she was in spetic shock. She was requiring Norepinephrine. In the presence of a murmur on exam subacute bacterial endocarditis was felt to be a possible etiology, thus an echo was done that was negative for vegetations, Normal LVEF >55%, +1MR. Her random cortisol was 59, with an appropriate decrease with cortisol challenge. As there were no ischemic changes in continguous leads cardiogenic etiology was not felt to be likely. On [**2-12**] she was weaned successfully off pressor support. She occasionally required small boluses for occasional decreases in blood pressure and to aid urine output. . ACUTE RENAL FAILURE: She had no known CRI by history (although no consistent medical care for several years). BUN/creatinine ratio suggestive of prerenal etiology, improved to nml range after IVFs. Admission BUN=63, Cr=1.3, Discharge BUN=23, Cr=0.5. . ILEUS: She had increasing abdominal distention with no BM. KUB done on [**2-10**] c/w ileus. Abd CT demonstrated ascites but no SBO. She was on a bowel regimen and TF with appropriate holding for residuals were done. This resolved [**2-13**]. . ALTERED MENTAL STATUS: She had ARDS, infection, but also heavy sedation while intubated. On [**3-4**], decreased scheduled diazepam with goal for autotaper, and decreased fentanyl patch to 12.5mg. On [**3-5**] the patient was found to be awakening, able to communicate somewhat with family and staff. Diazepam was discontinued [**3-6**] and ativan 1mg Q6h:PRN was started. . ANEMIA: She had a slowly decreasing Hct. She was guiaic negative and did not have any gross bleeding. Likely secondary to blood draws, hemolysis labs were negative, should continue to monitor. Admit HCT was 32. Discharge HCT was 26, this was stable for 3 days prior to discharge. During admission patient was transfused 1 unit of packed RBCs w/o complications. . RIGHT OTITIS MEDIA: ENT irrigated ear, no evidence of otitis externa, likely otitis media s/p perforation or drained fluid collection behind cerumen collection. Recieved ciprofloxacin/dexamethasone drops 5 drops TID in ear for 10 days. Started first full day [**2-18**], ended [**2-28**]. Now resolved. . NUTRITION: PEG was placed at the time of tracheostopy. Tube feed recs. tube feeds-Nutren Pulmonary Full strength; Additives:Beneprotein, 10 gm/day Starting rate: 40 ml/hr; Do not advance rate Goal rate: 40 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Other instructions: Please add 150 ml H20 TID to TF . GLAUCOMA: She remained on her home medications of timolol and travatan . ACCESS: PICC line placed [**2-27**]: NO signs of infection at picc site. . Follow up: Pt will continue voriconazole until [**3-14**] for a total of 2weeks of therapy -Pt needs LFTs drawn on [**3-12**]. -sputum culture needed [**2136-3-28**] (for fungal culture and KOH) -galactomannan and B-glucan [**2136-3-12**] -Please contact your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45938**] [**Telephone/Fax (1) 77110**] for a follow up appointment within 2 weeks. -Pt has an appointment with the infectious disease clinic; [**4-2**], 11:00am, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] on the [**Hospital Ward Name **] [**Hospital1 18**] [**Hospital Ward Name 23**] building [**Location (un) **]. Medications on Admission: `Glaucoma eye gtts Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection Q8H (every 8 hours). 2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs Inhalation Q4H (every 4 hours). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 6. Outpatient Lab Work LFTs on Monday [**2136-3-12**] 7. Outpatient Lab Work sputum culture [**2136-3-28**] (for fungal culture and KOH) 8. Outpatient Lab Work galactomannan and B-glucan [**2136-3-12**] 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain or fever. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 15. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML Mucous membrane [**Hospital1 **] (2 times a day). 16. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days: last day [**2136-3-14**]. 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: re-assess as necessary with intention to taper. 19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 20. Insulin Lispro 100 unit/mL Cartridge Sig: as per scale Subcutaneous every six (6) hours: as per scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 86**] Discharge Diagnosis: Pneumococcal Pneumonia Herpetic pulmonary infection Aspergillus Acute Respiratory Distress Syndrome history of tobacco use glaucoma Discharge Condition: stable -------- tube feeds-Nutren Pulmonary Full strength; Additives:Beneprotein, 10 gm/day Starting rate: 40 ml/hr; Do not advance rate Goal rate: 40 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Other instructions: Please add 150 ml H20 TID to TF ------------------- ventilator settings: CPAP 46% FiO2 PEEP 5 Pt averaging tidal volumes of 20 respiratory rate 30 Discharge Instructions: You were admitted with pneumonia and required intubation for respiratory failure. You also had a herpetic pulmonary infection and continued to require ventilation so a tracheostomy was done. You also had a PEG tube placed for feeding. You were treated for your pneumonia and herpetic lung infection with antibiotics which you have completed. You also had mold in your sputum requiring treatment with an antibiotic called voriconazole. You will continue to take this and complete a two week course, during which your liver function tests should be checked weekly. You are being discharged to a pulmonary rehab facility. You should call your doctor for any fevers, chills, increased sputum production, or any other concerning symptoms. Please follow up as outlined below. Followup Instructions: Follow up: Pt will continue voriconazole until [**3-14**] for a total of 2weeks of therapy -Pt needs LFTs drawn on [**3-12**]. -sputum culture needed [**2136-3-28**] (for fungal culture and KOH) -galactomannan and B-glucan [**2136-3-12**] -Please contact your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45938**] [**Telephone/Fax (1) 77110**] for a follow up appointment within 2 weeks. -Pt has an appointment with the infectious disease clinic; [**4-2**], 11:00am, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] on the [**Hospital Ward Name **] [**Hospital1 18**] [**Hospital Ward Name 23**] building [**Location (un) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2136-3-6**]

Admission Date: [**2168-12-5**] Discharge Date: [**2168-12-21**] Date of Birth: [**2092-6-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 2499**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Placement of left sided chest tube Placement of left sided pleuridex catheter History of Present Illness: 77F with NSCLC (LUL involvement, lymphangitis spread, pleural involvement, recurrent L pleural effusion though not pleurodesis candidate, brain mets) s/p cycle #2 paclitaxal/[**Doctor Last Name **] ([**11-24**]), presenting with dyspnea (RR=35) and hypoxia (81%RA). Pleural effusion last drained about 1.5wks PTA. Admision CXR showeed L white out and mediastinal/tracheal shift. ED unable to localize fluid with US for tap. Pt needed CT scan, but unable to lie flat, so she was intubated. Post intubation pt had immediate blood pressure drop responsive to fluids (2 liters), then continuing to have intermittent hypotension requiring bolusing despite minimum sedation and required norepinephrine x2days intermittently. Pt had equivocal cortasyn stimtest to 18.1 but started on stress dose steroid along with fludricorsone for low Na. Pt also transfused 4U PRBCs for hct of 25 with inapropriate rise to 30 although blood loss was thought to be lost in serosanguinous CT drainage and Hct stable for last 24h. On admission to MICU pt started on Cefepime, Vancomycin and Gentamycin due to fever and ANC of 340 and suspected sepsis, which was weaned to only vancomycin on [**12-8**] due to positive Bld Cx for coag neg staph [**1-31**] on [**12-5**]. Pt given GCSF with good effect and ANC up to 1800 yesterday. Admission CT also showed small subsegmental RLL PE but anticoagulation held due to brain mets. CT also showed enormous Left sided effusion with two fluid levels suggestive of hemothorax, mass effect w/ shift of mediastinum to Right. In face of tenuous BP + possible hemothorax, CT [**Doctor First Name **] placed Left Chest Tube for volume drainage (2100cc removed). Due to continued large amount of drainage she was planned for pleuradesis with doxycyline which was performed [**2168-12-9**] with plan for repeat tomorrow. Past Medical History: Past Medical History 1. Mild hypertension medicine controlled 2. diabetes mellitus type 2 diet controlled 3. mild osteoarthritis 4. elevated cholesterol diet controlled 5. s/p cystic breast lesion removal four years ago 6. s/p treatment of fungal meningitis 40 years ago. Social History: Social History Lives with son, She smoked less than one to two cigarettes per day for over 30 years but quit since [**2144**]. There is no history of ETOH. There is no history of IV drug use. She lives currently with son in [**Name (NI) **]/[**State 350**]. There is no transportation support. She works in a grocery store. Family History: Family History Mother died of uterine cancer, father died of myocardial infarction at age 80, bothers and sisters did not have cancer, do have history of hypertension. Physical Exam: Temp 97.5 BP 135/96 Pulse 106 irreg RR 14 O2 Sat's 97% 2lNC Gen - Alert, no acute distress HEENT - PERRL, anicteric, mucous membranes moist arcus senilis bilat Neck - RIJ in place, no elevated JVD, no cervical lymphadenopathy, thyroid nonpalp, Chest - severe crackles 1/2 up bilat, good air movement at rt apex, dullness at bases bilat CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema, 1+edema to ankles bilat Neuro - Alert and oriented x 3, 5/5 strength in flexors and extensors of upper and lower extrem bilat, distal sensation intact, [**3-30**] recall at 3 and 5 min Pertinent Results: [**2168-12-20**] 08:00AM BLOOD WBC-5.4 RBC-2.97* Hgb-8.8* Hct-27.6* MCV-93 MCH-29.8 MCHC-32.1 RDW-16.0* Plt Ct-68* [**2168-12-11**] 05:30AM BLOOD WBC-10.4 RBC-3.50* Hgb-10.5* Hct-31.7* MCV-91 MCH-30.0 MCHC-33.2 RDW-15.7* Plt Ct-98* [**2168-12-4**] 08:36PM BLOOD WBC-1.4* RBC-3.06* Hgb-9.1* Hct-26.9* MCV-88 MCH-29.9 MCHC-34.0 RDW-13.5 Plt Ct-193 [**2168-12-20**] 08:00AM BLOOD Plt Ct-68* [**2168-12-9**] 05:49AM BLOOD Plt Ct-114* [**2168-12-4**] 08:36PM BLOOD Plt Ct-193 [**2168-12-17**] 03:00PM BLOOD FDP-80-160* [**2168-12-17**] 03:00PM BLOOD Fibrino-531*# D-Dimer-5943* [**2168-12-8**] 04:00AM BLOOD Gran Ct-1800* [**2168-12-20**] 08:00AM BLOOD Glucose-85 UreaN-10 Creat-1.1 Na-142 K-4.8 Cl-103 HCO3-30* AnGap-14 [**2168-12-4**] 08:36PM BLOOD Glucose-169* UreaN-24* Creat-1.4* Na-130* K-6.2* Cl-96 HCO3-24 AnGap-16 [**2168-12-5**] 01:09PM BLOOD CK(CPK)-242* [**2168-12-5**] 01:09PM BLOOD CK-MB-5 cTropnT-0.05* [**2168-12-20**] 08:00AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8 [**2168-12-5**] 05:30AM BLOOD Hapto-189 [**12-18**] CXR There is an increasing hydropneumothorax in the left hemithorax since [**2168-12-14**]. The right lung is clear. The right IJ line has been removed. [**12-13**] Chest CT 1) Interval placement of left-sided chest tube with decrease in large left- sided pleural effusion with shift of the mediastinum back to the left. Small pneumothorax with loculated hydropneumothorax. 2) Partial re-expansion of the left lung with patchy opacities. These likely represent areas of atelectasis. 3) Scattered nodules within the right lobe and spiculated mass within the left upper lobe appears stable in short interval. 4) Right renal mass, left adrenal mass and osseous lesions again identified Brief Hospital Course: Pleural Effusion-Pt with known longstanding left sided malignant effusion. CT placed in the ED as per HPI and pt intubated due to inability to lay flat for CT to evaluate effusion but was quickly weaned. Pt had doxycyline Pleurodesis on [**12-9**] and 14 and CTube removed [**12-13**] due to pt discomfort and continued low grade fevers. She continued to have dullness at her left base with complete whiteout of L hemithorax except for area of pneumothorax on follow-up CXR, so IP saw pt and placed pleuridex [**12-18**] and drained 500cc serous fluid with plan for weekly pleurocentesis in pulmonary clinic. She was breathing comfortably and had O2Sats of 94% on room air upon discharge. Pancytopenia-Due to recent chemotherapy with paclitaxol/carboplatin although counts responded briskly to GCSF except for platelets. She was initially treated as neutropenia and sepsis due to hypotension and fever with Vancomycin, gentamycin, cefepime which were discontinued on transfer to the floor since no culture data was positive. Pt has history of thrombocytopenia, and platelet count was slowly declining. We started procrit and followed CBC daily. HitAb neg but held on heparin for HIT I. DIC panel negative. There were no known offending meds but did change ranitidine for protonix since it was only suspected med. Hypotension-Pt had acute episode of hypotension with intial intubation which responded well to aggressive fluid boluses. Pt had corasyn stim test to rule out adrenal insuffuciency which was equivocal at 18, so she was started on stress dose steroids. She was also placed on fludricorisone due to an elevated potassium and low sodium. Pt remained normotensive upon transfer to the floor on [**12-10**] and weaned off of steroids since there was no suspected reason for acute adrenal insufficiency. BP and lytes remained stable for the remaineder of her hospitalization except for mild hypernatremia that responded well to encouragement of free water intake. SVT-Pt with new afib per attg. Pt with LAA in previous ECG most likely due to longstanding HTN. Acute hypotension and stressed state may have contributed. No anticoagulation since it was thought to be transient. PE-Pt with known subsegmental PE on admission CT. Pt with appropriate sats on room air. SC heparin stopped for HIT possiblity and didn't anticoagulate initially due to brain mets although attending considering anticoagulation. No role for repeat CTPA since she has known PE. Oral thrush-Due to steroid use. Improving on clotrimazole lozenges now that steriods stopped. NSCLC-Pt receiving chemo prior to admission and effusion is not reason to stop treatment. Will restart chemo if Plat ct >100 per attg likely Iressa. Chest CT shows no interval change in size of pulmonary nodules post chemo. DM-Pt had poorly controlled blood sugars while on steroids, but were controlled to <150 when steroids weaned. She was initially on RISS but this was discontinued with steroid taper. Pain-Patient had pain at CTube site initially which was well controlled with oxycontin 10mg q12hours. Percocet prn was added with increasing pain after placement of tunneled pleuridex but plan is to wean as tolerated. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*12 syringes* Refills:*2* 4. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2* 5. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Disp:*120 Troche(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:*qs * Refills:*2* 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:*qs ML(s)* Refills:*0* 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*150 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Malignant left pleural effusion Discharge Condition: Stable oxygen saturation on room airHemodynamically stable Discharge Instructions: If you experience any increasing chest pain, shortness of breath, cough, fever or chills you should call your doctor, but if he/she is not available you should go to the emergency room.

Admission Date: [**2152-10-5**] Discharge Date: [**2152-10-15**] Date of Birth: [**2096-8-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2152-10-10**] Mitral Valve Repair (Quadrangular Resection w/28mm ring) & Coronary Artery Bypass Graft x 4 (LIMA-LAD, SVG-Dg, SVG-Ramus, SVG-OM2) History of Present Illness: Mr. [**Known lastname 4643**] presented to OSH c/o shortness of breath that developed approximately 1 month ago and progressively worsened over several days before presenting to ED. Past Medical History: Diabetes Mellitus, Hyperlipidemia, Astham/Chronic obstructive pulmonary disease, h/o Pancreatitis Social History: Quit smoking 20 yrs ago after 60pky. Denies alcohol for past 10 yrs. Family History: Mother w/ 2 MI's. Brother died from a MI in late 60's. Another brother died from a MI at 64. Physical Exam: VS: 105 16 132/79 5'5" 180# Gen: Well-appearing male in NAD Skin: Unremarkable HEENT: EOMI, PERRL Neck: Supple, FROM, -JVD, -Carotid bruit Chest: CTAB Heart: RRR 3/6 SEM Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**10-10**] Echo: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with added focalities inn inferior and septal walls with mildly preserved function in the anterior and lateral walls. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr.[**Last Name (STitle) **] was notified in person of the results on [**2152-10-10**] at 8:30AM. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including epinephrine at 0.03mcg/kg/min and phenylephrine at 0.7 mcg/kg/min. Normal Right ventricular function. LVEF 20%. There is a prosthesis (ring)in the mitral position. It is stable and functioning well. There is no stenosis or regurgitation across the mitral valve. Intact thoracic aorta. [**2152-10-6**] 12:43AM BLOOD WBC-8.6 RBC-4.62 Hgb-13.9* Hct-40.5 MCV-88 MCH-30.2 MCHC-34.5 RDW-13.1 Plt Ct-256 [**2152-10-12**] 05:30AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.7* Hct-28.1* MCV-90 MCH-30.9 MCHC-34.4 RDW-13.2 Plt Ct-139* [**2152-10-6**] 12:43AM BLOOD PT-14.0* PTT-23.5 INR(PT)-1.2* [**2152-10-10**] 12:35PM BLOOD PT-15.2* PTT-35.1* INR(PT)-1.3* [**2152-10-6**] 12:43AM BLOOD Glucose-122* UreaN-26* Creat-1.0 Na-142 K-4.5 Cl-106 HCO3-28 AnGap-13 [**2152-10-12**] 05:30AM BLOOD Glucose-115* UreaN-17 Creat-1.2 Na-136 K-4.9 Cl-106 HCO3-27 AnGap-8 Brief Hospital Course: Mr. [**Known lastname 4643**] was transferred from OSH after cardiac cath revealed left main and multi-vessel disease. As well as echo showing 3+ mitral regurgitation. Upon admission he was appropriately medically managed and worked-up for surgery. On [**10-10**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4 and mitral valve repair. Please see operative report for surgical detail. Following surgery he was transferred to the CVICU for invasive management in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one his chest tubes were removed. All drips were weaned off on post-op day one and on post-op day two he was transferred to the telemetry floor for further care. Beta blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. On post-op day three his epicardial pacing wires were removed. The remainder of his postoperative course was essentially uneventful. He was transfused a total of 2 units PRBCs postoperatively for anemia. He continued to progress and on POD#5 was discharged to home with VNA. He was instructed on all necessary follow up appointments. Medications on Admission: Tricor 145mg qd, Glucophage 500mg QID, Lantus 20U qAM, Lipitor 40mg qd, Byetta, Niacin 1000mg qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 6. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*60 Capsule, Sustained Release(s)* Refills:*1* 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 8. Potassium Chloride 20 mEq Packet Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day . Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once daily. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Mitral Regurgitation s/p Mitral Valve Repair PMH: Diabetes Mellitus, Hyperlipidemia, Astham/Chronic obstructive pulmonary disease, h/o Pancreatitis Discharge Condition: good Discharge Instructions: 1)Shower daily. Wash incisions with soap and water. Pat dry only. Please do not apply lotions or creams to surgical incisions. 2)No driving for at least one month. 3)No lifting more than 10lbs for at least 10 weeks. 4)Call cardiac surgeon if there is any concern for sternal wound infection. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 10740**] in [**2-16**] weeks Cardiologist in [**3-19**] weeks Completed by:[**2152-10-17**]

Admission Date: [**2200-11-16**] Discharge Date: [**2200-12-4**] Date of Birth: [**2175-8-19**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: s/p Found down Major Surgical or Invasive Procedure: [**2200-11-17**] 1. Decompressive fasciotomy right buttock, a with debridement of muscle. 2. Decompressive fasciotomy right thigh. 3. Application of large vac sponge to right thigh. 4. Decompressive fasciotomy left thigh without debridement. 5. Decompressive fasciotomy left buttock without debridement. 6. Application vac sponge left leg. [**2200-11-19**] I&D right hip and application of vacuum-assisted closure sponge left thigh. [**2200-11-25**] I&D and vac change left thigh wound [**2200-11-27**] I&D and primary closure of left thigh wound History of Present Illness: 25M directly transferred from OSH after being found down for unknown duration (hours) while intoxicated now w/ LE compartment syndrome w/ rhabdomyolysis and oliguria. At OSH, found to have potassium of 6.9, creatinine 3.8, CK >20,000. Ortho was consulted at OSH and compartment pressures were measured ~50 (L lateral?) w/ diastolic 78 and possibly also involving the R gluteal region. Pt received kayexelate 90mg and 3 doses of 10mg insulin w/ amps of D50 for hyperkalemia and was reportedly given 8L crystalloid (NS). He is transferred here for possible fasciotomy and further management. He c/o R gluteal and entire L thigh pain with weakness in R foot and L hip. He denies any other associated symptoms. Past Medical History: Anxiety/Depression Family History: Noncontributory Physical Exam: Upon presentation to [**Hospital1 18**]: Vitals: 95.6F 104 140/77 19 97% 2L NC GEN: A&O, shivering HEENT: No scleral icterus, mucus membranes moist CV: tachycardic, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: RLE: gluteal muscle tense, soft thigh/calf, diminished motor at foot, cool toes but 2+palp DP, PT, Fem [**Name (NI) **]: tense thigh, soft calf, motor intact at foot/toes, cool toes but 2+palp DP, PT, Fem Brief Hospital Course: Mr [**Known lastname **] was admitted on [**2200-11-16**] after being found unconscious in his home for an unknown duration of time (likely >12hrs). The patient was brought to an OSH and found to have a potassium of 6.9, creatinine 3.8, CK >20,000. The orthopedic service was consulted at OSH and compartment pressures were measured and found to be elevated. Pt received Kayexalate 90mg and 3 doses of 10mg insulin w/ amps of D50 for hyperkalemia and was reportedly given 8L crystalloid (NS). He was then transferred to [**Hospital1 18**] for further workup and management. ICU course: On admission to the trauma ICU, a left sided IJ dialysis catheter was placed for temporary dialysis access. He was taken to the operating room by orthopedics for bilateral decompressive fasciotomies of b/l gluteal and thigh compartments. VAC dressings were placed. Postoperatively he received 4 U of PRBC for dropping HCT in setting of copious VAC output, hypotension, tachycardia with good results. He was dialyzed on HD1. On HD2 he was taken back to OR for washout, debridement and VAC change. He was successfully extubated later that day. Per nephrology recommendations the patient did not undergo hemodialysis on HD2. He remained oliguric. The patient was transfused and additional unit of PRBC for falling HCT during the day (22 from 28 preop). He was started on a Dilaudid PCA for pain control. He received 2 U of PRBC overnight since the response to the first unit had not been adequate. His HCT was again 22.4 and 2 additional U of PRBC were given on HD3. On HD4 he was taken back to the operating room by Ortho for washout and closure of the RLE wound and VAC re-placement in the [**Hospital1 **]. Postoperatively he remained intubated for acute desaturation and was hypoxemia. A CXR showed bilateral pleural effusions, greater on the right. A bronchoscopy was also performed. On HD5 the patient was able to be extubated and CXR showed slight improvement in b/l pleural effusions. The patient received HD. His HCT remained stable at 23.2. The patient was deemed ready for transfer to the regular surgical floor. Floor course: Upon transfer out of the ICU he continued to progress slowly. His acute kidney injury continued to warrant close monitoring and hemodialysis treatments 3-4x/week. His BUN/Cr were followed closely remaining quite elevated until [**12-4**] when it was down to 5.6 after peaking at 10.3 on [**11-24**]. His temporary dialysis line was removed due to fever and elevated white blood. Once his fevers defervesced a right tunneled catheter for dialysis was placed without any complications. He has received several treatments since that time with most recent on [**2200-12-3**] where his pre-dialysis creatinine was 8.8 and as noted previously on [**12-4**] was 5.6 and he is making urine (total of 300 cc's for 24 hours on [**12-3**]). His electrolytes in general were abnormal due to his [**Last Name (un) **] and have begun to show signs of return to normal. It is expected that he will only require hemodialysis for another 1 possibly 2 weeks if he continues to show signs of improving kidney function. It should also be noted that he has received several rounds of blood transfusions for falling HCT with lowest value of 17.9 on [**2200-11-25**]. His HCT's since that time have ranged between 23-24. For a very short period he was given weekly Epogen but this was stopped per recommendations of Renal on [**2200-12-3**]. On [**2200-11-27**] he was taken back to the operating room by orthoepdics for irrigation and debridement down to and inclusive of muscle of 40 x 10 cm wound for a total of 400 sq cm, and staged primary closure. There were no complications. His staples were removed by Orthopedics on [**12-3**] and he will follow up in [**2-27**] weeks in their outpatient clinic. In the meantime he is receiving DVT prophylaxis with Heparin SQ, orthopedics is asking that once he is discharged from rehab that he be started on Aspirin 325 mg daily for a total 2 weeks. He is also being treated for a wound cellulitis per recomendations by ortho - total 7 day course. It is important that on his HD days that he receives this medication after dialysis treatment. He was followed by Physical and Occupational therapy and has been recommended for acute rhab after his hospital stay. Medications on Admission: -xanax 1mg TID -prozac 20mg [**Hospital1 **] Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. heparin (porcine) 1,000 unit/mL Solution Sig: 2,000-8,000 Injection PRN (as needed) as needed for dialysis. 8. alprazolam 0.25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day) as needed for anxiety. 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. heparin (porcine) 1,000 unit/mL Solution Sig: 4,000-11,000 units Injection PRN (as needed) as needed for line flush: Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 13. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 14. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. 15. Acetaminophen Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO Q 8H (Every 8 Hours) as needed for pain. 16. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 17. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): stop date [**2200-12-8**]. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP) Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 20. Ondansetron 4 mg IV Q6H:PRN nausea Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: s/p Found down w/Rhabdomyolosis 1. Compartment syndrome right gluteal muscle. 2. Compartment syndrome left thigh and left gluteal region. 3. Acute Kidney Injury requiring CVVH followed by HD 4. Hyperkalemia 5. Hyponatremia 6. Hypocalcemia 7. Wound cellulitis 8. Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after being found down for an unknown length of time. You were found to have damage to your muscles as a result of this which lead to compartment syndrome in both of your legs as well as acute injury to your kidneys The orthopedic doctors are recommending that after you are discharged from rehab that you take Aspirin 325 mg daily for 2 weeks and then stop at the end of those 2 weeks. They are recommending this medication as a preventative measure for developing blood clots. Followup Instructions: *Your acute kidney failure will be managed by the renal doctors at the [**Name5 (PTitle) **] facility* Department: ORTHOPEDICS When: THURSDAY [**2200-12-11**] at 9:20 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2200-12-11**] at 9:40 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SURGICAL SPECIALTIES When: MONDAY [**2200-12-15**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2200-12-4**]

Admission Date: [**2147-10-3**] Discharge Date: [**2147-10-9**] Date of Birth: [**2084-2-4**] Sex: M Service: MEDICINE Allergies: Enoxaparin / Gammagard Attending:[**Last Name (NamePattern1) 9662**] Chief Complaint: Diarrhea, Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 7168**] is a 63-year-old gentleman with stage IV small cell lung cancer w/ metastatic disease to brain and liver s/p last chemo [**9-19**] and radiation in [**2147-6-18**] presenting with profuse diarrhea and shortness of breath, and fluid responsive hypotension in the setting of large PE in right pulmonary artery extending into segmental branches. He reports going to ED for profuse, "projectile" diarrhea. Patient does have chronic intermittent diarrhea, usually worsened with courses of chemotherapy. He does have occasional nausea and vomiting that is usually associated with po intake. Patient has not been tolerating po well for several weeks. He denies any dysphagia, chest pain, fevers, cough, abdominal pain. Patient has not noticed a significant change in his shortness of breath. He had a PE in [**2146-10-18**] treated with lovenox for 2 months and then developed high fevers associated with medication. Patient was then switched to a 6 month course of Arixtra. In the ED, initial VS were: 96.8 118 98/79 26 100% on 2L NC ED course: -Reportedly short of breath and speaking in short sentences. -Heparin bolus followed by drip -Hypotension to systolic of 90's was responsive to 2L NS. -Levofloxacin 500mg x1 -pt on chronic steroids and hypotensive in triage: concern for adrenal insufficiency; gave 100mg hydrocortisone IVx1 On arrival to the MICU: AF 116/75 HR 90 sat 99% on 2L NC He denies any pain or change in his dyspnea. Review of systems: As per above Past Medical History: Past Medical History: 1. Small cell lung cancer, metastatic to liver and brain. Followed by [**Year (4 digits) **] [**Year (4 digits) 40356**] with [**Hospital1 18**]. Last chemo was [**2147-9-19**] and last radiation was [**2147-6-18**]. 2. Dermatomyositis (paraneoplastic syndrome), 3. Hx of bronchitis 4. Hx L ankle fracture; other bone fractures 5. BPH 6. Pulmonary embolism [**10/2145**], cancer and IVIG related. 7. right 5th toe fracture ~[**2146-6-20**]. ONCOLOGIC HISTORY: [**2144-7-18**]: Presented with rash over forearms and torso. [**2144-8-18**]: Later developed muscle weakness. Saw dermatologist, Dr [**Last Name (STitle) 16077**] - biopsy positive for dermatomyositis. Started on prednisone 60 mg daily with good improvement of his rash and weakness. He was also referred to a rheumatologist and neurologist for further evaluation. Dysphagia symptoms also apparent, evaluated by a speech and swallow therapist at [**Hospital1 18**]. [**2144-10-18**]: Radiographical workup - CT scanning showed a prominent right hilar node and a lesion in the liver. Liver lesion by MRI on [**2144-11-9**] at [**Hospital6 1109**] was equivocal. [**2144-11-23**]: PETCT scan performed at [**Hospital1 **] showed abnormal uptake in the right paratracheal lymph node, right hilum, liver nodule in the mid portion of the right lobe, also a region of the gallbladder. [**2144-11-17**]: [**2144-11-26**]- an ultrasound guided liver biopsy was performed at [**Hospital1 **]; lesion consistent with small cell lung cancer. Staining shows positivity for synaptophysin, TTF-1, with weak positivity for CK 7 and chromogranin (Pathologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 83828**]). Dr [**Last Name (STitle) **] from neurology ordered anti-[**Doctor Last Name **] and anti-striate muscle antibody which are positive, done on [**2144-12-7**]. (Anti-[**Doctor Last Name **] positive by immunofluorescence, but was not positive by Western blot). A head MRI was performed on [**12-16**] and showed no evidence of intracranial malignancy. [**2144-12-18**]: Started chemotherapy [**2145-3-18**]: Complete chemotherapy [**2145-6-17**]: Dermatomyositis flare; subsequently given course of steroids, IVIG, methotrexate. Interval CT scans do not show obvious evidence of cancer progression. [**2145-10-18**]: Pulmonary Embolism [**2145-11-7**], started on Lovenox [**2145-11-17**]: hematochezia thought to be inflammatory colitis, resolved with rectal steroids [**2145-12-18**]: Dermatomyositis (DM) flare with fevers and ulcerative lesions; CT on [**2146-1-7**] shows no progression of cancer [**2146-2-15**]: Fevers, DM continue; lovenox implicated as one of causes of fevers; fondiparinux substituted for lovenox. Hi dose IV steroids used to control DM sx. [**2146-3-18**]: Fevers abated with use of fondiparinux. PETCT suggests inflammatory changes rather than overt SCLC recurrence. [**2146-5-18**]: Recurrent disease seen mainly in liver on PETCT [**2146-6-6**]. TREATMENT HISTORY: FIRST LINE REGIMEN: carboplatin (5 AUC on day 1) and etoposide(80mg/m2 on days 1, 2, and 3) every 21 days per cycle. -Started [**2144-12-21**] and completed 6 cycles. Last chemo given on [**2145-4-9**]. SECOND LINE REGIMEN: carboplatin (5 AUC on day 1) and etoposide (80mg/m2 on days 1, 2, and 3) every 21 days per cycle. Repeated regimen since was >1 year at time of recurrence. Had response. -Started [**2146-6-14**] C1 D1, and completed 6 cycles without complication, last chemo on [**2146-10-6**]. [**2146-11-22**] - continues on chemotherapy break after good response on CT Social History: Unmarried, has one daughter- [**Name (NI) 40785**] ; girlfriend - [**Name (NI) 553**]. Computer engineer; unemployed -Smoking Hx: quit ~[**2144**]; 45 pkyr hx, has used Chantix. -Alcohol Use: 2 drinks approximately 3-4 times per week. -Recreational Drug Use: None Worked as construction supervisor. Family History: Autoimmune disorders. Sister has Grave's disease, mother had some sort of thyroid disease, 2 nephews have ulcerative colitis. Physical Exam: Admission: Vitals: AF 116/75 HR 90 sat 99% on 2L NC Gen: NAD, well-nourished Neck: no JVD or masses CV: NR, RR, no murmurs Pulm: CTAB Abd: soft, NT, ND Ext: no peripheral edema Neuro: A&O, no gross deficits, moving all extremities, Skin: no lesions noted Pertinent Results: [**2147-10-3**] 12:20PM BLOOD WBC-6.9# RBC-2.99* Hgb-9.5* Hct-28.5* MCV-95 MCH-31.7 MCHC-33.3 RDW-16.8* Plt Ct-256# [**2147-10-3**] 12:20PM BLOOD Neuts-65 Bands-0 Lymphs-13* Monos-14* Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-4* [**2147-10-3**] 12:20PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Tear Dr[**Last Name (STitle) **]1+ [**2147-10-3**] 12:20PM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.3* [**2147-10-4**] 04:31AM BLOOD Glucose-94 UreaN-21* Creat-0.9 Na-142 K-3.1* Cl-107 HCO3-24 AnGap-14 [**2147-10-3**] 12:20PM BLOOD Glucose-138* UreaN-25* Creat-1.9*# Na-140 K-3.2* Cl-98 HCO3-27 AnGap-18 [**2147-10-3**] 12:20PM BLOOD cTropnT-<0.01 [**2147-10-3**] 09:21PM BLOOD cTropnT-<0.01 [**2147-10-4**] 04:31AM BLOOD cTropnT-<0.01 [**2147-10-3**] 12:34PM BLOOD Lactate-2.1* [**2147-10-3**] 12:20PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.8 CTA Pulmonary [**2147-10-3**]: Acute pulmonary emboli to the right main, upper, middle and lower lobar pulmonary arteries. Small focus of thrombus in the distal left main pulmonary artery. Focal consolidation in the right lower lobe may represent pulmonary infarct or pneumonia. Brief Hospital Course: Mr. [**Known lastname 7168**] is a 63-year-old gentleman with stage IV small cell lung cancer s/p carboplatin, etoposide, and irinotecan C4 with metastases to brain and liver, now presenting with complaint of profuse diarrhea, shortness of breath, and fluid-responsive hypotension in the setting of a newly diagnosed large pulmonary embolism and [**Last Name (un) **]. # PULMONARY EMBOLISM: In setting of active malignancy. Patient was initially started on a heparin gtt then subsequently transitioned to fondaparinux and coumadin (allergy to lovenox). Discharged when INR was 2.1 (given fondaparinux on day of discharge so technically bridged for 24 hours). Patient was written for coumadin 5mg QD but switched to 4mg QD on discharge given steep rise of INR. Did not have oxygen requirement on discharge. Mr. [**Known lastname 7168**] should likely remain on coumadin indefinitely. He will follow-up with PCP for INR check (this was confirmed with Dr. [**First Name (STitle) 391**] [**Name (STitle) **] on day of discharge). Patient will have blood drawn for INR checks by VNA). # ACUTE KIDNEY INJURY WITH HYPOTENSION: Prerenal etiology. Creatnine normalized with fluids. # DIARRHEA: Likely irinotecan related. Resolved. Stool studies negative. # CONSTIPATION: Although initially admitted with diarrhea, patient subsequently developed consipation. He moved his bowels on day of discharge after receiving an aggressive bowel regimen. He will be discharged on stool softeners and laxatives to use as needed. # PAIN MANAGEMENT: Patient denied pain during this admission, and said that he was not taking oxycontin at home. This medication was stopped on discharge (as it wasn't needed), but can be resumed at patient's and PCP's discretion. He can continue percocet as needed. # SMALL CELL LUNG CANCER: Metastatic disease to brain and liver, now s/p C4 irinotecan and s/p carboplatin and etoposide. Last chemotherapy dosing on [**2147-9-19**]. Mr. [**Known lastname 7168**] will have close follow-up with his outpatient heme/onc providers. # DERMATOMYOSITIS (paraneoplastic syndrome): Long-standing, complicated issues that even pre-dates his cancer diagnosis. No acute issues during this hospitalization. Patient was continued on cellcept at 1500 [**Hospital1 **]. # ANEMIA: Likely secondary to chemotherapy. Patient's hct trended down during admission and he was given 1 unit of blood on [**2147-10-5**] to increase his reserve. He has no evidence of bleeding and likely his hct was concentrated at time of admission. # CODE: FULL, confirmed, would not want prolonged care # DISPOSITION: Home with VNA. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Dexamethasone 4 mg PO DAILY 3. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN rash 4. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea 5. Opium Tincture 10 DROP PO Q4H:PRN diarrhea 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Lorazepam 0.5 mg PO HS:PRN insomnia 8. Docusate Sodium 100 mg PO BID 9. Ranitidine 150 mg PO BID 10. Mycophenolate Mofetil 1500 mg PO BID 11. Lidocaine Viscous 2% 20 mL PO QID:PRN mouth pain swish and swallow 12. Oxycodone SR (OxyconTIN) 10 mg PO Q12H 13. Oxycodone-Acetaminophen (5mg-325mg) [**12-19**] TAB PO Q6H:PRN pain 14. Nystatin 1,000,000 UNIT PO Q6H 5 ml by mouth four times a day swish and spit 15. Calcium Carbonate 500 mg PO TID 16. Amitriptyline 25 mg PO QHS:PRN insomnia Discharge Medications: 1. Amitriptyline 25 mg PO QHS:PRN insomnia 2. Calcium Carbonate 500 mg PO TID 3. Dexamethasone 4 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Lidocaine Viscous 2% 20 mL PO QID:PRN mouth pain swish and swallow 6. Lorazepam 0.5 mg PO HS:PRN insomnia 7. Mycophenolate Mofetil 1500 mg PO BID 8. Nystatin 1,000,000 UNIT PO Q6H 5 ml by mouth four times a day swish and spit 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Oxycodone-Acetaminophen (5mg-325mg) [**12-19**] TAB PO Q6H:PRN pain 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. Ranitidine 150 mg PO BID 13. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN rash 14. Warfarin 4 mg PO DAILY RX *warfarin [Coumadin] 1 mg Four tablet(s) by mouth Once a day Disp #*60 Tablet Refills:*0 15. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose One packet by mouth Once a day Disp #*30 Packet Refills:*0 16. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1-2 tablets by mouth For constipation Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: VNA carenetwork Discharge Diagnosis: Pulmonary Embolism Diarrhea induced by chemotherapy Constipation Anticoagulation management Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 7168**], It was a pleasure taking care of you during your admission to [**Hospital1 18**]. You came in for progressive shortness of breath and diarrhea and were ultimately found to have a new lung blood clot. You were started on blood thinners (initially a heparin drip and then a daily shot of fondaparinux), and you will be discharged on a medication called warfarin. You will need to have your INRs (measure of how thin your blood is) checked on a regular basis. This will be done at your hematology/oncology appointment on [**10-10**] as well as by your primary care doctor. Your diarrhea was likely due to the chemotherapy irinotecan, and this issue resolved. You subsequently had constipation but you did move your bowels before you were discharged. You will have follow up with your oncologist Dr. [**Last Name (STitle) **] soon after your discharge and determine the next steps of cancer management. PATIENT INSTRUCTIONS: 1. Warfarin check at hematology/oncology appointment on [**10-10**]. 2. Stop anti-diarrheals 3. Stop oxycontin as your pain is well-controlled without it Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2147-10-10**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2147-10-10**] at 9:30 AM With: [**Name6 (MD) 80068**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2147-10-10**] at 10:15 AM With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name:[**Name6 (MD) **] [**Name7 (MD) 83829**],MD Specialty: Primary Care Location: [**Hospital1 **] INTERNAL MEDICINE Address: [**Location (un) **], [**Apartment Address(1) 5524**], [**Location (un) **],[**Numeric Identifier 7331**] Phone: [**Telephone/Fax (1) 7401**] When: Thursday, [**10-12**] at 2:00pm

Unit No: [**Numeric Identifier 67318**] Admission Date: [**2116-5-29**] Discharge Date: [**2116-6-10**] Date of Birth: [**2052-9-16**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 64 year old man with a history of hypertension, diabetes, and tobacco use who presented at [**Hospital6 **] with chest, jaw, and arm pain. He has had intermittent chest pain x2 months and it has been associated with nausea and vomiting for the past 3 days. Chest pain has relieved with sublingual Nitroglycerin. On the day of presentation to [**Hospital6 31672**], he took several subinguinal Nitroglycerin tablets prior to presenting to the ER. When he arrived, his chest pain had resolved. He was admitted to the CCU at [**Hospital1 **] and he underwent cardiac catheterization which revealed a left main 20% distal stenosis, LAD with 80-90% proximal ulcerated stenosis, ramus with a 99% stenosis, left circumflex with 70% ostial stenosis, an OM with a 90% proximal tubular stenosis and an RCA with a 60-65% ulcerated stenosis. His EF is 30% with septal and apical hypokinesis. Patient had ST depressions in leads II, III and V2 through 6 which improved after treatment with IV Nitroglycerin. His troponin at [**Hospital1 **] was 1.4 with a CK of 353 and an MB of 4.3. Following his cardiac catheterization, he was put on Integrilin and Heparin and was transferred to [**Hospital1 18**] for surgical evaluation. PAST MEDICAL HISTORY: Patient's past medical history is significant for non-ST MI, hypertension, insulin dependent diabetes mellitus, status post CVA in [**2114**] with no residual, prostate CA status post prostatectomy, testicular CA status post orchiectomy, status post left BKA, history of skin lesions. MEDICATIONS PRIOR TO ADMISSION: 1. Lisinopril 40 q. d. 2. Lopressor 50 t.i.d. 3. Hydrochlorothiazide 25 q. d. 4. Humalog 80 q. a.m., 6 q. p.m. 5. Humulin 30 q. a.m., 16 q. p.m. 6. Metformin 1 gram b.i.d. 7. Celexa 60 mg q. d. 8. Pravachol, no dose specified. 9. Heparin 1300 units per hour IV. 10.Nitroglycerin 40 mg/kg/hr. 11.Integrilin 2 mg/kg/min. ALLERGIES: Patient states no known drug allergies. SOCIAL HISTORY: Lives alone. He is a widower. Positive tobacco, 5 packs per day x40 years. Alcohol use, 6 beers per night plus 1 quart of hard liquor per week. FAMILY HISTORY: Family history is noncontributory. REVIEW OF SYSTEMS: Dentures upper and lower. PHYSICAL EXAMINATION: Elderly man in no acute distress. Vital signs: Heart rate 72, blood pressure 112/51, respiratory rate 20, weight 112 kg. HEENT: Pupils equally round and reactive to light with extraocular movements intact, anicteric, noninjected. Oropharynx is benign. Neck is supple, no lymphadenopathy. Carotids are 2+ bilaterally without bruits. Lungs are clear to auscultation bilaterally with occasional expiratory wheezes. Cardiovascular regular rate and rhythm, no murmurs, rubs or gallops. Abdomen is obese, soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. Extremities: Pulses are 2+. No posterior tibial or dorsalis pedis pulses palpable. Left BKA. Neuro is nonfocal. LABORATORY DATA: White count 7.6, hematocrit 37.4, platelets 219. Sodium 138, potassium 3.6, chloride 102, CO2 27, BUN 15, creatinine 0.9, glucose 205. Troponin on hospital day 2 is 0.17 with CK MB of 2. Patient was scheduled for carotid ultrasound which showed less than 40% stenosis bilaterally. HOSPITAL COURSE: Over the next several days, the patient was maintained on the cardiothoracic service on Heparin and Nitroglycerin and Integrilin, giving him a little time to recover from his NST MI and on [**6-2**], he was brought to the operating room where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, he had a CABG x3 with LIMA to the LAD, saphenous vein graft to ramus and saphenous vein graft to the RCA. His bypass time was 72 minutes with a crossclamp time of 57 minutes. He was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, he was in a sinus rhythm at 96 beats per minute with a CVP of 19 and a mean arterial pressure of 74. He had insulin at 2 units per hour, epinephrine at 0.02 mcg/kg/min, and Neo- Synephrine at 0.5 mcg/kg/min, Milrinone at 0.25 mcg/kg/min, and propofol at 20 mg/hour. Patient did well in the immediate postoperative period. On the day of surgery, he was weaned off his epinephrine drip. Over the next 12 hours, he was weaned from his Milrinone drip. On postoperative day 1, he was weaned from his sedation. His ventilator was weaned and he was successfully extubated following which he had an uneventful postoperative day. He was, following extubation, weaned from his Nitroglycerin, insulin, and amiodarone drips as well. He remained hemodynamically stable throughout these periods. On postoperative day 2, patient's chest tubes were removed. He was begun on diuretics as well as beta blockade and he was transferred from the ICU to Far-2 for continuing postoperative care and cardiac rehabilitation for further hemodynamic monitoring. Over the next several days, the patient had a largely uneventful recovery. However, on postoperative day 3, following the removal of his Foley catheter, he failed to void and his catheter was replaced. He was also begun on Flomax at that time. His activity level was slowly advanced with the assistance of the nursing staff as well as the physical therapy staff. Also on postoperative day 3, the patient was noted to have an erythematous rash, mainly on his back and trunk. He was begun on Sarna lotion and Benadryl at that time. The rash did not improve over the next several days and on postoperative day 5, a dermatology consult was requested. On dermatology's recommendation, the patient's medications were tailored to eliminate all unnecessary possibilities. His Lasix was discontinued. His Vancomycin had been stopped for several days and Hydralazine. Additionally, the patient had a biopsy. By postoperative day 7, the rash appeared to be stable without further progression. The patient's chest x-ray that day showed mild pulmonary edema and the patient was begun on Diuril. Additionally, he was restarted on a low dose of Lisinopril and he was screened for rehabilitation placement with the hopes he could continue his postoperative care in a rehabilitation center. At the time of this dictation, the patient's physical examination is as follows: Temperature 98.3, pulse 69 sinus rhythm, blood pressure 150/66, respiratory rate 20, O2 saturation 93% on room air, finger stick blood sugars at 125 to 200. Lab data: White 21, hematocrit 28, platelets 570. Sodium 140, potassium 5.1, chloride 99, CO2 28, BUN 15, creatinine 1.1, glucose 140, mag 2.5. Physical examination, general, no acute distress, alert and oriented x3, moves all extremities, follows commands. Cardiovascular: Regular rate and rhythm, S1, S2, with no murmur. Sternum is stable. Incision clean and dry. Lungs clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Skin is erythematous rash with some small papules and no mucosal lesions, mainly involving the back, the buttock and the lower trunk. Extremities have no cyanosis, clubbing, or edema. MEDICATIONS: 1. Amiodarone 400 mg b.i.d. 2. Aspirin 81 mg q. d. 3. Bactroban ointment. 4. Celexa 60 mg q. d. 5. Benadryl 25 mg p.r.n. 6. Colace 100 mg b.i.d. 7. Regular insulin sliding scale. 8. Lopressor 75 mg b.i.d. 9. Percocet p.r.n. 10.Milk of magnesia p.r.n. 11.Zocor 40 mg q. d. 12.Sarna lotion b.i.d. 13.Flomax 0.4 q. d. 14.NPH 16 units in the a.m., 8 units in the p.m. [**Last Name (STitle) 67319**] is to discharge to rehabilitation. Follow up will be with Dr. [**Last Name (Prefixes) **] in 4 weeks, with Dr. [**First Name (STitle) **] in 2 to 3 weeks following discharge from rehabilitation and with his primary care in 2 to 3 weeks after discharge from rehabilitation. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2116-6-9**] 17:53:02 T: [**2116-6-9**] 19:10:15 Job#: [**Job Number 67320**]

Admission Date: [**2122-9-16**] Discharge Date: [**2122-9-25**] Date of Birth: [**2056-8-21**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 398**] Chief Complaint: Transfer from OSH with fevers, back pain, and pathologic evidence of Sweet Syndrome Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Bone marrow biopsy Central venous line placement History of Present Illness: (Primary historians: wife & daughter): 66 y/o male with lung cancer s/p RUL lobectomy, back pain w/ spondylolisthesis, s/p lumbar laminectomes x2, initially admitted to OSH with back pain, now transferred to [**Hospital1 18**] with fevers, leukocytosis, and delirium. . Patient was in his usual state of health until mid-[**8-11**]-2 weeks after returning to [**State 350**] from [**State 8842**]. He initially complained of acute onset R lower back pain that started after leaning over quickly. He went to see his chiropractor. Pain worsened and developed L sided back pain as well. Also with + constipation and LE weakness. Around this same time, the patient started developing a productive cough and fevers. . He presented to [**Hospital **] Hospital on [**9-2**]. Initially alert and oriented x 3, but noted to "say odd things". He was febrile to 101 in the ED, and was intermittently confused. MRI back showed L5-S1 central disc protrusion without mass effect or abnormal enhancement. CT of the head showed diffuse mild cerebral atrophy with no evidence of intracranial hemorrhage. MRI with and without contrast showed no evidence for meningitis and no enhancing mass lesion. Neurosurgery was consulted and felt no intervention needed based on lumbar imaging. ID consulted, and felt the patient had no clear signs of infection, aside from fevers, so antibiotics have been generally held. Neurology assessment was to assess the patient for viral illness, including viral meningitis, less likely paraneoplastic disorder. Lumbar puncture was attempted x 4, with records indicating that one attempt may have yielded venous blood. Acyclovir was temporarily started and then d/c'd when LP fluid was negative for HSV PCR. Heme/onc consulted for leukocytosis, bone marrow aspirate revealed myelodysplasia with no evidence of leukemia. Chromosomal and cytogenetic studies were sent. . Required ICU stay for angioedema of tongue with rash of neck and cheek. He did not require intubation, and the angioedema resolved with dexamethasone. He developed nodules on his face and neck; biopsies revealed neutrophilic dermatosis, c/w Sweet Syndrome (acute febrile neutrophilic dermatosis. . Found to be hypercalcemic with low albumin levels and ionized calcium of 1.61 on day prior to transfer. PTHrP and PTH were sent with Vitamin D studies. These were pending at the time of transfer. . Timeline: [**9-3**]: Tmax 102. LP under fluoro - ?was this venous blood per dc summary. Acyclovir. [**9-4**]: Tmax 102.7. Joint arthrocentesis of ? - culture neg and crystals neg. [**9-5**]: Tmax 102.2. [**9-6**]: Tmax 102.6. WBCs 18.2K. skin biopsy with neutrophilic dermatosis (Sweet). AFB negative. Started IV decadron 6mg Q6H. Vanco and ceftriaxone started. [**9-7**]: Tmax 99.2. Antibiotics stopped. [**9-8**]: afebrile. BMBx performed - aspirate c/w myelodysplasia, no leukemia. [**9-11**]: decadron decreased to 3 mg Q8H. Tmax 101.9. WBC 20.5K. [**9-12**]: Tmax 102.2 [**9-13**]: Tmax [**9-14**]: Tmax 101.4. WBC 34.8K. [**9-15**]: Tmax 100.8. WBC 33.1K. Ca [**23**].9/alb 2 (corrected 13.8) ionized 1.61. Received pamidronate IV 60 mg. PTH and PTHrP pending. . Review of sytems: (+) Per HPI; feels clammy. Wife believes the patient has been hallucinating and seeing people that aren't in the room. When asked who is in the room with him, the patient states "just my family." (-) Deniesheadache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Lung ca, unknown path, s/p RUL lobectomy 6 years ago - Chronic back pain s/p back surgery x 2 for disc herniation - Hyperlipidemia - s/p L TKR Social History: Recently quit smoking. No EtOH. Lives in [**State 8842**] with wife. Former [**Name2 (NI) **] welder Family History: Mother died of unknown cancer, potentially GI. Grandmother had DM. Physical Exam: Vitals: T:96.5 BP:98/64 P:84 R:20 O2:92% RA General: Caucasian well nourished male in NAD, but with unclear mental status. HEENT: Mildly icteric conjunctivae. MMM without OP exudate or hyperemia. No appreciable JVD. Sclera anicteric, MMM, oropharynx clear. PERRLA 3 mm -> 2mm. Lungs: Dry crackles at bilateral lung bases. No wet crackles or wheeze. Good inspiratory effort. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: softly distended, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly. No pulsatile masses. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No asterixis. Skin: Scattered small telangiectasias over face Neuro: Speech is halting, with long pauses mid-sentence. Able to repeat three words immediately but cannot recall at one minute. Oriented to person and time ("Football season"), and oriented to "hospital" but does not know city. Cranial nerves II-XII grossly intact. No nystagmus. Motor: 5/5 strength upper/lower extrems proximally & distally. Sensation: Grossly intact to touch, pinprick. DTR: 2+ biceps/brachoradialis/patellar reflexes bilaterally. Coordination: Intact finger-to-nose test. Gait: Deferred. Pertinent Results: Admission labs: [**2122-9-16**] 09:00PM BLOOD WBC-38.9* RBC-3.58* Hgb-11.6* Hct-35.5* MCV-99* MCH-32.4* MCHC-32.6 RDW-15.4 Plt Ct-180 [**2122-9-16**] 09:00PM BLOOD Neuts-65 Bands-4 Lymphs-8* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-8* Promyel-2* [**2122-9-16**] 09:00PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3* [**2122-9-16**] 09:00PM BLOOD ESR-124* [**2122-9-16**] 09:00PM BLOOD Glucose-145* UreaN-41* Creat-1.1 Na-136 K-4.3 Cl-103 HCO3-26 AnGap-11 [**2122-9-16**] 09:00PM BLOOD ALT-47* AST-26 LD(LDH)-600* AlkPhos-186* TotBili-0.7 [**2122-9-17**] 08:40AM BLOOD Lipase-25 [**2122-9-16**] 09:00PM BLOOD TotProt-5.9* Albumin-2.6* Globuln-3.3 Calcium-12.1* Phos-3.7 Mg-2.6 [**2122-9-16**] 09:00PM BLOOD PTH-106* [**2122-9-16**] 09:00PM BLOOD TSH-0.27 [**2122-9-16**] 09:00PM BLOOD CRP-GREATER TH [**2122-9-16**] 09:00PM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG Barbitr-NEG [**2122-9-17**] 09:03AM BLOOD freeCa-1.54* ------------ [**2122-9-16**] Chest X-ray: FINDINGS: Lung volumes are low, and apical lordotic projection and portable technique also contribute to an accentuation of the cardiomediastinal contours. Patchy opacities are present at both lung bases, and may reflect atelectasis in the setting of low lung volumes. Differential diagnosis includes aspiration and early infectious pneumonia. Followup PA and lateral radiographs are suggested when the patient's condition permits. ----------- CSF: Cytology-NEGATIVE FOR MALIGNANT CELLS. [**2122-9-17**] 02:31PM CEREBROSPINAL FLUID (CSF) WBC-288 HCT,Fl-5.5* Polys-60 Lymphs-33 Monos-4 Other-3 [**2122-9-17**] 02:31PM CEREBROSPINAL FLUID (CSF) TotProt-363* Glucose-76 --------------- [**2122-9-17**] CT Head: No evidence of acute hemorrhage [**2122-9-17**] CT Abdomen/Pelvis: 1. No evidence of spinal or paraspinal abscess. Note that if concern exists for focal discitis or osteomyelitis, MR would be the more sensitive modality for evaluation. 2. Nodularity of the pancreas and left adrenal gland. Given history of previous lung malignancy, metastatic disease is the primary consideration at the pancreas. Additionally, though the adrenal nodule is statistically likely an adenoma, metastatic disease must be considered. Ongoing followup is recommended with repeat CT within 6 months, or with comparison to prior imaging. 3. Large bilateral consolidations in the lower lobes bilaterally. Given the history of fever and cough reported on the previous chest radiograph, these are concerning for infectious pneumonia. Nevertheless underlying mass is not excluded. Followup to resolution is recommended. 4. Large mediastinal lymphadenopathy as detailed above. 5. Numerous healing left lateral rib fractures as well as deformity in the right sixth rib, presumably post-surgical. ---------------- [**2122-9-18**] EEG: This is an abnormal routine EEG due to reduced voltage, slowing, and disorganization of the background rhythm. These findings are suggestive of a mild to moderate encephalopathy involving both cortical and subcortical structures. Medications, toxic/metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no clearly epileptiform features. --------------- [**2122-9-18**] Echo: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Limited study. No significant aortic or mitral regurgitation seen. Grossly preserved biventricular systolic function Brief Hospital Course: # Fevers: Transferred from outside hospital with pathologic diagnosis of Sweet's Syndrome, based on skin biopsy and persistent fevers/leukocytosis. The patient was febrile from his first day on the floor. Initial infectious workup including blood and urine cultures was unrevealing. Stable infiltrate opacities on OSH CXR may represent PNA, especially in setting of productive cough. CT of the chest revealed large bilateral consolidations, and the patient was started on broad antibiotic coverage for hospital acquired pneumonia, including vancomycin and ceftriaxone. The patient underwent lumbar puncture with IR guidance, which yielded ~15 cc of bloody CSF. Initial gram stain on the CSF revealed gram negative rods, and ampicillin was added for potential listeria meningitis, in the event that the gram negative rods reported on gram stain were actually gram variable. The CSF gram stain findings were subsequently changed from gram negative rods to "no organisms." Infectious disease was consulted prior to the above CT findings, and initially recommended holding antibiotic therapy, as well as sending a number of serologic infectious studies (HSV PCR in CSF, VZV PCR, West [**Doctor First Name **] PCR, Eastern Equine Encephalitis PCR, enteroviral PCR, mycoplasma PCR, VDRL per ID). He was treated with broad spectrum antibiotics that were eventually tapered to doxycyline. The patient underwnet TTE, to evaluate for fever of unknown origin. No vegetations were noted. Rheumatology was also consulted, and they recommended tapering the patient's dexamethasone, as the patient's fevers were clearly not responding to the steroid treatments. He also underwent bone marrow biopsy; pathology is pending. # Mental status changes/Delirium: The patient was clearly confused and disoriented, which--per the family's report--was strikingly different from his baseline cognition/personality. Potential etiologies were thought to include infectious (meningoencephalitis, abscess or non-CNS infection), metabolic/endocrine (hypercalcemia), renal failure/uremia, hepatic encephalopathy, or persistently febrile state. It was thought unlikely to be hydrocephalus or brain metastases from unknown primary (hx of lung CA), given reportedly normal OSH imaging. Toxicology screens were negative. Liver function tests were benign. EEG revealed mild to moderate encephalopathy involving both cortical and subcortical structures, without epileptiform features. The patient's mental status seemed to wax and wane somewhat in proportion to his fevers; he would be more engaged and responsive to questioning when afebrile. # Leukocytosis: The patient had reportedly undergone bone marrow aspiration at the OSH, with findings consistent with myelodysplastic syndrome. His WBC count increased rapidly to 47,000. Hematology/oncology was consulted and performed another bone marrow aspiration to further assess the leukocytosis. Marrow analysis is pending. # Hypercalcemia: Calcium was highly elevated at OSH, where he received pamidronate treatment prior to transfer. On arrival initial calcium levels were measured at 12.1, with an albumin of 2.6. PTH levels were elevated at 106. PTHrP was sent off to an outside lab. His calcium trended downwards after receiving pamidronate. Endocrine was following and suspect primary hyperparathyroidism. . # Hypotension: Per patient's family, he has never had difficulty with high or low blood pressures, and was not on home anti-hypertensives. He had had very limited PO intake over the 2-3 weeks prior to admission. He was initially placed on maintenance IV fluids, and subsequently had the rate of infusion increased. He transiently required vasopressors while in the unit. . # History of carcinoid syndrome: His lung cancer was found to be carcinod. Endocrine was consulted and felt his symptoms were unlikely to be carcinoid-mediated. Chromogranin A and 5-HIAA were sent and are pending. . # HIT: His HIT antibody returned positive and he was started on Argatroban. SRA was sent and is pending. LENIs were negative for clot. . # Respiratory failure: Patient required intubation on [**9-19**]. This was due to ARDS; he was initiated on ARDSnet ventilation. He had difficultly oxygenating and required high PEEPs directed by balloon. . # Mediastinal lymphadenopathy: Unclear etiology. Patient was not stable enough for biopsy. . Patient acutely decompensated on morning of [**9-25**]. Patient was made CMO by family. He died that day. Autopsy is pending. Medications on Admission: UPON TRANSFER FROM OSH - omeprazole 20 mg daily - nystatin susp QID - heparin SQ 5000 TID - bisacodyl 10 mg daily - ibuprofen 600 mg QID prn - acetaminophen rectal 650 mg Q6H prn - NS at 75 cc/hr - dexamethasone 3 mg IV Q8H Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary: Fevers of unknown origin Concern for MDS Hypoxemia respiratory failure Acute Respiratory Distress Syndrome Acute renal failure Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

Admission Date: [**2117-8-26**] Discharge Date: [**2117-8-29**] Date of Birth: [**2051-11-8**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 65-year-old male who was previously hospitalized in [**2117-6-1**] for a large right sided subdural hematoma, which developed while he was on Coumadin on atrial fibrillation with no history of trauma. The patient underwent bedside drainage of subdural hematoma without complication, and was discharged off Coumadin. Patient had a four week followup CT which showed a left sided subdural hematoma with 5 mm rightward shift. The patient denies any current symptoms. However, his wife noted difficulty with gait and occasional tripping prior to admission. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Hypertension. 3. Hypercholesterolemia. 4. Anxiety. 5. Questionable pulmonary embolus on [**7-4**]. 6. Status post IVC filter in the right groin. Patient neurologically was awake, alert, and oriented times three and slightly anxious with equal pupils and full extraocular motions on initial exam. Patient had a questionable right pronator drift with a slight facial droop, but motor strength was [**4-5**] throughout upper and lower extremities on admission. Patient was admitted to the floor and preoped for craniotomy and left subdural evacuation, which he underwent on [**2117-8-27**] without complication. Subdural drain was placed. The patient was transferred to the PACU status post procedure. Patient was placed on fluid restriction on [**8-28**] for a sodium of 132. Patient's repeat head CT showed some postoperative air in the left subdural space and some layering of fluid. Drain was placed. There is scant drainage in the subdural drain since OR. Drain was flushed on [**10-1**], and [**8-29**] without significant change in the amount of drainage. Patient continued to neurologically remain intact postoperatively. Patient's drain was D/C'd on [**8-29**] without sequelae. The patient was transferred to the floor. Patient had no complaints at the time of discharge. Was neurologically stable at time of discharge. DISCHARGE MEDICATIONS: 1. Zolpidem tartrate 5 mg p.o. q.h.s. 2. Phenytoin 100 mg p.o. t.i.d. 3. Lisinopril 10 mg p.o. q.d. 4. Atorvastatin 10 mg p.o. q.d. 5. Lorazepam 1 mg p.o. q.4-6h. prn. 6. Peroxetine 40 mg p.o. q.d. FOLLOW-UP INSTRUCTIONS: The patient was instructed to followup with Dr. [**Last Name (STitle) 1327**] in the office in two weeks with prior head CT. Again, the patient is neurologically stable at time of discharge. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 27454**] MEDQUIST36 D: [**2117-8-29**] 23:51 T: [**2117-8-31**] 08:25 JOB#: [**Job Number 51255**]

Admission Date: [**2172-1-12**] Discharge Date: [**2172-2-7**] Date of Birth: [**2136-12-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2172-1-14**] bronchoscopy, VATS, Thoracotomy, decortication, chest tube insertion [**2172-1-22**] Left diagnostic thoracentesis History of Present Illness: 35 M with Down syndrome transferred from [**Hospital3 **] with fevers, jaundice, and RUQ pain with outside ultrasound revealing sludge with CBD distension, elevated white count. Transferred for workup of presumed cholecystitis. No history of biliary colic. Denies any n/v. + anorexia. BMs WNL. Chest Xray here showed R lateral effusion and L consolidation, CT revealed multiple loculated R pleural fluid collections. Thoracic surgery consulted. Past Medical History: s/p b/l tympanic tubes seasonal allergies Social History: Works as a landscaper, denies tobacco, EtOH once a week. Family History: Noncontributory Physical Exam: On admission: VS: & 99.2, HR 58, BP 116/54, RR 18, O2 95% on RA Gen: NAD, AAO HEENT: PERRLA, EOMI, NC/AT, anicteric, neck supple, no LAD Lungs: Decreased breath sounds on R, esp lower lung fields Cards: S1S2 RRR no M/G/R GI: Mild RUQ tenderness to palpation, nondistended, + BS Ext: No C/C/E Pertinent Results: [**2172-1-12**] 06:00PM WBC-21.7* RBC-3.66* HGB-11.3* HCT-33.9* MCV-93 MCH-30.8 MCHC-33.2 RDW-14.0 [**2172-1-12**] 06:00PM GLUCOSE-107* UREA N-18 CREAT-1.5* SODIUM-134 POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-29 ANION GAP-15 [**2172-1-12**] 06:00PM PLT COUNT-464* [**2172-1-12**] 06:19PM LACTATE-2.3* [**2172-1-12**] 06:00PM ALT(SGPT)-36 AST(SGOT)-67* ALK PHOS-40 AMYLASE-15 TOT BILI-0.9 ***** [**2172-1-12**] CT CHEST: Reason: Please eval extent and location of loculation and PNA [**Hospital 93**] MEDICAL CONDITION: 35 year old man with Downs syndrome and lg PNA with loculations on CXR REASON FOR THIS EXAMINATION: Please eval extent and location of loculation and PNA CONTRAINDICATIONS for IV CONTRAST: None. STUDY: CT chest without contrast and reconstructions. INDICATION: 35-year-old male with Down syndrome and pleural loculations on chest x- ray. Initial presentation is right upper quadrant pain and fever. COMPARISON: Chest x-ray from the same date. TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet to the upper abdomen without intravenous contrast administration. Multiplanar reformatted images were obtained. Intravenous contrast was not administered secondary to elevated creatinine. CT CHEST WITHOUT CONTRAST: The thyroid gland is grossly unremarkable. The major airways are patent down to the subsegmental level. The unopacified heart and great vasculature are grossly unremarkable without pericardial effusion given limitation of no IV contrast administration. There are scattered prominent lymph nodes within the mediastinum, the largest of which measures 1.5cm in short axis in a subcarinal location. No axillary adenopathy is present. Limited views of the upper abdomen without contrast demonstrate no abnormalities within the liver, stomach, adrenal glands or spleen so far as visualized. The left lung is clear. There is a small left pleural effusion. Multiple loculated right-sided pleural fluid collections are noted. The largest of these is along the right upper lobe measuring approximately 12.2 x 4.4 cm in greatest dimension. Two other prominent loculations lie in the right lung base, the larger of which measures 7.4 x 7.2 cm. The attenuation of these pleural collections is consistent with simple fluid. Compressive atelectasis is noted in the right lung with septal thickening at the right lung base. There is no pneumothorax. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are detected. IMPRESSION: 1. Loculated right pleural fluid collections. Given the absence of contrast evaluation for enhancement and nodularity along the pleura is limited. 2. Septal thickening and atelectasis in the right lung. 3. Borderline mediastinal lymphadenopathy, may be reactive. 4. Small left pleural effusion. ***** [**2172-1-12**] RUQ ULTRASOUND: Reason: Please eval for GB pathology or other pathology contributing [**Hospital 93**] MEDICAL CONDITION: 35 year old man with fever, jaundice, RUQ tenderness REASON FOR THIS EXAMINATION: Please eval for GB pathology or other pathology contributing to his sx INDICATION: 35-year-old man with fever, jaundice, right upper quadrant tenderness. COMPARISON: None. FINDINGS: There is a subtle rounded hyperechoic area seen adjacent to the right hepatic vein, measuring approximately 2.5 cm in greatest dimension. No definite Doppler flow is seen within this lesion. No other definite focal lesion is identified within the liver. Gallbladder appears unremarkable, without evidence of stones. Normal direction of flow is seen in the portal vein. Right pleural effusion incidentally noted. IMPRESSION: 1. No evidence of cholecystitis. 2. Subtle hypoechoic lesion seen within the right lobe of the liver without significant mass effect, possibly representing focal fatty infiltration, hemangioma or FNH. Multiphasic MRI (with "echo-offset" sequences) or CT is recommended for further evaluation on a non-emergent basis. 3. Right pleural effusion. ***** [**2172-1-18**] ECHOCARDIOGRAM: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be quantified. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global biventricular systolic function. No pericardial effusion or pathologic flow identified. CLINICAL IMPLICATIONS: Based on [**2171**] 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. ***** [**1-25**] CT ABDOMEN/PELVIS REASON FOR THIS EXAMINATION: Please perform w/ PO and IV contrast - hypoechoic liver lesion on previous US [**2172-1-12**], now w/ elevated LFTs, fever CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Hypoechoic liver lesion on previous ultrasound and elevated liver function tests. COMPARISON: An ultrasound of the abdomen from [**2172-1-12**]. TECHNIQUE: Axial volumetric images have been obtained through the abdomen and pelvis according to the triphasic liver protocol. Pre-contrast, arterial face, portovenous phase images were obtained. FINDINGS: The liver appears normal with no evidence of abnormal lesions corresponding to the son[**Name (NI) 493**] finding within the right lobe. The spleen, the pancreas, and the gallbladder appear unremarkable. The bilateral adrenal glands are within normal limits. There is an NG tube in place with the tip seen within the stomach. The bowel appears unremarkable with no evidence of pneumatosis or obstruction. There is no evidence of free fluid within the abdomen. There is a Foley catheter in place. There are bilateral basilar atelectases with consolidation in the right lower lobe. There are also bilateral chest tubes in place. There is a small right- sided pleural effusion. There is a subcutaneous collection seen in the right hemithorax more laterally on image 122 measuring 4.4 anteroposteriorly x 2.5 cm axially. This collection is surrounded by fat stranding and inflammatory changes. There are no suspicious bony lesions. IMPRESSION: 1. There is no hepatic lesion detected that would correspond to the ultrasonographic finding within the right lobe. 2. Bilateral lower lobe atelectases and consolidation within the right lower lobe with a small effusion. There are bilateral two chest tubes in place. 3. A collection within the subcutaneous tissues in the lateral aspect of the right hemithorax with evidence of surrounding inflammatory changes. Findings were communicated to Dr. [**First Name (STitle) **] on the same day at 6:45 p.m. Brief Hospital Course: Mr. [**Known lastname 77155**] [**Last Name (Titles) 1834**] VATS decortication converted to thoracotomy with bilateral chest tubes on [**2172-1-14**]. He remained intubated and was transferred to the SICU postoperatively on empiric Vancomycin and Zosyn. He continued to spike fevers with elevated white count, and his cultures grew out strep viridans from the pleural fluid and yeast from sputum. ID was consulted for antibiotic management, and felt that the yeast was likely a contaminant. Echo was done which was negative for vegetations, and all lines were changed. On [**1-25**] he had a CT of the abdomen/pelvis to rule out intraabdominal source, which revealed a fluid collection below his thoracotomy wound, so the incision was opened. Minimal purulent fluid and old clotted blood was expressed. Subsequently his fever curve began to trend down, and pressors and ventilation were weaned. All subsequent cultures were negative. He was extubated on [**1-26**], and transferred to the floor on [**1-28**]. He [**Month/Year (2) 1834**] a speech and swallow evaluation and was started on PO diet. His right chest tube was converted to an empyema tube, and the left chest tube was pulled on [**2-5**]. There was a small left apical pneumothorax post-pull which was stable on subsequent xray. He completed his course of Zosyn on [**2-4**], but developed C diff colitis so was started on PO flagyl. As his vital signs were stable, he was tolerating regular diet, and was feeling well, he was discharged to rehab on [**2172-2-6**]. Medications on Admission: PRN [**Doctor First Name **] (seasonal) Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for prn wheeze. 5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscellaneous Q6H (every 6 hours) as needed for mucus. 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days. 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Right lower lobe pneumonia Right pleural empyema Down syndrome Clostridium dificile colitis Discharge Condition: Good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops redness or discharge No lifting greater than 10 pounds for 4 weeks No driving while taking narcotics: take stool softners with narcotics No swimming or tub baths for 6 weeks Continue to ambulate frequently Diet: Ground, regular diet with thin liquids, supervised feeds, sitting up for all meals. Activity: as tolerated Followup Instructions: Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**] Date/Time:[**2172-2-13**] 4:00 Completed by:[**2172-2-7**]

Admission Date: [**2105-2-27**] Discharge Date: [**2105-3-3**] Date of Birth: [**2044-9-25**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7333**] Chief Complaint: Fatigue, lightheadedness, bradycardia, sinus pauses Major Surgical or Invasive Procedure: Pacemaker placement (St. [**Hospital 923**] Medical Accent PM2210 dual chamber pacemaker) on [**2105-3-2**] History of Present Illness: 60 M with history of HTN, HL, and lyme disease s/p treatment presents with lightheadedness and palpitations. He noted the onset of palpitations and lightheadedness about 4 weeks ago, describes it as feeling like he is about to pass out. Has a sensatino of palpitations like his heart is skipping beats. Finds that they are most commonly triggered by exercise, finds that he is very winded and tired after going to the gym, significantly more than usual. They have become more frequent in the last few days. . He first brought these symptoms to his PCP's attention on [**2-18**] when He complained of feeling weak and lightheaded about 15 minutes after exercise. It was similar to what he felt 5 years ago when he was on the golf course. At that time, he was found to have a cardiac conduction defect [**1-15**] Lyme disease. He was worried about the recurrence of Lyme disease. He has had no recent contact with ticks, no rashes. He started noticing palpitations several weeks ago. but he felt that they improved by stopping caffeine. . He came to the ED tonight when his symptoms returned. Dr [**Last Name (STitle) **] was consulted while he was in the ED. Dr. [**Last Name (STitle) **] noted him to have frequent sinus pauses that correlated with his symptoms. The longest pause noted was 4.6 seconds. He felt fine when he was in Sinus. . In the ED, initial vitals were 97.6 56 174/90 16 99%. He had pacer pads placed. No medications were given. CXR was benign. Vitals on transfer were 97.6 56 174/90 16 99%RA. . He was on the floor overnight for a few hours, however his heart rate continued to dwindle. He was spending most of his time in a junctional rhythym, and from that rhythym was having pauses, the longest of which was 5.54 seconds. He continued to be symptomatic with the sensation of feeling "awful, washed out, and nauseous." Discussion was initiated with the cardiology fellow, and the decision was made to bring the patient up to the CCU for a trial of chronotropic support to bridge him to getting a pacemaker, and if that failed, placing a temporary pacer. . ROS: 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. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, or syncope. Past Medical History: Dyslipidemia Hypertension Syncope related to lyme carditis 5 years ago s/p treatment Social History: Lives in [**Location **] with his wife and daughter. Retired investment manager. Tobacco: smokes cigars occassionally. ETOH: 1-2 drinks a night. Illicts: Denies. Family History: Father and mother are both alive at 90 and 88, respectively with only HTN. No early CAD or sudden cardiac death. Physical Exam: Admission VS: T=98.0 BP=158/91 HR=61 RR=18 O2 sat=95 GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. Fit HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP below clavicle at 90 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. 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. CTAB, no crackles, 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+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge Tmax: 36.7 ??????C (98.1 ??????F) Tcurrent: 36.6 ??????C (97.9 ??????F) HR: 60 (36 - 82) bpm BP: 138/97(106) {137/75(88) - 200/118(126)} mmHg RR: 15 (12 - 20) insp/min SpO2: 95% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 86 kg (admission): 86 kg GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. Fit HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP below clavicle at 90 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. CHEST: Pocket site mimimal sero-sanginous fluid at incision site, dressing c/d/i LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. A EXTREMITIES: No c/c/e. Pertinent Results: I. Laboratory A. Admission [**2105-2-27**] 05:10PM BLOOD WBC-8.9 RBC-4.98 Hgb-15.8 Hct-46.2 MCV-93 MCH-31.7 MCHC-34.2 RDW-12.8 Plt Ct-200 [**2105-2-27**] 05:10PM BLOOD Neuts-57.0 Lymphs-35.1 Monos-5.4 Eos-1.8 Baso-0.7 [**2105-2-27**] 05:10PM BLOOD PT-11.0 PTT-29.3 INR(PT)-1.0 [**2105-2-27**] 05:10PM BLOOD Plt Ct-200 [**2105-2-27**] 05:10PM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-138 K-3.5 Cl-102 HCO3-25 AnGap-15 [**2105-2-28**] 05:53AM BLOOD CK-MB-2 cTropnT-<0.01 [**2105-2-27**] 05:10PM BLOOD cTropnT-<0.01 [**2105-2-28**] 05:53AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.1 B. Discharge [**2105-3-3**] 06:29AM BLOOD WBC-7.6 RBC-5.01 Hgb-15.9 Hct-47.2 MCV-94 MCH-31.6 MCHC-33.6 RDW-12.8 Plt Ct-169 [**2105-3-3**] 06:29AM BLOOD Plt Ct-169 [**2105-3-3**] 06:29AM BLOOD Glucose-99 UreaN-14 Creat-0.8 Na-142 K-3.6 Cl-104 HCO3-26 AnGap-16 [**2105-3-3**] 06:29AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.2 II. Radiology A. CXR ([**2105-2-27**]) INDICATION: Patient with arrhythmia. COMPARISONS: None available. FINDINGS: Portable upright view of the chest demonstrates normal lung volumes without pleural effusion, focal consolidation or pneumothorax. Hilar and mediastinal silhouettes are unremarkable. Heart size is normal. The imaged upper abdomen is unremarkable. IMPRESSION: No evidence of acute cardiopulmonary process. B. CXR ([**2105-3-3**]) ** PRELIM ** No acute process. Leads in proper position. III. Cardiovascular A. ECG Sinus bradycardia with blocked atrial premature complexes and some which are conducted, along with a junctional escape. Non-specific ST segment changes. Since the previous tracing of [**2098-8-14**] the Q-T interval is somewhat shorter. There is a normalized P-R interval and the ST segment changes are less marked. Intervals Axes Rate PR QRS QT/QTc P QRS T 49 142 88 420/400 75 37 34 B. EXERCISE STRESS TEST RESTING DATA EKG: SR, WNL HEART RATE: 62 BLOOD PRESSURE: 150/88 PROTOCOL [**Doctor First Name 569**] - TREADMILL STAGE TIME SPEED ELEVATION HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 0-3 1.7 10 108 178/80 [**Numeric Identifier 13436**] 2 [**2-17**] 2.5 12 120 202/78 [**Numeric Identifier 13437**] 3 [**5-23**] 3.4 14 123 212/80 [**Numeric Identifier 13438**] 4 [**8-26**] 4.2 16 146 232/80 [**Numeric Identifier 13439**] TOTAL EXERCISE TIME: 12 % MAX HRT RATE ACHIEVED: 91 SYMPTOMS: NONE ST DEPRESSION: EQUIVOCAL INTERPRETATION: This 60 year old man with a h/o Lyme disease was referred to the lab for evaluation of sick sinus syndrome and syncope. The patient exercised for 12 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol (12.9 METS) and stopped for fatigue. This represents a good functional capacity for his age. There were no chest, neck, back, or syncopal symptoms reported by the patient throughout the procedure. There was 1 mm of upsloping ST segment depressions inferolaterally at peak exercise. The rhythm was sinus with rare APBs and one ventricular couplet. The heart rate response to exercise was appropriate. Resting mild systolic hypertension. The blood pressure response to exercise was mildly exaggerated (232/80mmHg). IMPRESSION: No exercise induced arrhythmia or anginal symptoms with non-specific ST changes at the achieved workload. Good functional capacity. Resting mild systolic hypertension with mildly exaggerated blood pressure response to exercise. C. ECHO ([**2105-3-2**]) Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. No valvular patholology or pathologic flow identified. Mildly dilated ascending aorta. Compared with the report of the prior study (images unavailable for review) of [**2098-9-3**], the left ventricular cavity size is smaller (now normal) and the heart rate is now lower. CLINICAL IMPLICATIONS: Based on [**2099**] 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. Brief Hospital Course: 60-year-old male with history of hypertension, hyperlipidemia, and lyme disease presented with fatigue, lightheadedness, bradycardia, and significant sinus pauses (up to 4.6 seconds) that seemed to occur after cessation exercise was found to have sinus node dysfunction and is status post pacemaker placement for sinus node dysfunction. # Sinus node dysfunction Patient had noted onset of palpitations and lightheadedness about 4 weeks ago and described it as a feeling like he was about to pass out. He also felt weak and lightheaded about 15 minutes after exercise. He presented to the [**Hospital1 18**] ER for return of his symptoms. It was noted that he had frequent sinus pauses that correlated with his symptoms up to 4.6 seconds. He was asymptomatic when in normal sinus rhythm. He was initially admitted to the [**Hospital1 1516**] service but had significant bradycardia and transferred to the CCU. His rhythm was mostly junctional with continuing long pause intervals (4 to 5 seconds at times) with continuing symptoms including feeling "awful, washed out, and nauseous." He was placed on chronotropic support to bridge him while awaiting potential pacemaker evaluation requiring isoproterenol especially during rest given bradycardia to 30-40s. An ECHO was performed on [**2105-3-2**] showing normal biventricular sizes and function with no overt valvular pathology. He had a mildly dilated ascending aorta. He also had an exercise stress test to evaluate cardiac rhythm during and post-exercise. He was able to exercise for 12 minutes on [**Doctor First Name **] protocol (12.9 METS) with the test stopped for fatigue. There was 1 mm of upsloping ST segment depressions inferolaterally at peak exercise. Rhythm was sinus with rare APBs and one ventricular couplet. The heart rate response to exercise was appropriate. The blood pressure response to exercise was mildly exaggerated (232/80). There was no apparent exercise induced arrhythmia or anginal symptoms with non-specific ST changes at achieved workload. The patient was taken to the EP lab on [**2105-3-2**] for pacemaker implanation given sinus note dysfunction specifically sinus pause/arrest and had a St. [**Hospital 923**] Medical Accent DR [**Last Name (STitle) **] PM2210 placed in the left pectoral region. He was given vancomycin 1 gm IV for the procedure and while in the hospital. There were no apparent complications. Post-procedure CXR was within normal limits showing good lead placement. He was discharged on a three day course of keflex with post-pacemaker care instructions and activity limitations. He will follow-up in device clinic in one week. # Hypertension He was continued on hydrochlorothiazide and lisinopril. # Hyperlipidemia He was continued on simvastatin # Hct drop Labs on [**3-2**] showed Hct decrease from 46.1 to 35.3 with repeat labs stable at 44.7 -47.2 likely reflecting an isolated and spurious value. # Transitional issues - Pacemaker follow-up # Pending studies - follow-up final CXR report performed on [**2105-3-3**] Medications on Admission: HCTZ 25 mg daily lisinopril 20 mg daily simvastatin 20 mg daily aspirin 81 mg daily propranolol 20 mg Q6H PRN hypertension (rarely takes) triamcinolone acetonide 0.1% [**Hospital1 **] Discharge Medications: 1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. triamcinolone acetonide 0.1 % Ointment Topical 6. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 3 days: Take all of this medication. The prescription was routed to your pharmacy. . Discharge Disposition: Home Discharge Diagnosis: Primary: Sinus node dysfunction specifically sinus pause/arrest Secondary: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 69**] for fatigue, lightheadedness, and a slow heart rate. You were monitored closely in the Cardiac Care Unit, and it was decided that given your slow heart rate that you needed a pacemaker to keep your heart rate at a good level while at rest. You had an exercise test that showed that your heart was doing well when you exerted yourself. Please see the pacemaker discharge instruction sheet for activity limitations and other instructions related to your new pacemaker. Medications: STOP propranolol as this can slow your heart rate. Discuss with your primary care doctor if you need additional medications to control your blood pressure. START keflex 500 mg by mouth four times daily for the next 3 days. This is to prevent infection at the site of your new pacemaker. The prescription has been routed to your [**Location (un) 535**] in [**Location (un) **]. Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2105-3-12**] at 10:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2126-2-7**] Discharge Date: [**2126-2-20**] Date of Birth: [**2069-4-1**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 56-year-old male who experienced chest pain while undergoing an exercise tolerance test. He was preoperative for right inguinal herniorrhaphy repair. He was referred for cardiac catheterization, which he had when he came into the hospital on [**2-7**]. This revealed a 70% distal left main, 85% ostial circumflex, and 70% ostial right coronary artery, and an ejection fraction of 62%. He was referred to Dr. [**Last Name (STitle) 70**] for coronary artery bypass grafting. PAST MEDICAL HISTORY: Hypertension, former smoker with a 4- pack per day history for which he quit in [**2111**], polio at age 7, former ETOH abuse, and remote fracture of nose and skull. SOCIAL HISTORY: He lives alone, and he works at [**Hospital3 2576**] as a cargo transporter. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. once a day, Toprol-XL 50 mg p.o. once a day. ALLERGIES: He had no known drug allergies. PREOPERATIVE LABORATORY DATA: White count 6.0, hematocrit 33.3, platelet count 329,000. PT 13.6, PTT 32.8, INR 1.2. Urinalysis was negative. Glucose 182, sodium 134, K 3.9, chloride 102, bicarbonate 24, BUN 18, creatinine 0.7, anion gap of ALT 30, AST 14, alkaline phosphatase 34, amylase 42, total bilirubin 0.8, albumin 3.8. Preoperative chest x-ray showed no acute cardiopulmonary disease, but some suggestive changes of emphysema. On exam he had a left facial droop, status post his childhood polio. Temperature of 97.5, heart rate 65 in sinus rhythm, respiratory rate 18, he was saturating 93% on room air, with a blood pressure of 121/71. His lungs were clear bilaterally. His heart was regular rate and rhythm with S1 and S2 and no murmur. His abdomen was benign. His extremities were warm with no edema, and 2+ pulses bilaterally. He was also seen by Dr. [**Last Name (STitle) **] and consented for coronary artery bypass grafting. On the following day, on [**2-8**] he did undergo coronary artery bypass grafting x 3 with a LIMA to the LAD, a RIMA to the RCA, and a vein graft to the OM by Dr. [**Last Name (STitle) 70**]. He was transferred to the cardiothoracic ICU in stable condition on a propofol titrated drip and a Neo-Synephrine drip at 1 mcg per kg per minute. On postoperative day 1, he had a blood pressure of 102/51, was A-paced at 90, was saturating 92% on 2 liters nasal cannula. Postoperatively, his white count rose to 21.2, with a hematocrit of 28.7, platelet count 346,000. K 4.2, BUN 9, creatinine 0.6. His chest tubes remained in place for some drainage overnight. His Neo-Synephrine was at 2.4 mcg per kg per minute. His PA line was discontinued. On postoperative day 2, he received 1 unit of packed red blood cells overnight. His hematocrit rose to 26.8 the following morning. His white count dropped to 12.9. His creatinine was stable at 0.6. His Neo-Synephrine continued to be weaned and was at 0.1 mcg per kg per minute on the morning of rounds. His chest tubes and pacing wires remained in place. His heart rate was 95 and blood pressure 109/57. On postoperative day 3, his Neo was discontinued. He began his metoprolol beta blockade, and Lasix diuresis was started. His hematocrit rose to 25.4. He transferred to the floor. His mediastinal chest tubes were discontinued. His pleural chest tube remained in place. His pacing wires were discontinued. His Foley was discontinued, and he began metoprolol 25 b.i.d. On the floor he was seen and evaluated by physical therapy. He began his ambulation and increasing his activity level. He was alert, awake, and oriented and was working with physical therapy and the nurses to also improve his pulmonary toilet. On postoperative day 4, he was in sinus rhythm and was hemodynamically stable. He had a nonfocal exam. His sternum was stable with no click. His incisions were clean, dry, intact. He had 2 pleural tubes which remained in place. They were removed on postoperative day 4. His Lopressor was increased to 50 b.i.d. to reduce his sinus tachycardia and bring his blood pressure down. He was encouraged to continue to increase his activity level. On postoperative day 5, the patient was in sinus rhythm with a good blood pressure. His exam was unremarkable, but he had slightly decreased urine output which responded to an increase in Lasix, and he was encouraged to continue ambulating. His Lopressor was also increased to 75 mg p.o. b.i.d. He also had 1+ extremity edema. On postoperative day 6, he continued diuresis and then was orthostatic, but he had improved oxygenation, and he continued to have a low-grade temperature of 100.3. His creatinine was stable at 0.7, his hematocrit was stable at 32.0, and his white count was normal. He was below his preoperative weight on postoperative day 6. Lasix was changed from b.i.d. to daily. Cultures were sent off, as it was unclear what the fever origin was. The patient continued to ambulate with a plan for discharge the following day if he remained afebrile and had improved blood pressure. On postoperative day 7, he was febrile the evening prior and he continued to be lightheaded while ambulating. His lab work was unremarkable. His Lasix was discontinued. His Lopressor was decreased from 75 down to 50 b.i.d., and he continued to be monitored. On postoperative day 7 he had some diarrhea, and the following day that resolved. There was a question of a possible thrombophlebitis, but it turned out there was no thrombophlebitis. He continued to be very orthostatic. Follow- up cultures did not have any growth at that point. He was given some IV fluids bolus for hypotension, and all the rest of his nonessential medications were discontinued. On postoperative day 9, he had no fever in the 24 hours prior. He continued to diurese on his own, and attempt was made to keep him positive for his I's and O's. His central venous line had already been discontinued as well as his pacing wires. He was in sinus rhythm at 90 with a good blood pressure. On postoperative day 11, an echocardiogram was performed which showed an ejection fraction of 55%, a dilated aortic root, and good wall function. On [**2-20**], postoperative day 12, he was discharged to home with VNA services. On the day of discharge he was in sinus rhythm, with a blood pressure of 111/81, a pulse rate of 88, saturating 97% on room air. White count 10.2, hematocrit 36.1, platelet count normal. K 4.8, BUN 11, creatinine 0.7. His neurologic exam was nonfocal. His lungs were clear bilaterally. His heart was regular rate and rhythm. He had no drainage or erythema from any of his incisions, and he was discharged home in stable condition with VNA services. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting x 3. 2. Right inguinal hernia. 3. Status post broken nose and skull 30 years ago. 4. Polio at age 7. 5. Former ethanol and tobacco abuse. DISCHARGE INSTRUCTIONS: He was instructed to make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**], his primary care physician, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] visit 1 to 2 weeks post discharge and to make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], his surgeon, 6 weeks post discharge for his postoperative surgical visit. MEDICATIONS ON DISCHARGE: 1. Aspirin enteric coated 81 mg p.o. once a day. 2. Colace 100 mg p.o. twice a day. 3. Percocet 5/325 1 to 2 tablets p.o. q.4 hours p.r.n. pain. 4. Metoprolol 50 mg p.o. twice a day. 5. Lipitor 10 mg p.o. once a day. He was discharged to home with VNA services in good condition on [**2126-2-20**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2126-3-18**] 16:08:05 T: [**2126-3-19**] 10:17:06 Job#: [**Job Number 60668**]

Admission Date: [**2200-3-3**] Discharge Date: [**2200-3-11**] Date of Birth: [**2150-10-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: increased lethargy, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 1932**] is a 49-year-old right-handed man with a history of [**Location (un) 849**]-Gastaut syndrome with intractable epilepsy and intellectual disability who presented as a transfer from [**Hospital 7912**] due to increased lethargy. The staff at his group home reported that he had been very somnolent over the last few days. They also reported a cough and some congestion and think he might have had a fever. He has not had any increase over his baseline seizure frequency (usually has 1-2 drop attacks per day). On the morning of admission he was eating breakfast when he reportedly fell forward and hit his head on the table: unclear if he fell asleep or had a drop attack. There was no evidence of convulsive activity. EMS was called and he was taken to [**Hospital6 33**]. Upon arrival his vitals were within normal limits (99.1F 77 102/65 16). He received aspirin 81mg and 1L NS and was subsequently transferred to [**Hospital1 18**] for further evaluation. . Upon arrival to [**Hospital1 18**] [**Name (NI) **], pt was noted to be somnolent and inattentive, not answering questions appropriately and had difficulty following commands. Otherwise there were no focal neurologic deficits noted. ROS is positive for recent cough/congestion, negative for headache, chest pain, shortness of breath, nausea/vomiting, abdominal pain, changes in bowel/bladder habits. Past Medical History: 1. [**Location (un) 849**]-Gasteau syndrome; refractory seizure disorder with baseline [**1-6**] seizures per day (drop attacks per group home assistant, [**Male First Name (un) 17661**]) despite multiple AEDs and vagal nerve stimulator. VNS was implanted in [**2187**]; staff swipes with magnet on wrist after drop attacks. Followed in clinic by Dr. [**First Name (STitle) **]. Recently cross-titrating off zonegran and onto clobezam (as above). Seizure Types (per [**12/2199**] discharge summary): Type 1: Atonic Aura: none Ictal: head falls forward, sudden drop to ground TB/incont: no Postictal: confused for up to 30-40 min First: age 7-8 years Frequency: Up to 4/wk Precipitants: none Type 2: Tonic Aura: none Ictal: loud cry, arm elevation or stiffening, head moves forward, then fall TB/incont: some incontinence, no tongue biting Postictal: confused for up to 30 min First: age 7-8 years Frequency: [**1-6**]/wk, often in clusters Precipitants: none Type 3: Probable atypical absence Aura: none Ictal: staring, blinking, altered awareness, sometimes drooling TB/incont: no Postictal: none First: childhood Frequency: Unclear, many per day Precipitants: none Type 4: Generalized tonic clonic Aura: none Ictal: Ictal cry, generalized stiffening, jerking of extremities, last 2-4 minutes, up to 10 min TB/incont: yes Postictal: obtunded, confused for hours First: childhood Frequency: 1-2 per year Precipitants: none other PMH: 2. Intellectual disability (moderate to severe by neuropsych testing [**2191**]) and depression with behavioral disorder (h/o aggression, agitation, violent behavior intermittently), followed here at [**Hospital1 18**] by Dr. [**Last Name (STitle) **]. 3. Obstructive Sleep apnea, followed by Dr. [**Last Name (STitle) **] in sleep clinic, per past notes "unable to use CPAP mask well." 4. Left preauricular skin squamous cell carcinoma s/p excision in [**2188**], superficial parotidectomy, left supralmohyoid neck dissection, and skin graft to left cheek from left thigh. 5. s/p Inguinal hernia repair in childhood. Social History: Lives in a group home (Road to Responsibility), all of his medications are given by the workers in the home in blister packs. Visits from sister and mother. Family History: Non-contributory, no seizures or psychiatric history. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.5 BP 112/70 HR 80 RR 18 O2 94% 2L General: Lethargic, arouses to voice, answers some basic questions, intermittently cooperative with exam, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: Lungs with rhonchi and crackes L>R Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Lethargic, arouses to voice. Oriented to [**Hospital1 18**], [**2200-2-5**]. Says it is Tuesday (one day off). Follows some simple commands, otherwise somewhat inattentive. -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 voice bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Lifts all extremities anti-gravity and wiggles toes b/l. Has some difficulty cooperating with formal strength testing of individual muscle groups at this time. -Sensory: Responds to light touch throughout, testing of other modalities limited by cooperation -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: Reaches well b/l -Gait: Deferred . DISCHARGE PHYSICAL EXAM: Vitals: 98.4 106/64 57-74 16-22 94% 2L (90-95% RA) General: pleasant M in NAD, AAOx3, talking comfortably. EEG leads in place. HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse BS in b/l bases L>R; no wheezes; faint bibasilar crackles Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no calf tenderness Neuro: AAOx3, moving all 4 extremities. CN II-XII grossly intact. Pertinent Results: ADMISSION LABS: WBC-5.2 RBC-3.18* HGB-10.3* HCT-29.0* MCV-91 MCH-32.3* MCHC-35.4* RDW-12.4 NEUTS-52.7 LYMPHS-34.4 MONOS-9.3 EOS-2.9 BASOS-0.6 PLT COUNT-203 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG VALPROATE-100 AMMONIA-48 CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-2.1 GLUCOSE-91 UREA N-13 CREAT-0.6 SODIUM-138 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11 LACTATE-0.8 URINE: BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 . Imaging: CHEST X-RAY ([**2200-3-4**]): As compared to the previous radiograph, there are newly appeared bilateral parenchymal opacities. These are better seen on the lateral than on the frontal radiographs and are both located in the lower lobes. The opacities are ill-defined and show multiple air bronchograms as well as bronchocentric predominance. In the appropriate clinical setting, the opacities are highly suggestive for pneumonia. . CTA CHEST ([**2200-3-6**]): 1. Bilateral pulmonary emboli involving the distal left main pulmonary artery and bilateral segmental and subsegmental arterial branches. Mild contrast reflux into the IVC suggests mild right heart strain. 2. Moderate bibasilar atelectasis, worse at the left lower lobe, with superimposed pneumonia and/or aspiration. 3. 4 mm right minor fissure nodule, which may represent inflammatory focus. No dedicated followup is required if there are no higher risk factors such as malignancy. 4. Small left pleural effusion. . TRANSTHORACIC ECHO ([**2200-3-7**]): The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . LE ULTRASOUND ([**2200-3-7**]): No evidence of deep vein thrombosis in either right or left lower extremity. . VIDEO SWALLOW [**2200-3-7**]: RECOMMENDATIONS: 1. PO diet: regular solids, thin liquids. 2. PO meds whole with thin as tolerated, but whole with puree if pt has pocketing of meds. 3. [**Hospital1 **] oral care. 4. Assist with meals only if needed to maintain standard aspiration precautions. Discharge/Notable Labs: [**2200-3-11**] 07:35AM BLOOD WBC-12.5* RBC-3.79* Hgb-11.7* Hct-33.8* MCV-89 MCH-30.9 MCHC-34.6 RDW-13.1 Plt Ct-486* [**2200-3-11**] 10:40AM BLOOD PTT-127* [**2200-3-11**] 07:35AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-141 K-4.5 Cl-107 HCO3-25 AnGap-14 [**2200-3-8**] 04:35AM BLOOD ALT-15 AST-18 LD(LDH)-209 AlkPhos-48 TotBili-0.1 [**2200-3-6**] 04:11PM BLOOD cTropnT-<0.01 proBNP-148* [**2200-3-11**] 07:35AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.8 [**2200-3-6**] 04:11PM BLOOD Albumin-3.3* Calcium-9.1 Phos-4.6* Mg-2.0 Iron-34* [**2200-3-6**] 04:11PM BLOOD calTIBC-270 VitB12-759 Ferritn-217 TRF-208 [**2200-3-6**] 04:11PM BLOOD TSH-3.7 [**2200-3-3**] 02:45PM BLOOD Valproa-100 Studies pending on discharge: None Brief Hospital Course: 49 year-old right-handed man with h/o Lennaux-Gastaut syndrome with intractable epilepsy and mild intellectual impairment admitted with a several day history of increased somnolence, initially felt to be due to upper respiratory tract infection/anti-epilpetic drug uptitration found to have pneumonia and bilateral pulmonary emboli requiring transient ICU admission. . #SOMNOLENCE/Community Acquired Pneumonia: Per the patient's group home, the patient was noted to have lethargy and cough, but did not have any increase in his baseline seizure frequency and his neuro exam was unchanged exam for intermittent subtle twitching of the right thumb. Chest X-ray revealed bilateral lower lobe pneumonia, which was felt to be the most likely cause of the patient's somnolence. He was treated for community acquired pneumonia with Ceftriaxone and azithromycin and completed his full course of antibiotics in the hospital. #Epilepsy: Patient was maintained on continuous EEG throughout his hospitalization which showed a slow encephalopathic pattern throughout the recording with frequent bursts of rapid generalized epileptiform discharges, consistent with patient's diagnosis of symptomatic generalized epilepsy as well superimposed toxic-metabolic encephalopathy. Per his previous titration schedule as specified by Dr. [**First Name (STitle) **], his zonegran was discontinued. His clobazam was initially uptitrated to 10mg/20mg per previous titration level, then decreased back to 10mg/10mg due to concern that this could be increasing somnolence. The rest of his home AED's were continued at their current doses (Levetiracetam 2500mg [**Hospital1 **], Lacosamide 300mg [**Hospital1 **], Depakote ER 500mg q8am / 750mg q8pm). His somnolence improved with treatment of his underlying pneumonia. He was followed by Neurology throughout his hospital course. . #PULMONARY EMBOLI: Although the patient was initially satting in mid-90s on 1-3L per nasal cannula on admission, while working with physical therapy on [**3-6**] he had an acute desaturation which required O2 by 50% ventimask to maintain O2 saturation >90%. He was transferred to the Medical ICU where his antibiotics were initially broadened to Vanc/Zosyn/Azithromycin. Chest CTA subsequently showed bilateral pulmonary emboli in the distal left main pulmonary artery and bilateral segmental and subsegmental arterial branches. A transthoracic echocardiogram was done which showed minimal right heart strain and bilateral lower extremity ultrasounds showed no DVT. He was treated with anticoagulation with an IV heparin gtt and transferred to the floor on [**2200-3-8**]. His O2 saturation remained in the high 90s on RA-2L O2 by nasal canula. After extensive discussion with the Neurology team and the patient's mother and case worker at his group home, the decision was made to discharge the patient on a Lovenox bridge to Coumadin. Given his frequent seizures and falls, it was felt that Coumadin would be a better option given its ability to be reversed should the patient suffer a bleed. The interactions of coumadin with the patient's anti-epileptic drugs were discussed with the patient's outpatient Neurologist, and the decision was made to try to manage anticoagulation with coumadin, with lovenox as a second option should the goal INR of [**2-7**] be difficult to obtain. Patient should continue on anticoagulation for 6-12 months and will have INR followed and Coumadin titrated by the patient's PCP and [**Hospital6 33**] [**Hospital 3052**]. Patient will also require use of a helmet while ambulating to minimize risk of bleed. . #Obstructive sleep apnea: Pt has known OSA for which he has not tolerated CPAP in the past. Trial of CPAP was performed on the medical floor which the patient seemed to tolerate however. Pt's outpatient neurologist Dr. [**Last Name (STitle) **] will follow up and initiate nasal CPAP as an outpatient. . #ANEMIA: Pt has hypoproliferative anemia, HCT was stable throughout hospitalization. B12 and folate WNL. Iron studies were relatively normal. #Disposition: Patient was discharged to rehab. =================== TRANSITIONS OF CARE: -Upon discharge from rehab, please arrange to have INR checks done by VNA or other laboratory and faxed to patient's PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17662**], phone #[**Telephone/Fax (1) 17663**] and fax #[**Telephone/Fax (1) 17664**]) -Pt needs PT/INR and Dilantin levels checked q2 days for 2 weeks after discharge. If Dilantin levels are supra/subtherapeutic, please fax to epileptologist Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **], phone #[**Telephone/Fax (1) 3294**] and fax #[**Telephone/Fax (1) 7020**] -Please overlap Lovenox and coumadin until INR is between 2 and 3 for >24 hours Medications on Admission: 1. clobazam - currently being uptitrated over the last 3 weeks, now taking 10mg QAM and 20mg QPM. 2. zonisamide - tapering off from 600mg/d --> now taking 100mg [**Hospital1 **] 3. levetiracitam 2500mg [**Hospital1 **] 4. lacosamide 300mg [**Hospital1 **] 5. VPA (Depakote ER) 500mg q8am / 750mg q8pm 6. sertraline 200mg q.8am 7. sinmvastatin 10mg q.8pm 8. MVI 9. Ca/D3 10. Perdex mouthwash [**Hospital1 **] 11. melatonin 1mg q8pm 12. loratadine PRN Discharge Medications: 1. Outpatient Lab Work Please check PT/INR and Depakote level on [**2200-3-13**]. If Depakote supratherapeutic/subtherapeutic, please call Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3294**]. 2. Outpatient Lab Work Please check PT/INR and Depakote level on [**2200-3-15**]. If Depakote supratherapeutic/subtherapeutic, please call Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3294**]. 3. Outpatient Lab Work Please check PT/INR and Depakote on [**2200-3-17**] If Depakote supratherapeutic/subtherapeutic, please call Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3294**]. 4. Outpatient Lab Work Please check PT/INR and Depakote level on [**2200-3-19**]. If Depakote supratherapeutic/subtherapeutic, please call Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3294**]. 5. Outpatient Lab Work Please check PT/INR and Depakote level on [**2200-3-21**]. If Depakote supratherapeutic/subtherapeutic, please call Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3294**]. 6. Outpatient Lab Work Please check PT/INR and Depakote level on [**2200-3-23**]. If Depakote supratherapeutic/subtherapeutic, please call Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3294**]. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily): Stop once INR is therapeutic ([**2-7**]) on Warfarin for 48 hours. 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. clobazam 10 mg Tablet Sig: One (1) Tablet PO twice a day. 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day. 13. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. lacosamide 150 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. clobazam 10 mg Tablet Sig: One (1) Tablet PO twice a day. 16. levetiracetam 500 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). 17. melatonin 1 mg Tablet Sig: One (1) Tablet PO q8 PM. 18. loratadine Oral 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 22. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough, secretions. 23. warfarin 2 mg Tablet Sig: AS DIRECTED Tablet PO AS DIRECTED for 6 months: Please start with 2mg daily and increase dosing based on INR checks (goal INR [**2-7**]). 24. divalproex 500 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO Q8AM (). 25. divalproex 250 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO Q8PM (). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: 1. Community-acquired pneumonia 2. Bilateral pulmonary emboli 3. [**Location (un) 849**]-Gastaut syndrome with intractable epilepsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 1932**], You were admitted to [**Hospital1 69**] on [**2200-3-3**] due to increased somnolence. You were found to have pneumonia in both lungs, and were started on antibiotics. You then developed worsening shortness of breath, and were found to have pulmonary emboli (blood clots in lungs). You were started on a blood thinner called heparin, and your oxygen requirements improved. You will need to stay on blood thinners (called Warfarin) for 6 more months to dissolve the clots. For your epilepsy, you were put on continuous EEG, which showed changes due to being sick with pneumonia as well as your underlying seizure activity. Some of your anti-epileptic medications were decreased because they seemed to be making you overly sleepy/lethargic. . Please attend the follow up appointments with neurology listed below. . We made the following changes to your medications: 1. STARTED Enoxaparin (Lovenox) 120mg subcutaneously once daily, to be continued until you have therapeutic blood levels of Warfarin for at least 48 hours 2. STARTED Coumadin (Warfarin) 2mg by mouth daily today, which will be increased based on what your blood levels are (goal INR [**2-7**]). These levels will be followed at rehab and then at Dr. [**Name (NI) 17665**] office ([**Hospital3 **]). You will need to continue this for at least SIX MONTHS after discharge. 3. STOPPED Zonisamide (Zonegram) 4. DECREASED Clobazam from 10mg in the morning and 20mg at night to 10mg in the morning and 10mg at night Followup Instructions: Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [**2200-4-10**] at 4:00 PM With: [**Known firstname 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: NEUROLOGY When: MONDAY [**2200-6-9**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SLEEP UNIT NEUROLOGY When: THURSDAY [**2200-6-12**] at 4:00 PM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 6856**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2137-9-2**] Discharge Date: [**2137-9-5**] Date of Birth: [**2098-4-9**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Demerol Attending:[**First Name3 (LF) 3376**] Chief Complaint: Post-operative hypopnea Major Surgical or Invasive Procedure: laparoscopic proctocolectomy, J-pouch ileoanal anastamosis and diverting ileostomy for refractory ulcerative colitis History of Present Illness: 39yo F s/p laparoscopic proctocolectomy, J-pouch ileoanal anastamosis and diverting ileostomy for refractory ulcerative colitis who is admitted to the [**Hospital Unit Name 153**] from the [**Hospital Unit Name 13042**] for hypopnea/apnea. Per the [**Hospital Unit Name 13042**]/ five hour case the patient received 250mg of fenatanyl, 4mg of midazolam, 5.6 mg of dialudid, 280mg of propofol, and 1mg of haldol, as well as scopolamine patch, and after the case she was extubated and had a respiratory rate of [**5-13**] with excellent oxygenation. The floor refused her [**1-8**] low respiratory rate and she was admitted to the [**Hospital Ward Name **] ICU. The [**Hospital Ward Name 13042**] nurse [**First Name (Titles) **] [**Last Name (Titles) 14593**] given naloxone because the patient was stable and she didn't want to cause undo pain. Social History: Lives in [**Hospital1 392**] with her husband and 3 children, works for her husband who is an attorney. No tobacco, social EtOH, and no illicit drugs. Family History: Mom - Died of PE at 73, COPD Father - Died of EtOH cirrhosis No h/o autoimmune diseases or IBD in family members. Physical Exam: General Appearance: Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, well preseverd ostomy site at RLQ, tactile crepitus on exam Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Sedated, Tone: Not assessed Pertinent Results: [**2137-9-5**] 09:00AM BLOOD WBC-6.2 RBC-3.54* Hgb-10.6* Hct-32.7* MCV-92 MCH-30.1 MCHC-32.6 RDW-14.7 Plt Ct-237 [**2137-9-3**] 03:53AM BLOOD WBC-11.4*# RBC-3.25* Hgb-9.7* Hct-30.5* MCV-94 MCH-29.8 MCHC-31.7 RDW-15.1 Plt Ct-221 [**2137-9-2**] 06:37PM BLOOD Hct-30.0* [**2137-9-5**] 09:00AM BLOOD Plt Ct-237 [**2137-9-3**] 03:53AM BLOOD Plt Ct-221 [**2137-9-3**] 03:53AM BLOOD [**2137-9-5**] 09:00AM BLOOD Glucose-83 UreaN-5* Creat-0.7 Na-144 K-3.3 Cl-107 HCO3-28 AnGap-12 [**2137-9-3**] 03:53AM BLOOD Glucose-117* UreaN-7 Creat-0.7 Na-139 K-3.9 Cl-104 HCO3-29 AnGap-10 [**2137-9-2**] 06:37PM BLOOD Glucose-103* UreaN-7 Creat-0.9 Na-140 K-3.9 Cl-105 HCO3-26 AnGap-13 [**2137-9-5**] 09:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9 [**2137-9-3**] 03:53AM BLOOD Calcium-8.0* Phos-4.5 Mg-2.0 [**2137-9-2**] 06:37PM BLOOD Calcium-8.1* Phos-4.8* Mg-2.1 Brief Hospital Course: 39 yo F s/p Single-incision laparoscopic proctocolectomy, J-pouch ileoanal anastomosis and diverting ileostomy for refractory ulcerative colitis who is admitted to the [**Hospital Unit Name 153**] from the [**Hospital Unit Name 13042**] for hypopnea/apnea. Per the [**Hospital Unit Name 13042**], during the five hour case the patient received 250mg of fentanyl, 4mg of midazolam, 5.6 mg of Dilaudid, 280mg of propofol, and 1mg of Haldol, as well as scopolamine patch, and after the case she was extubated and had a respiratory rate of [**5-13**] with excellent oxygenation. The floor refused her [**1-8**] low respiratory rate and she was admitted to the [**Hospital Unit Name 153**]. [**Name8 (MD) 13042**] RN felt [**Name8 (MD) 14593**] administering naloxone because the patient was stable and she didn't want to cause undue pain. In summary, a 39F with PMH of anxiety & refractory ulcerative colitis s/p protocolectomy who came out of the OR too hyponeic to go to the floor. Low respiratory drive/rate: Resolved. This is undoubtedly due to polypharmacy and is clearing as the meds clear. Patient is mentating well with SpO2 in high 90s. No indication for narcan overnight. The patient remained stable throughout her hospitalization once transferred to the inpatient [**Hospital1 **]. UC s/p Proctocolectomy: Patient with a PMH of UC from her teen years, dx'd at 25. Currently on prednisone taper s/p proctocolectomy. The patient was progressed from sips of clears to a regular diet as her bowel function returned. The day prior to discharge the patient was noted to have increasing ileostomy output and immodium was initiated. The following day the ileostomy output was acceptable, she was taught by the wound/ostomy nursing team as well as the floor nursing team to care for her ileostomy and how to monitor herself for signs and symptoms of dehydration and how to measure and record her the ileostomy output. Her prednisone taper was continued as an outpatient. Pain management: As the patient's bowel function returned she was progressed from intravenous morphine and dilaudid PCA to pain medications by mouth. The patients pain was adequately controlled by the discharge pain regimen. Anxiety: Patient c/o anxiety and concerned she might have a panic attack. The patient was mantained on her outpatient regimen of anxiolytics. Medications on Admission: Prednisone Taper Xanax 2mg prn Klonopin 1mg prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 5 days: Please do not drink alcohol or drive a car while taking this medication. Do not take more than 4000mg of Tylenol daily. . Disp:*40 Tablet(s)* Refills:*0* 2. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO TID (3 times a day): Please take with meals. Disp:*42 Wafer(s)* Refills:*0* 4. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day: Please take 10mg Prednisone daily for 3 more days, then 5mg daily for 7 days, 2.5mg for 7 days, and 1mg for 7 days. You will then stop the prednisone. . Disp:*60 Tablet(s)* Refills:*0* 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)) as needed for anxiety. 6. Xanax 2 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety: Please use caution if taking this medication with narcotic pain medication. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Medically Refractory Ulcerative Colitis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for Single-incision laparoscopic total proctocolectomy with ileal J-pouch, anal anastomosis and temporary diverting ileostomy for treatment of your ulcerative colitis. You have tolerated this procedure well, tolerated a regular diet, your pain is well controlled with pain medications by mouth and you are now ready to be disharged home. Please monitor your bowel function closely. You have a new ileostomy which puts you at risk for dehydration if you do not monitor the output from your ostomy and do not repleate yourself with enough fluid. It is important to monitor the output from the ostomy. The goal for your ileostomy output is to put out between 500cc-1200cc daily. The ileostomy output has been high prior to your discharge, you have been started on immodium 2mg twice daily, please take this and monitor your ostomy output. You will also be taking metamucil wafers as ordered. As your stool becomes thickened, you may titrate these medications. Please call the office if you have any questions. Care for your ostomy as you have been instructed by the wound/ostomy nurses. Please eat small frequent meals and keep yourself well hydrated. Monitor your self for signs and symptoms of dehydration including: increased thrist, dizziness, dizziness on standing, or dry mouth. You will be prescribed the medication Percocet (oxycodone-acetaminophen) for pain. Please take this as written. Donot drink alcohol or drive a car while taking these medications. Please be aware that this medication could increase the affects of the medications you currently are taking for anxiety, if you find that the percocet is making you sedated please refrain from taking these medications at the same time. Please monitor the skin around the ostomy for signs and symptoms of infection including: increasing redness, increased pain, increased drainage from the stoma or drainage from this area that is white/green/thick/malodorous. If you notice these symptoms please call the office or go to the emergency room if the symptoms are severe. You will be tapering your prednisone. You are currently taking 10mg of prednisone daily, please continue to take this dose until Sunday [**2137-9-8**]. At this time you will taper to 5mg for 7 days, then taper to 2.5mg daily for 7 days, and to 1mg for 7 more days. At this time you may stop the prednisone. You will return to the hospital for the ileostomy take down at a time determined appropriate by Dr. [**Last Name (STitle) 1120**]. Followup Instructions: Please make an appointment to see Dr. [**Last Name (STitle) 1120**] in follow-up in [**1-9**] weeks. Call [**Telephone/Fax (1) 160**] to make an appointment. Completed by:[**2137-9-10**]

Admission Date: [**2199-12-31**] Discharge Date: [**2200-1-6**] Date of Birth: [**2151-2-25**] Sex: F Service: [**Hospital1 139**] CHIEF COMPLAINT: Chief complaint shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old female with a history of severe asthma leading to 25 intubations who presented to [**Hospital1 188**] for acute shortness of breath. The patient had had purulent drainage from her nose two weeks prior to admission; consistent with sinusitis and was treated with Augmentin twice per day. The patient finished her course four days prior to admission; but on [**12-28**], she noticed a mild sore throat, cough, and nasal congestion. On [**2199-12-29**], she increased her prednisone to 60 mg p.o. q.d. without effect. On [**2199-12-30**], she noticed shortness of breath which had continued to progress. Therefore, she increased her prednisone to 80 mg p.o. q.d. and presented to the Emergency Department. She had no fevers, chills, nausea, vomiting, muscle aches, or pain. The patient was found to have had a severe asthma attack and was intubated and sent to the Medical Intensive Care Unit. The patient had improved by [**2200-1-5**] and was transferred out to the floor. PAST MEDICAL HISTORY: 1. Asthma (as described above) with baseline peak flows of 150. 2. Chronic sinusitis. 3. Osteoporosis (from steroid use). 4. Acute steroid myopathy. 5. Hypercholesterolemia. 6. Abnormal mammogram in the past. MEDICATIONS ON ADMISSION: (Her medications in the Intensive Care Unit included) 1. Albuterol nebulizers and albuterol inhalers. 2. Protonix 40 mg p.o. q.d. 3. Guaifenesin/dextromethorphan 5 mg p.o. q.4h. as needed. 4. Prednisone 60 mg p.o. q.d. 5. Montelukast 10 mg p.o. q.d. 6. Ipratropium bromide 2 puffs q.i.d. 7. Benzonatate one tablet p.o. t.i.d. 8. Beclomethasone one spray NU b.i.d. 9. Levaquin 500 mg p.o. q.d. 10. Salmeterol 2 puffs b.i.d. 11. Prempro 0.625 mg p.o. q.d. 12. Multivitamin one tablet p.o. q.d. 13. Zolendronate 70 mg p.o. every Monday. 14. Fluticasone 110 6 puffs b.i.d. 15. Fexofenadine 60 mg p.o. b.i.d. ALLERGIES: The patient has an allergy to ASPIRIN which causes increased wheezing. SOCIAL HISTORY: Her social history was negative for alcohol or tobacco use. She lives with her children. FAMILY HISTORY: Family history is positive for asthma and for hypertension. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the floor revealed the patient was afebrile with stable vital signs. General appearance revealed a well-appearing thin female, pleasant, in no apparent distress. Head, eyes, ears, nose, and throat examination revealed pupils were equally round and reactive to light and accommodation. No scleral or sublingual icterus. A soft voice. The neck revealed no jugular venous distention. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs, or gallops. Pulmonary examination revealed decreased breath sounds diffusely. Positive expiratory wheezes anteriorly. The abdomen revealed positive bowel sounds. Soft, nontender, and nondistended. Extremities revealed no cyanosis, clubbing, or edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission to the floor included a white blood cell count of 10.5, hemoglobin was 11.7, hematocrit was 35.1, and platelets were 220. Coagulation studies included a PT of 11.7, PTT was 33.8, and INR was 0.9. Electrolytes revealed sodium was 135, potassium was 5, chloride was 97, bicarbonate was 27. Her theophylline level was measured at less than 0.8. RADIOLOGY/IMAGING: A chest x-ray performed on [**2199-12-31**] showed hyperinflation with flatted diaphragms bilaterally, pulmonary vasculature congestion, clear lungs. Cardiac silhouette and mediastinal silhouette were normal. Soft tissues and osseus structures were unremarkable. HOSPITAL COURSE: Given the above, the patient was remained on the floor for one day. She was continued on her medications from the Intensive Care Unit and codeine 15 mg p.o. q.4-6h. as needed was added given her severe cough. DISCHARGE DISPOSITION/CONDITION: The patient was able to ambulate down the hallway with an oxygen saturation of 93% to 95%. She also reached a peaked flow of 140 and felt that she was ready to return home. MEDICATIONS ON DISCHARGE: 1. Albuterol nebulizers and albuterol inhalers. 2. Protonix 40 mg p.o. q.d. 3. Guaifenesin/dextromethorphan 5 mg p.o. q.4h. as needed. 4. Prednisone 60 mg p.o. q.d. 5. Montelukast 10 mg p.o. q.d. 6. Ipratropium bromide 2 puffs q.i.d. 7. Benzonatate one tablet p.o. t.i.d. 8. Beclomethasone one spray NU b.i.d. 9. Levaquin 500 mg p.o. q.d. 10. Salmeterol 2 puffs b.i.d. 11. Prempro 0.625 mg p.o. q.d. 12. Multivitamin one tablet p.o. q.d. 13. Zolendronate 70 mg p.o. every Monday. 14. Fluticasone 110 6 puffs b.i.d. 15. Fexofenadine 60 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with her primary care physician within one week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. [**MD Number(1) 13930**] Dictated By:[**Name8 (MD) 10249**] MEDQUIST36 D: [**2200-1-7**] 21:00 T: [**2200-1-11**] 03:12 JOB#: [**Job Number **]

Admission Date: [**2189-7-9**] Discharge Date: [**2189-7-14**] Date of Birth: [**2112-8-2**] Sex: F Service: CARDIOTHORACIC Allergies: Thiopental Attending:[**First Name3 (LF) 1505**] Chief Complaint: burning in chest over past 3 months with exertion Major Surgical or Invasive Procedure: OPCABx2(LIMA->LAD, SVG->OM) [**2189-7-9**] History of Present Illness: 76 year old woman with 3 month hx of chest pain with exertion with + ETT and EF 66%. Pain relieved with rest and TUMS. Referred for cath which showed 50% LM into LAD and CX, LAD 80%, D2 70%, 50% CX/OM1, LPDA 80%, RCA 99%. Referred to Dr. [**Last Name (STitle) **] for CABG. Past Medical History: NIDDM HTN PVD L CEA [**2185**] LVH L mastectomy [**2184**] with breast Ca elev. chol. TIA 11 years ago exc. skin growth chest wall s/p cholecystectomy obesity Social History: widowed, but lives near son Family History: father MI at 62 Physical Exam: on day of discharge [**7-14**]: 98.4 SR 73 131/57 RR 20 95% RA sat. 74.6 kg nonfocal neurologically lungs CTA bil. RRR sternal and leg incisions C/D/I, abd unremarkable with BS extrems 1+ edema Pertinent Results: [**2189-7-13**] 07:00AM BLOOD WBC-7.9 RBC-3.41* Hgb-10.3* Hct-29.9* MCV-88 MCH-30.3 MCHC-34.6 RDW-14.5 Plt Ct-177 [**2189-7-13**] 07:00AM BLOOD Plt Ct-177 [**2189-7-13**] 07:00AM BLOOD Glucose-103 UreaN-26* Creat-0.9 Na-144 K-4.2 Cl-106 HCO3-29 AnGap-13 [**2189-7-11**] 04:07AM BLOOD Phos-3.2 Mg-2.1 [**2189-7-11**] 04:44AM BLOOD freeCa-1.21 Brief Hospital Course: see HPI above. Underwent off pump CABG x2 on [**7-9**] with LIMA to LAD and Y graft SVG to OM1 by Dr. [**Last Name (STitle) **].Transferred to CSRU on neo, propofol, epinephrine and insulin drips. Weaned to CPAP on POD #1 and weaned from epi, remained on neo drip. Lasix diuresis begun. On nitroglycerin drip for BP control on POD #2 and extubated. Beta blockade started , nitro weaned and transferred to the floor later in the day. Alert and oriented, worked with PT to increase activity level, lopressor increased in SR on POD #3. Foley and pacing wires removed without incident. Continued to progress well on POD #4 and lisinopril restarted on POD #5. Discharged to home with VNA services on [**7-14**]. Medications on Admission: ASA 325 mg qd atenolol 12.5 qd glipizide 2.5 mg qd HCTZ 12.5 mg qd lisinopril 20 mg qd metformin 500 mg qd Centrum silver qd TUMS X strength TID lipitor 10 mg qd Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease off pump CABG X2 Non-insulin dependent DM hypertension peripheral vasc. dz with L CEA left ventricular hypertrophy elev. cholesterol TIA L breast Ca with mast. chest wall growth excision Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Do not use lotions, creams, or powders on wounds. Call our office for sternal drainage, temp.>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 36037**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2189-8-14**]

Admission Date: [**2161-10-29**] Discharge Date: [**2161-11-2**] Service: SURGERY Allergies: Codeine / Keflex Attending:[**First Name3 (LF) 4691**] Chief Complaint: right hip pain Major Surgical or Invasive Procedure: [**10-29**] pelvic arteriogram History of Present Illness: HPI: [**Age over 90 **]F s/p fall at [**Hospital3 **] c/o R hip pain. Patient was in usual state of health until this AM when she notes mechanical fall in bathroom. Walks w assistance of cane at baseline but did not have cane this AM at time of fall. Denies syncope, lightheadedness, chest pain or shortness of breath at time of fall. Denies head strike. Patient brought to [**Hospital1 18**] ED by ambulance for evaluation. Surgery consultation is obtained for traumatic injury. At time of evaluation patient complains of severe R hip pain but denies associated symptoms as per above. Denies headache, blurry vision, fever, chills, blurry vision, double vision, chest pain, shortness of breath, abdominal pain, dysuria. Past Medical History: 1. Breast cancer, bilaterally. 2. Hypertension. 3. History of recurrent urinary tract infection. 4. Inferior myocardial infarction [**2126**]. 5. Osteoporosis. 6. Depression. 7. Rectocele. 8. Left arm lymph edema secondary to breast cancer treatment. 9. Herpes zoster [**2157**]. 10. Memory loss. 11. Status post CVA [**2157**] 12. Cystocele 13. History of falls. 14. Hemorrhoidectomy. 15. Left cataract surgery. 16. Right carotid endarterectomy [**2148**]. 17. Left dermoid ovarian cyst removal. 18. Two lumpectomies of the left breast, followed by XRT. 19. CAD (per nursing home records) Social History: The patient is currently a resident at [**Location (un) **] [**Hospital3 400**]. She is widowed since [**2148**] and has a son [**Name (NI) 449**] [**Name (NI) **] who lives in [**Name (NI) 7349**]. Tobacco: Quit many years ago, cannot quantify use ETOH: None Illicits: None Family History: Non-contributory Physical Exam: PHYSICAL EXAMINATION upon admission: [**2161-10-29**] Temp: 98.3 HR: 93 BP: 114/56 Resp: 18 O(2)Sat: 95 Normal Constitutional: Uncomfortable. HEENT: Normocephalic., Pupils equal, round and reactive to light, Extraocular muscles intact Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft Extr/Back: Tenderness over right greater trochanter. Decreased ROM, , No cyanosis, clubbing or edema Neuro: Speech fluent. Alert and oriented x 3. Psych: Normal mood, Normal mentation Pertinent Results: [**2161-11-2**] 04:40AM BLOOD WBC-5.6 RBC-2.81* Hgb-9.0* Hct-26.6* MCV-95 MCH-31.9 MCHC-33.8 RDW-14.8 Plt Ct-184 [**2161-11-2**] 12:31AM BLOOD WBC-5.9 RBC-2.76* Hgb-8.5* Hct-26.5* MCV-96 MCH-31.0 MCHC-32.2 RDW-13.9 Plt Ct-238 [**2161-11-1**] 09:10PM BLOOD WBC-5.7 RBC-2.61* Hgb-8.3* Hct-24.4* MCV-94 MCH-32.0 MCHC-34.2 RDW-14.4 Plt Ct-183 [**2161-10-31**] 05:00PM BLOOD Hct-22.5* [**2161-10-29**] 09:21PM BLOOD WBC-7.9 RBC-3.30*# Hgb-10.5*# Hct-30.8*# MCV-93 MCH-31.6 MCHC-33.9 RDW-14.1 Plt Ct-185 [**2161-11-1**] 04:45AM BLOOD Neuts-77.6* Lymphs-15.4* Monos-3.4 Eos-2.9 Baso-0.6 [**2161-10-29**] 07:45AM BLOOD Neuts-85.9* Lymphs-9.7* Monos-2.6 Eos-1.1 Baso-0.8 [**2161-11-2**] 04:40AM BLOOD Plt Ct-184 [**2161-11-2**] 04:40AM BLOOD PT-15.5* PTT-49.3* INR(PT)-1.4* [**2161-11-2**] 04:40AM BLOOD Glucose-100 UreaN-23* Creat-1.2* Na-139 K-5.1 Cl-105 HCO3-24 AnGap-15 [**2161-11-1**] 04:45AM BLOOD Glucose-94 UreaN-26* Creat-1.3* Na-142 K-4.3 Cl-106 HCO3-28 AnGap-12 [**2161-10-31**] 08:40AM BLOOD Glucose-127* UreaN-26* Creat-1.2* Na-139 K-4.3 Cl-104 HCO3-28 AnGap-11 [**2161-10-29**] 07:45AM BLOOD Glucose-114* UreaN-25* Creat-1.2* Na-138 K-5.9* Cl-102 HCO3-24 AnGap-18 [**2161-11-2**] 04:40AM BLOOD Albumin-3.4* Calcium-8.6 Phos-2.9 Mg-2.4 [**2161-11-1**] 04:45AM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.8 Mg-2.3 [**2161-10-31**] 08:40AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1 0/29/11: EKG: Normal sinus rhythm. Leftward axis. Non-specific ST segment depression in leads I and aVL and ST segment elevation in leads II, III, aVF and V6. There are only tiny R waves or small QR deflections in leads V3-6 consistent with an extensive anterior wall myocardial infarction of undetermined age. Consider left ventricular hypertrophy. Consider inferior wall myocardial infarction. Compared to the previous tracing of [**2161-6-3**] the voltage in leads V3-V6 has decreased with tiny R waves or tiny Q waves. Consider anterior wall myocardial infarction and inferior wall infarction of undetermined age. [**2161-10-29**]: hip x-ray: IMPRESSION: Comminuted fracture of the right iliac [**Doctor First Name 362**] with no associated widening or diastasis of the right sacroiliac joint which is better seen on the subsequent CT of the pelvis. [**2161-10-29**]: chest x-ray: IMPRESSION: Low lung volumes without acute cardiopulmonary abnormality [**2161-10-29**]: cat scan of the head: IMPRESSION: 1. No acute intracranial process. 2. Age related global atrophy. 3. Soft tissue swelling overlying the left posterior vertex and left frontal bone without underlying fracture. [**2161-10-29**]: cat scan hip: IMPRESSION: 1. Comminuted fracture of the right iliac [**Doctor First Name 362**] involving the right sacroiliac joint without widening or diastasis of the sacroiliac joint. There is an overlying extraperitoneal hematoma measuring 7 x 3 cm which extends into the right hemipelvis measuring 6 x 6 cm and displaces the urinary bladder to the left. Active extravasation cannot be assessed on this unenhanced study. 2. Degenerative changes of the bilateral femoroacetabular joints and visualized portion of the lumbar spine without fracture. 3. Sigmoid diverticulosis without evidence of diverticulitis. 4. Calcified atherosclerosis of the visualized distal infrarenal abdominal aorta extending into the bilateral common iliac, internal iliac and femoral arteries [**2161-10-29**]: CTA pelvis: IMPRESSION: Focus of active extravasation in the pelvis adjacent to the right superior pubic ramus with surrounding extraperitoneal hematoma concerning for active arterial bleed. [**2161-10-29**]: pelvic arteriogram: CONCLUSION: No evidence of active arterial extravasation on pelvic arteriogram with targeted catheterization of the right internal iliac artery, right superficial pudendal artery in addition to bilateral common iliac artery angiograms [**2161-10-29**]: arteriogram: CONCLUSION: No evidence of active arterial extravasation on pelvic arteriogram with targeted catheterization of the right internal iliac artery, right superficial pudendal artery in addition to bilateral common iliac artery angiograms Time Taken Not Noted Log-In Date/Time: [**2161-10-30**] 5:31 am URINE Site: NOT SPECIFIED 0603C. **FINAL REPORT [**2161-11-1**]** URINE CULTURE (Final [**2161-11-1**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: [**Age over 90 **] year old female presents to the acute care service after a mechanical fall. Upon admission, she was made NPO, given intravenous fluids, and underwent radiographic imaging. She was reported to have a comminuted fracture of the right iliac [**Doctor First Name 362**] with note of an extraperitoneal hematoma. Because of these findings, she underwent a pelvic angiogram which was negative for extravasation and she required no embolization. She was evaluated by orthopedics who recommmended non-surgical intervention at this time with follow-up in 2 weeks. Her head cat scan did not show a inter-cerebral bleed. She was admitted to the intensive care unit for monitoring of her hematocrit. She required additional intravenous fluids for hemodynamic support, but her hematocrit stablized without blood products. Initial EKG did show q waves in V3-V6 with normal CPK. She did resume her aspirin and plavix. She was transferred to the surgical floor on HD #2. Her vital signs remained stable and she is afebrile. She is tolerating a regular diet and voiding without difficulty. She was evaluated by physical therapy who recommended discharge to a rehabilitation facility where she can regain her strength and mobility. She will be discharged to an extended care facility with instructions to follow up with the acute care service, orthopedics, and her primary care provider. Of note: she was started on ciprofloxacin [**11-2**] for UTI. Medications on Admission: MED: [**Last Name (un) 1724**]: AMLODIPINE 2.5', CITALOPRAM 15', PLAVIX 75', MIRTAZAPINE 30', 15 prn, ASA 325', CALCIUM CARBONATE-VITAMIN D3 600-400'', VITAMIN D-3 400', CO Q-10 (unknown), MVI' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 6. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: started [**11-2**]. 7. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for systolic blood pressure <110. 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Celexa 10 mg Tablet Sig: 0.5 Tablet PO once a day. 16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours) as needed for pain: hold for increased sedation, resp. rate <12. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Trauma: fall right posterior ring pelvic fracture (large iliac [**Doctor First Name 362**] fx) UTI extra-peritoneal hematoma Discharge Condition: Mental Status: Clear and coherent ( HOH) Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hosptial after you fell at home. YOu reported right hip pain and you were brought to the hospital. You had x-rays of your hip taken and found to have a smalll fracture in your pelvis with a small amount of bleeding around your hip. Your hematocrit stabilzed and you did not need any further intervention. You were seen by Orthopedics and they recommended that you not put weight on that leg, but no surgery was warrented at this time. You will need follow-up visit with Orthopedics in 2 weeks and with your primary care provider Followup Instructions: Please follow-up with Orthopedics, Nurse Practitioner, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in 2 weeks [**Hospital 1957**] clinic with AP pelvis radiograph. The telephone number is#[**Telephone/Fax (1) 1228**] Please follow up with the acute care service in 2 weeks. You can schedule this appointment by callling # [**Telephone/Fax (1) 600**] You will need to follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] # [**Telephone/Fax (1) 719**] in 1 week Completed by:[**2161-11-2**]

Admission Date: [**2176-10-25**] Discharge Date: [**2176-11-2**] Date of Birth: [**2176-10-25**] Sex: F Service: NEONATOLOG HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **]-[**Known lastname **] is the former 1.895 kilogram product of a 34 and [**3-8**] week gestation pregnancy, born to a 31 year old gravida V, para III woman. PRENATAL SCREENS: 1. Laboratory Data: Blood type is O positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, rubella immune, GBS negative. 2. Mother's medical history is notable for epilepsy, currently on no medications. 3. Past obstetrical history notable for vaginal deliveries in [**2166**], and [**2173**]. This pregnancy was conceived by IVF with an estimated date of confinement of [**2176-12-2**]. Dichorionic diamniotic twins were noted on prenatal ultrasound. The pregnancy was complicated by incompetent cervix and preterm labor. Mother was hospitalized [**2176-7-9**], to [**2176-7-13**], for cervical incompetence at which point a cerclage was placed and the mother was started on indomethacin and Nifedipine. She was readmitted again on [**2176-8-4**], for recurrent preterm labor. She was beta complete at 24 weeks. On the day of delivery, the mother presented in spontaneous labor. She was allowed to progress with Pitocin augmentation. Rupture of membranes occurred five hours prior to delivery with clear fluid. She received one dose of Clindamycin for unknown GBS status. She received epidural anesthesia. There was no maternal fever or fetal tachycardia. The infant was born by spontaneous vaginal delivery. Apgar was seven at one minute and eight at five minutes. She was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit, weight was 1.895 kilograms, 25th to 50th percentile, length 41 centimeters and 10th percentile, head circumference 29 centimeters and 10th percentile. General, the infant is a nondysmorphic infant in no acute distress. Head, eyes, ears, nose and throat - anterior fontanelle is soft and flat. Eyes with red reflux visualized both. Ears normally set without anomalies. Palate intact. Clavicles intact. Neck supple. Chest - The lungs are clear to auscultation, equal breath sounds, some periodic breathing. Cardiovascular - regular rate and rhythm, no murmur, 2+ femoral pulses. The abdomen is soft, positive bowel sounds, no hepatosplenomegaly. Genitourinary - normal female, patent anus. Spine - no sacral anomalies. Extremities - hips stable. Extremities are pink and well perfused. Neurologic - normal and symmetrical tone and activity. HOSPITAL COURSE: 1. Respiratory - [**Known lastname **] required blow by oxygen briefly at the time of admission and then weaned to room air. She has been in room air her entire Neonatal Intensive Care Unit admission. She has not had any episodes of spontaneous apnea or bradycardia. 2. Cardiovascular - A soft murmur was heard on day of life two and has continued to be heard intermittently. It is consistent with peripheral pulmonic stenosis. No cardiovascular sx or compromise. WIll need routine follow-up by pediatrician. 3. Fluids, electrolytes and nutrition - [**Known lastname **] has p.o. feeds from day of life one. She has been breast feeding and bottle feeding, taking in greater than 130cc per kilogram per day. We supplemented her calories to 24 calories per ounce to facilitate growth. Her discharge weight is 1.87 kilograms. 4. Infectious disease - Due to the unknown GBS status of the mother and prematurity, [**Name (NI) **] was evaluated for sepsis. A white blood cell count was 11.2 with a differential of 25% polys, 0% bands. A blood culture was obtained prior to starting intravenous Ampicillin and Gentamicin. The blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. Gastrointestinal - Peak serum bilirubin occurred on day of life one with a total of 6.6/0.3 mg/deciliter with subsequent repeat levels lower with one most recently on [**2176-10-30**], of a total of 3.6/0.3 direct. She did not receive any treatment. 6. Neurologic - [**Known lastname **] has maintained a normal neurological examination during admission and there were no neurological concerns at the time of discharge. 7. Sensory - Hearing screening was performed with automated auditory brain stem responses. The infant passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) 8170**], [**Apartment Address(1) 50442**], [**Location (un) **], [**State 350**], telephone [**Telephone/Fax (1) 39087**]. CARE AND RECOMMENDATIONS AT DISCHARGE: 1. Breast feedings or ad lib p.o. feedings, breast milk four to five to 24 calories per ounce with Enfamil powder or Enfamil 24 calorie formula. 2. No medications. 3. Car Seat Position screening was performed. The infant was observed for ninety minutes in her car seat without any oxygen or heart rate drop. 4. State Newborn Screen was sent on day of life three and repeat on [**2176-11-2**]. No notification of abnormal results to date. 5. Immunizations Received - Hepatitis B vaccine administered on [**2176-11-2**]. 6. Immunizations Recommended: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet either of the following three criteria: a. Born at less than 32 weeks. b. Born between 32 and 35 weeks with two or more of the following plans for Day Care during RSV season, with a smoker in the household, neuromuscular disease, airway abnormalities or with school siblings. c. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. 7. Follow-up Appointments - With primary pediatrician, Dr. [**Last Name (STitle) **], within three days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 34 and 3/7 weeks gestation. 2. Twin I of twin gestation. 3. Suspicious for sepsis ruled out. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2176-11-2**] 07:50 T: [**2176-11-2**] 09:10 JOB#: [**Job Number 50443**]

Admission Date: [**2123-12-21**] Discharge Date: [**2123-12-30**] Date of Birth: [**2055-4-8**] Sex: F Service: MEDICINE Allergies: Lipitor / Sulfa (Sulfonamides) / Clarithromycin / Epinephrine / Thiopental / Tetanus / Shellfish / Iodine; Iodine Containing Attending:[**First Name3 (LF) 2297**] Chief Complaint: Transferred from OSH for Trach + PEG MICU Transfer: Pneumonia on vent Major Surgical or Invasive Procedure: -tracheostomy -G-tube placement -right thoracentesis History of Present Illness: 68F h/o 02-dependent COPD, chronic hypercapneia, s/p mult admits in last 6mo's COPD exacerbations, though never intubated until current admission, who was transferred to [**Hospital1 18**] for trach and PEG on [**2123-12-22**]. On arrival to [**Hospital1 18**], pt spiked fever to 103. Workup of the fever revealed severe RLL as well as large, loculated R pl. effusion (see full report below). Trach and PEG postponed to treat these issues. Pt being transferred to MICU service for management and tx of PNA. . Relevant recent hx includes admission to [**Hospital6 **] on [**2123-12-12**] w/ hypercarbic resp failure & MS changes. Admission ABG on [**2123-12-12**] was 7.13/>115/64 on [**1-5**] of BiPAP. She was treated w/ IV steroids, abx, and lasix. She was thought to have COPD exacerbation & PNA, as well as possible CHF exacerbation. Pt failed BiPAP & required intubation. A triple lumen R-IJ was placed on [**2123-12-14**] in the setting of hypotension: she reportedly had SBP into the 80s & required pressors for a short period--dopamine initially (which made her tachycardic) then vasopressin. Cause for her hypotension is unclear. [**Name2 (NI) **] sputum from [**12-13**] grew pseudomonas (sensitive to gent, tobra, cefepime, imipenem, and zosyn). Because of this cx data, her abx were changed from levoflox to cefepime. Bld cx's there were w/o growth. Pt was started on TF via NGT. . Despite tx, pt was unable to be weaned off of vent. ABG on [**2123-12-21**] was 7.36/83/78 on AC [**1-5**], TV 450, Fi02 45%. Given overall picture, pt evaluated for trach & PEG at OSH; however, it was felt that she would be high risk for procedure given her kyphosis & body habitus, so she was transferred here for intervention. . On arrival to [**Hospital1 18**], pt was con't on cefepime for tx of PNA as well as IV steroids & nebs for COPD and dilt gtt for rapid afib. The day following admission, [**2123-12-22**], WBC 20 (up from 15 day prior) and pt febrile to 103. She was started on vanc in addition to cefepime. She underwent chest CT which showed PNA w/ large, complex effusion. Additionally, CT showed possible filling defect in pulm artery, for which CTA was recommended to further eval. However, b/c of pt's allergy to iodine, she did not undergo CTA. Pt underwent flex bronch on [**12-23**], which showed small white exophytic playw in RML (likely aspirated food). Biopy x2 of RML orifice and BAL of LLL performed. PPD performed--result pending. . Pt currently c/o dyspnea--stable since admission. She has had moderate amount of secretions. Her afib has improved w/ regard to rate control. She was transitioned off dilt gtt and controlled with dilt PO. . ROS: Pt notes no pain, including CP. Fever y'day. Feels "scared" about all that is going on medically. This is her first time being intubated. She feels like she needs lasix. No LE swelling, She notes that she only has diabetes while on steroids. Past Medical History: -COPD 02 dependent, chronic hypercapnia, never intubated prior to current admission -mild CHF-->LVED 40-45% on OSH echo -mild pulm HTN w/ PA pressure of 35mmhg by OSH echo -P-Afib-->not on coumadin, unclear why not -[**Name (NI) 15764**]>pt reports this is only present while on steroids -kyphosis -PVD w/ LE ulcers Physical Exam: VS: T: HR: 87 (70-110s) BP: 130/50 RR: 19 Sat: 96 on AC 15/8, 0.45 Gen: awake, alert, oriented x3, mouthing words/writing to communicate, sl uncomfortable appearing HEENT: NCAT, PERRL, sclera anicteric Neck: Supple, no LAD, no JVD CV: RRR S1/S2, no m/r/g Resp: Roncherus w/ exp wheezes throughout anterior fields Abdomen: Soft, NTND, BS+ Ext: Trace LE edema DP pulses are 2+ bilaterally Neuro: A + O x 3, CN II-XII grossly intact, Motor [**6-5**] both upper and lower extremities Skin: B/l LE healed scars from old wounds/ulcers; scattered ecchymoses on b/l feet. Skin warm. Pertinent Results: [**2123-12-21**] 08:21PM WBC-15.7* RBC-3.96* HGB-11.4* HCT-34.7* MCV-88 MCH-28.8 MCHC-32.9 RDW-16.3* [**2123-12-21**] 08:21PM NEUTS-88* BANDS-0 LYMPHS-5* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2123-12-21**] 08:21PM GLUCOSE-295* UREA N-18 CREAT-0.4 SODIUM-134 POTASSIUM-4.6 CHLORIDE-88* TOTAL CO2-42* ANION GAP-9 [**2123-12-21**] 08:21PM CALCIUM-8.9 PHOSPHATE-2.2* MAGNESIUM-2.0 [**2123-12-21**] 08:47PM TYPE-ART PO2-58* PCO2-47* PH-7.52* TOTAL CO2-40* BASE XS-13 Brief Hospital Course: 68F h/o severe COPD, vent-dependent, planned for trach & PEG on admission deferred after finding MRSA LLL PNA + B pleural effusions (L>R), treated with vanc/cefepime, also on heparin gtt for PE. . # MRSA Pneumonia: Pt was found to have LLL pneumonia, initially considered CAP vs. nosocomial as pt had been transferred from [**Hospital6 **] after being admitted there from home w/ PNA, and because pt had been vented for over a week before transfer. Pt received cefepime for pseudomonal coverage per OSH cultures, and was started on vancomycin for MRSA in sputum. She should be continued on vancomycin and cefepime until [**1-1**]. . # Respiratory distress: Pt originally intubated at OSH because of hypercarbic failure related to severe COPD, PNA, and pleural effusions. Pt found to have bilateral pleural effusions likely [**3-5**] chronic process, and possibly related to previous infection (considered unlikely acute empyema). Because of PNA, pt initially continued on vent. A right-sided thoracentesis was performed on [**2123-12-27**] seeking to drain an effusion; this was complicated by the development of a pneumothorax which required the placement of a chest tube. Bedside tracheostomy was subsequently performed by interventional pulmonology on [**2123-12-28**]. . # Pulmonary embolism: CT w/o contrast demonstrated filling defect in pulmonary artery. Pt administered heparin gtt and to r/o possible future PE source, bilateral lower extremity ultrasounds were obtained and confirmed no DVTs. Pt's outpatient mgt will require long-term anticoagulation. Anticoagulation was held briefly in anticipation of her multple procedures; warfarin was re-started on [**2123-12-29**]. INR 1.3 on [**2123-12-30**]. . # COPD, possible exacerbation: Pt's baseline pulmonary function marked by severe COPD with hypercarbia & baseline 02 requirement. Pt was therefore maintained on nebulizers and guaifenesin, and was started on methylprednisolone (Solumedrol) IV at 40mg IV q8h, which was tapered to 20mg q8h. Before [**12-27**] procedure, pt was maintained on stress-dose steroids. On [**2123-12-29**], she was transitioned to 15 mg daily of PO prednisone. This dose may be tapered as follows: 15mg on [**12-31**], 10mg on [**1-1**], 5mg on [**1-2**], 3mg on [**1-3**] mg on [**1-3**] and then discontinue. . # CHF: Pt uses furosemide 60mg daily as home regimen for baseline CHF, and was restarted on furosemide 60mg QOD to maximize respiratory capacity and was increased to 60mg PO daily. She should continue on lasix 60mg PO daily. . # Type II DM: Per pt, elevated glucose only when steroids used. Pt was initially placed on insulin gtt, which was then changed to NPH 30units x1 dose AM after MICU transfer. NPH was titrated to control sugars Fs<150, and as of [**12-29**], was 20 units [**Hospital1 **]. This may require adjustment as steroids are tapered and eventually discontinued. . # AFib: Patient was rate-controlled initially on diltiazem gtt and later on diltiazem PO. Anticoagulation was held in the setting of surgial procedures but restarted on [**2123-12-29**]. Continue warfarin and titrate to INR 2.0-3.0. . # Nutrition: Nutrition was consulted and recommended tube feeds as follows: Half strength Nutren 2.0 at 50ml/hour with 15g Benepro, 1251kcal, 61g protein. Medications on Admission: Medications on Transfer: Diltiazem 10 mg/hr IV DRIP INFUSION Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **] Ipratropium Bromide MDI 8 PUFF IH QID Miconazole Powder 2% 1 Appl TP [**Hospital1 **] Acetaminophen 650 mg PO/PR Q6H:PRN Albuterol 8 PUFF IH Q6H:PRN Lorazepam 2-4 mg PO/IV Q4H:PRN Morphine Sulfate 2-4 mg IV Q1H:PRN Insulin SC Heparin 5000 UNIT SC TID Famotidine 20 mg PO BID CefePIME 1 gm IV Q8H Dexamethasone 4 mg IV Q6H Tobramycin-Dexamethasone Ophth Oint 1 Appl BOTH EYES QID Digoxin 0.25 mg IV DAILY Metoprolol 5 mg IV Q2-3H PRN Ibuprofen Suspension 400 mg NG Q6H:PRN pain Vancomycin 1000 mg IV Q 12H Ibuprofen Suspension 400 mg NG Q6H:PRN pain Discharge Medications: 1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal TID (3 times a day) as needed. 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 4. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please monitor INR until stable. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): Hold for loose stools. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 10. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML Inhalation q6hr prn () as needed for SOB, wheezing. 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO WITH DRESSING CHANGES () as needed for Administer 30 min prior to dressing changes. 12. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection four times a day: Per sliding scale. 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous twice a day: [**Month (only) 116**] require titration as prednisone is tapered. 14. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 16. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 1 days: To be followed by 10mg daily for 1 day then 5 mg daily for 1 day then 3mg daily for 2 days then discontinue. 18. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 days: TO be completed on [**2124-1-1**]. 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): To be completed on [**2124-1-1**]. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital Discharge Diagnosis: Primary Diagnoses -ventilator dependent COPD -MRSA LLL PNA and bilateral pleural effusions -tension pneumothorax -question of PE Secondary Diagnoses -CHF -diabetes -atrial fibrillation Discharge Condition: Good; Discharge Instructions: You are being transferred to a rehabilitation facility for further care and treatment to improve your breathing over the long-term. While at the rehab, be sure to alert your caregivers should you experience any fever, chills, chest pain or pressure, shortness of breath, nausea, vomiting or change in your bowel or urinary functions. Followup Instructions: Schedule a follow-up appointment with Dr. [**Last Name (STitle) 1693**] when you are discharged from your rehabilitation facility. . You were given the number for pulmonology clinic at [**Hospital1 771**]. Call ([**Telephone/Fax (1) 513**] to make an appointment.

Admission Date: [**2120-2-14**] Discharge Date: [**2120-2-24**] Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: The patient is an 86-year-old woman with a history of hypothyroidism, B12 deficiency, referred by her primary care provider for evaluation of her chest pain with exertion which lasted five to ten minutes each time resolving with rest. No nausea, vomiting, or palpitations. No headache or dizziness. No recurrent symptoms since the episode. The patient was referred to the Emergency Department, afebrile, vital signs stable. The patient had an EKG which showed possible anterior infarct of undetermined age and ruled out for an MI with negative enzymes. A stress echo showed reversible ischemia. The patient was admitted for a catheterization. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Levoxyl 50 micrograms q.d. five times a week, 75 micrograms q.d. two times a week. 2. Vitamin B12 1 gram IM q. month. 3. Calcium carbonate q.d. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Vitamin B12 deficiency. 3. No history of coronary artery disease, hypertension, or hypercholesterolemia. SOCIAL HISTORY: The patient is a nonsmoker. Social drinker. PHYSICAL EXAMINATION ON ADMISSION: Heart: On admission, the patient had a regular rate and rhythm. Lungs: Clear to auscultation. LABORATORY DATA/STUDIES: White count 7.4, hematocrit 34.3, 02 saturations within normal limits. The cardiac enzymes negative. Chest x-ray showed no failure, no infiltrates, no effusions. Normal size heart. Hyperinflated lungs consistent with COPD. Echocardiogram showed positive regional LV systolic dysfunction with mid to distal anteroseptal, mid to distal anterior and apical akinesis, moderate MR, no AR, worsening basilar anterior wall motion with exercise. EF 35-40%. HOSPITAL COURSE: The patient was admitted for catheterization which she underwent on hospital day two. It showed left main stenosis with three vessel disease. The patient was asymptomatic at present. There were some issues with obtaining type and cross and, therefore, this surgery was postponed until hospital day number five. She underwent a CABG times three. She tolerated the procedure well. She was transferred to the unit. Postoperatively, she was extubated and transferred to the floor on postoperative day number one. The patient continued to have an uncomplicated hospital course having only a couple of very short episodes of A fib lasting less than one minute which spontaneously converted back to sinus with p.o. medications. By postoperative day number five, the patient was tolerating a regular diet, ambulating well, and having good p.o. pain control. The patient was felt to be ready for discharge to her [**Hospital3 **] facility with VNA. She will follow-up with Dr. [**Last Name (STitle) **] in four weeks and her primary care provider in one to two weeks and with the cardiologist in two to three weeks. DISCHARGE MEDICATIONS: 1. Lopressor 12.5 mg b.i.d. 2. Zantac 150 mg q.d. until follow-up with the surgeon. 3. Levothyroxine 75 micrograms Wednesday and Saturday, 50 micrograms Sunday, Monday, Tuesday, Thursday, and Friday. 4. Percocet one to two tablets p.o. q. four to six hours p.r.n. 5. Tylenol 650 mg q. four to six hours p.r.n. 6. Enteric coated aspirin 325 mg q.d. 7. Colace 100 mg b.i.d. 8. Milk of magnesia 30 milliliters q.h.s. p.r.n. 9. Lasix 20 mg b.i.d. times seven days. 10. Potassium chloride 20 mEq b.i.d. times seven days. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To an [**Hospital3 **] facility with VNA. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft times three; left internal mammary artery to the left anterior descending artery, saphenous vein graft to the diagonal and obtuse marginal. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2120-2-24**] 07:19 T: [**2120-2-24**] 19:36 JOB#: [**Job Number 110556**] cc:[**Initial (NamePattern1) 110557**]

Admission Date: [**2128-4-17**] Discharge Date: [**2128-4-21**] Date of Birth: [**2063-11-19**] Sex: M Service: MEDICINE Allergies: Seroquel / Ibuprofen / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2485**] Chief Complaint: Mental status change Major Surgical or Invasive Procedure: none History of Present Illness: 64 M rehab resident with history of DM2, ESRD on HD, CHF, HTN, AFIB, was picked up in ambulance to go to HD today and patient became acutely SOB and confused, repeatedly calling out for his brother [**Name (NI) **], and ambulance was diverted to [**Hospital1 18**] ED. HD was skipped today; last HD was on Thurs. . In the ED, patient had labored breathing but normal VS, T 97.0, 75, 106/52, 20, 99% 2Lnc. ABG: 7.69 / 15 / 127 / 19. Serum HCO3 15. CXR negative with no pulmonary edema, no infiltrate. CTA chest negative. CT head negative. EKG with no previous shows severe AFIB, Q waves II, III, F, V1-V3, IVCD. CK 17, Trop 0.34 likely from renal disease. . In the ED, patient was yelling for [**Doctor Last Name **] and yelling for the nurse, alternating between getting agitated and calming down. TSH pend. Serum tox negative for ASA. Had two blood cxs from PIV and one blood cx from HD cath. Concern for performing LP since patient has large sacral decub. Gets HD at [**Hospital3 5097**] TThS. Received Haldol 5 IV, Ceftriaxone 2g IV, Vanco 1g IV, Acyclovir 800 IV over 1 hr, Ativan 1 mg IV. . Labs from [**2128-4-13**]: K 5.0, BUN 60, Ca 9.4, Phos 3.2, Albumin 2.5, TG 197, Fluid gains 2.2 kg, weight 146.7 kg. Past Medical History: DM2 ESRD on HD TThS CHF HTN AFIB L BKA Social History: No ETOH, no smoking, no IVDU. Family History: Unknown. Physical Exam: ADMISSION EXAM: 97.7 / 139/92 / 101 / 24 / 100% 1Lnc GEN: Delirious, calling out for [**Doctor Last Name **] and nurse, right hand shaking tremor, obese HEENT: Cannot assess JVD, 2 mm minimally reactive, OP dry with poor dentition LUNGS: Rhonchorous bilaterally HEART: Irregularly irregular ABD: Soft, +BS, ND NT, obese. PEG tube in place. EXTR: 4+ pitting edema NEURO: [**4-10**] motor . . DISCHARGE EXAM: AF BP 143/66 P 66 RR 20 O2: 100% 2L NC GEN: Alert and oriented, cooperative, appropriate HEENT: PERRL, EOMI. OP with MMM and poor dentition NECK: Cannot assess JVD due to body habitus. LUNGS: Distant breath sounds bilaterally, good air movement. CHEST: Left SCL HD line in place HEART: Irregularly irregular ABD: Soft, +BS, ND/NT, obese. PEG tube in place. EXTR: 2+ pitting edema NEURO: [**4-10**] motor Pertinent Results: [**2128-4-17**] 03:10PM PT-12.3 PTT-31.6 INR(PT)-1.1 [**2128-4-17**] 03:10PM WBC-9.1 RBC-4.50* HGB-12.9* HCT-38.7* MCV-86 MCH-28.7 MCHC-33.4 RDW-19.3* [**2128-4-17**] 03:10PM NEUTS-71.6* BANDS-0 LYMPHS-21.7 MONOS-2.6 EOS-2.5 BASOS-1.6 [**2128-4-17**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2128-4-17**] 03:10PM TSH-2.7 [**2128-4-17**] 03:10PM ACETONE-SMALL [**2128-4-17**] 03:10PM CALCIUM-9.6 PHOSPHATE-2.5* MAGNESIUM-1.7 [**2128-4-17**] 03:10PM CK-MB-3 [**2128-4-17**] 03:10PM cTropnT-0.34* [**2128-4-17**] 03:10PM LIPASE-10 [**2128-4-17**] 03:10PM ALT(SGPT)-25 AST(SGOT)-20 CK(CPK)-17* ALK PHOS-376* AMYLASE-17 TOT BILI-0.2 [**2128-4-17**] 03:10PM GLUCOSE-91 UREA N-47* CREAT-4.4* SODIUM-138 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-15* ANION GAP-23 [**2128-4-17**] 03:31PM LACTATE-2.4* K+-4.0 [**2128-4-17**] 05:11PM TYPE-ART TEMP-37.2 O2-100 O2 FLOW-2.5 PO2-127* PCO2-15* PH-7.69* TOTAL CO2-19* BASE XS-1 AADO2-589 REQ O2-94 INTUBATED-NOT INTUBA . CXR [**4-17**]: Findings consistent with increased volume status, but no overt pulmonary edema. . CTA chest [**4-17**]: 1. No evidence for pulmonary embolus or other explanation for shortness of breath. 2. Incidentally noted 4-mm left lower lobe pulmonary nodule for which a one-year followup is recommended in the absence of known malignancy. . CT head [**4-17**]: There is no intracranial hemorrhage. The ventricles, cisterns, and sulci are prominent secondary to brain atrophy. There is no mass effect or shift of normally midline structures and [**Doctor Last Name 352**]-white matter differentiation is preserved. Periventricular white matter hypodensities are the sequelae of small vessel infarction. There is atherosclerotic disease of the cavernous carotids. The visualized paranasal sinuses are clear. . EKG: AFIB 65, demand pacing, Q waves II, III, F, V1-V3, IVCD. . [**2128-4-17**] 3:10 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Final [**2128-4-21**]): BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE. bld cx [**4-17**], [**4-19**], [**4-20**]: NGTD . [**2128-4-18**] 10:22 am SACRAL SWAB GRAM STAIN (Final [**2128-4-18**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Final [**2128-4-20**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. ENTEROCOCCUS SP.. SPARSE GROWTH. GRAM NEGATIVE ROD #1. RARE GROWTH. GRAM NEGATIVE ROD #2. ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. [**2128-4-18**] 2:54 pm BKA stump SWAB **FINAL REPORT [**2128-4-20**]** GRAM STAIN (Final [**2128-4-18**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2128-4-20**]): CITROBACTER KOSERI. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Trimethoprim/Sulfa sensitivity testing available on request. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 8 R TOBRAMYCIN------------ <=1 S Brief Hospital Course: 64 M rehab resident with history of DM2, ESRD on HD, CHF, HTN, and AFIB who presented with with acute mental status change on the way to HD, found to have acute respiratory alkalosis and metabolic acidosis, as well as GNR bacteremia. Hospital course by problem below: . #. GNR sepsis: He had an episode of hypothermia, hypotension, and GNR bacteremia. Most likely source is sacral decubitus ulcer. Repeat blood cultures were no growth to date. Initial culture is preliminarly B.fragilis. Wound swabs were sent for culture, as well as MRSA screens. He was covered broadly with renally-dosed vanco, zosyn, and gent (gram positives and double coverage for pseudomonas). His wound grew citrobacter, resistant to piperacillin. He was switched to ciprofloxacin, and should continue a total 14 day course of antibiotics. . # Mental status change: This was thought to be due to infection as above, acute on chronic psychiatric symptoms, and alkalosis with pH 7.69. Repeat blood gas was significantly improved. Serum tox screen was negative; due to baseline anuria, urine tox screen was not able to be obtained. LP was deferred due to sacral ulcer overlying site. His valproate level was 22, but the medication is given for agitation and mood disorder. Psych was [**Month/Day/Year 4221**] for agitation and recommended haldol IV prn. His mental status improved by discharge. . # Respiratory alkalosis: This was noted on admission, and was thought to be due to compensation for metabolic acidosis, question from uremia vs. sepsis. Repeat blood gas was improved. . # ESRD on HD: Patient with anion gap metabolic acidosis on admission. This improved with hemodialysis. He was last dialyzed on [**4-21**]. . # DM2: He was continued on his outpatient lantus and glargine. . # HTN: Metoprolol was held in house due to hypotension. On discharge he was hypertensive, and this was restarted with hold parameters. . # AFIB: He received metoprolol for rate control. The patient is not on coumadin because he does not want frequent blood draws. He is also s/p pacer. . # Wound Care: The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] re his stage IV ulcers. He is to receive wound care as an outpatient, and frequent repositioning. . # PEG: His PEG tube material was hemooccult positive. He was continued on [**Hospital1 **] PPI. He is to continue receiving daily flushes, although he is no longer relying on tube feeds for adequate pos. . # LLL Lung nodule: 4 mm nodule was found incidentally on CT scan. The radiologists recommended one-year follow-up. . #. FEN: He was given a renal, diabetic, cardiac diet. . #. PPX: PPI, heparin sc, bowel regimen . #. CODE: He is DNR/[**Hospital 24351**] hospice care only but with exception of dialysis per paperwork and discussion with Dr. [**Last Name (STitle) 53939**] at [**Hospital 228**] nursing home. . #. COMMUNICATION: Brother [**Name (NI) 73171**] [**Name (NI) **]: [**Telephone/Fax (1) 73172**]. Brother [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 73173**]. ?Power of attorney [**First Name8 (NamePattern2) **] [**Known lastname **]: [**Telephone/Fax (1) 73174**] . #. ACCESS: HD cath in LIJ, pacer on R chest Medications on Admission: NPH insulin 10 units sc QAM, 8 units sc Q4:30 pm Fentanyl 50 mcg patch and 25 mcg patch Reglan 5 per PEG TID prn Tylenol #3 2 tabs [**Hospital1 **] Colace Vitamin C 500 [**Hospital1 **] Metoprolol 12.5 [**Hospital1 **] Valproic acid 250 via PEG Q8H Ativan 0.5 QHS Nephrocaps daily ASA 81 daily Nexium 40 daily Heparin sc NTG sl prn Albuterol prn Ativan 0.5 Q4H prn MOM Dulcolax prn Fleet prn Tylenol #3 prn . ALLERGIES: Bactrim, Motrin, Seroquel Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous QHD for 4 doses: last given on [**4-21**]. 14. Gentamicin 40 mg/mL Solution Sig: One (1) Injection QHD (each hemodialysis) for 4 doses: last given on [**4-21**]. 15. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day as needed: per sliding scale. 16. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 17. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed. 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: Hold for SBP <100 or P <60. 19. Insulin Glargine 100 unit/mL Solution Sig: One (1) unit Subcutaneous twice a day: Given 10 units QAM and 8 units QPM. 20. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: 1. altered mental status 2. gram negative rod bacteremia .... 3. sacral decubitus ulcer - stage IV 4. ESRD on HD 5. DM2 6. HTN 7. AFib Discharge Condition: afebrile, oriented, alert Discharge Instructions: You were hospitalized for altered mental status. You were found to have bacteria in your blood, and were started on antibiotics for this. You underwent hemodialysis on [**4-19**] and [**4-21**]. . Please call the [**Hospital1 18**] micro lab tomorrow for exact speciation of organisms at [**Telephone/Fax (1) 73175**]. Followup Instructions: to be arranged after discharge from acute rehab

Admission Date: [**2196-5-10**] Discharge Date: [**2196-5-12**] Date of Birth: [**2123-11-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none this admission -coronary artery bypass grafts x 2(LIMA-LAD,SVG-OM),mitral valve replacement(27mm St. [**Male First Name (un) 923**] Epi tissue),MAZE [**2196-4-22**] History of Present Illness: 72 yo male underwent MVR(27mm St. [**Male First Name (un) 923**] porcine)/CABGx2(LIMA-LAD, SVG->OM)/MAZE on [**2196-4-22**] who presented to ED from rehab with acute SOB. Found to have a Hct of 13. Hemodynamically stable. Had previously been on Coumadin for afib. Being admitted to [**Date Range **] for workup for low Hct. Past Medical History: Rheumatic heart disease Mitral Stenosis Atrial Fibrillation (new onset) Colonic Polyps, Adenomatous Erectile Dysfunction Social History: Race: Caucasian Last Dental Exam: 1-2 months ago (had extraction for infected tooth) Lives with: Alone, has 3 grown children Occupation: Retired mechanical engineer Tobacco: Denies ETOH: Rare Family History: Father s/p MI age 65, mother with valvular heart disease and died during childbirth; brother died of ?[**Last Name **] problem age 65 Physical Exam: VSS NAD, A&Ox3 PERRL breath sounds decreased (B)bases Abd benign (B)LE edema Sternal wound-steris intact. Pertinent Results: [**2196-5-10**] 07:25PM BLOOD WBC-2.6*# RBC-1.31*# Hgb-3.9*# Hct-13.0*# MCV-100* MCH-30.1 MCHC-30.2* RDW-15.0 Plt Ct-148* [**2196-5-12**] 04:35AM BLOOD WBC-5.3 RBC-2.94* Hgb-9.3* Hct-28.4* MCV-96 MCH-31.6 MCHC-32.8 RDW-15.4 Plt Ct-272 [**2196-5-12**] 04:35AM BLOOD PT-17.4* INR(PT)-1.6* [**2196-5-10**] 09:05PM BLOOD PT-31.4* PTT-38.1* INR(PT)-3.1* [**2196-5-12**] 04:35AM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-138 K-3.8 Cl-103 HCO3-26 AnGap-13 [**2196-5-10**] 07:25PM BLOOD Glucose-75 UreaN-19 Creat-0.7 Na-143 K-2.8* Cl-116* HCO3-18* AnGap-12 [**2196-5-12**] 04:35AM BLOOD ALT-76* AST-35 LD(LDH)-228 AlkPhos-89 TotBili-0.5 [**2196-5-10**] 11:55PM BLOOD ALT-94* AST-54* LD(LDH)-238 AlkPhos-105 TotBili-0.3 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 86257**], [**Known firstname 86258**] [**Hospital1 18**] [**Numeric Identifier **]Portable TTE (Complete) Done [**2196-5-11**] at 1:07:54 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2123-11-11**] Age (years): 72 M Hgt (in): 66 BP (mm Hg): 122/48 Wgt (lb): 170 HR (bpm): 55 BSA (m2): 1.87 m2 Indication: Pericardial effusion. S/p MVR/MAZE. ICD-9 Codes: 423.9, 424.1, 424.0, 424.2 Test Information Date/Time: [**2196-5-11**] at 13:07 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 8154**] Bzymek, RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2010W000-0:00 Machine: Vivid q-1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.40 >= 0.29 Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Stroke Volume: 82 ml/beat Left Ventricle - Cardiac Output: 4.52 L/min Left Ventricle - Cardiac Index: 2.42 >= 2.0 L/min/M2 Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Arch: 2.5 cm <= 3.0 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 29 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - Mean Gradient: 4 mm Hg Mitral Valve - E Wave: 2.1 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 3.50 TR Gradient (+ RA = PASP): *32 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. No LA mass/thrombus (best excluded by TEE). LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal diastolic septal motion/position consistent with RV volume overload. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal descending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Filamentous strands on the aortic leaflets c/with Lambl's excresences (normal variant). Trace AR. MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated, with normal leaflet/disc motion and transvalvular gradients. No MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Significant PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Frequent atrial premature beats. Conclusions The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 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. There are filamentous strands on the aortic leaflets suggestive of Lambl's excresences (normal variant (clip [**Clip Number (Radiology) **]; cannot excluded vegetations if clinically suggested). Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. No mitral regurgitation is seen (may be UNDERestimated by acoustic shadowing). Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Well functioning bioprosthetic mitral prosthesis. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Pulmonary artery hypertension. Likely Lambls on the aortic valve. No pericardial effusion. Compared with the prior study (images reviewed) of [**2196-1-26**], the mitral valve has been replaced with a normal functioning bioprosthesis, the right ventricular cavity is smaller, and the estimated pulmonary artery systolic pressure is lower. CLINICAL IMPLICATIONS: Based on [**2192**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis IS recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2196-5-11**] 15:24 ?????? [**2188**] CareGroup IS. All rights reserved. Brief Hospital Course: 72 yo male who underwent MVR(27mm St. [**Male First Name (un) 923**] porcine)/CABGx2(LIMA-LAD, SVG->OM)/MAZE on [**2196-4-22**] presented to ED from rehab with acute SOB. Found to have a Hct of 13. Hemodynamically stable. Had previously beenon Coumadin for afib. Was admitted to [**Date Range **] for workup for low Hct. Repeat labs revealed the first HCT to be erroneous.Repeat HCT=28. Chest/Abd CT scan was performed to rule out pulmonary embolism. Scan was negative, however showed bilateral pleural effusions. He was placed back on diuresis with resolving dyspnea. He continued to progress and anticoagulation with Coumadin for postoperative atrial fibrillation was resumed. Transesophageal echo for cardiac tamponade was negative. On HD# 3 readmit Mr.[**Known lastname **] was cleared by Dr.[**Last Name (STitle) 914**] for discharge to home with VNA. All follow up appointments were advised. Dr.[**Last Name (STitle) **],[**Doctor Last Name **] J (PCP) was contact[**Name (NI) **] to follow INR/Coumadin dosing. Medications on Admission: Aspirin 81 mg [**Name (NI) 8426**], Delayed Release (E.C.) Sig: One (1) [**Name (NI) 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 [**Name (NI) 8426**], Delayed Release (E.C.)(s)* Refills:*2* Coumadin 2.5 mg [**Name (NI) 8426**] Sig: as directed [**Name (NI) 8426**] PO once a day: INR goal 2-2.5. Disp:*100 [**Name (NI) 8426**](s)* Refills:*2* Acetaminophen 325 mg [**Name (NI) 8426**] Sig: Two (2) [**Name (NI) 8426**] PO Q4H (every 4 hours) as needed for fever/pain. Disp:*120 [**Name (NI) 8426**](s)* Refills:*0* Oxycodone-Acetaminophen 5-325 mg [**Name (NI) 8426**] Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 [**Name (NI) 8426**](s)* Refills:*0* Lisinopril 5 mg [**Name (NI) 8426**] Sig: Two (2) [**Name (NI) 8426**] PO DAILY (Daily). Disp:*60 [**Name (NI) 8426**](s)* Refills:*2* Amiodarone 200 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO BID (2 times a day): one [**Name (NI) **] twice daily for 4 weeks then one daily until instructed otherwise. Disp:*60 [**Name (NI) 8426**](s)* Refills:*2 Discharge Medications: 1. Furosemide 40 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO DAILY (Daily). Disp:*30 [**Name (NI) 8426**](s)* Refills:*2* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg [**Name (NI) 8426**], Delayed Release (E.C.) Sig: One (1) [**Name (NI) 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 [**Name (NI) 8426**], Delayed Release (E.C.)(s)* Refills:*2* 5. Warfarin 1 mg [**Name (NI) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily): INR goal =2.-2.5 for atrial fibrillation. Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2* 6. Warfarin 2.5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for 1 doses. Disp:*1 [**Last Name (Titles) 8426**](s)* Refills:*0* 7. Pantoprazole 40 mg [**Last Name (Titles) 8426**], Delayed Release (E.C.) Sig: One (1) [**Last Name (Titles) 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 [**Last Name (Titles) 8426**], Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Shortness of breath Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with **** Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema: RLE>LLE Discharge Instructions: 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. 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, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([**Telephone/Fax (1) 170**]). Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge of sternal wound. **Please call cardiac surgery office with any questions or concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call person during off hours.** Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [**Last Name (STitle) 914**] on Tuesday,[**5-31**] at 1:15pm Please call to schedule appointments with: Primary Care: Dr. [**Last Name (STitle) 59860**] [**Name (STitle) 86262**] ([**Telephone/Fax (1) 86263**]) in [**12-19**] weeks *Please call cardiac surgery office with any questions or concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call person during off hours.** Dr. [**Last Name (STitle) 59860**] [**Name (STitle) 86262**] #([**Telephone/Fax (1) 86263**])**will follow INR/Coumadin dosing Labs: PT/INR for Coumadin (atrial fibrillation) Goal INR:2-2.5 First draw: [**2196-5-13**] Completed by:[**2196-5-12**]

Admission Date: [**2177-12-5**] Discharge Date: [**2177-12-12**] Date of Birth: [**2106-8-2**] Sex: F Service: MEDICINE Allergies: Aspirin / Heparin Agents / Morphine / Tylenol Attending:[**First Name3 (LF) 943**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: NONE History of Present Illness: 71 F with DM, cirrhosis [**3-7**] NASH, h/o gastric angioectasia (GAVE/watermelon stomach) with GIB, ESRD on HD MWF, diastolic CHF, HIT, seizure dx on [**Month/Day (2) 13401**], admitted [**12-5**] to medical floor with altered mental status suspected [**3-7**] hepatic encephalopathy. She improved overnight with lactulose. On the evening of [**12-6**], she had transient hypotension to 68 systolic/doppler which responded to fluid bolus to 98 systolic. She was transfered to the ICU for monitoring. Her BP on admission to the hospital was 110/50 and her baseline from previous discharge summaries is approx 110/50. Her BP on admission the ICU was 104/40. . Blood and urine culutres were drawn on admission. Urine shows 6-10WBC with moderate bacteria, small leuks and a pH of 9.0. Blood cultures with no growth to date. She was started on ciprofloxacin 500mg po Q24 hours by her medicine team. A diagnostic paracentesis was not performed. CXR on [**12-5**] showed an increasing size of a suspected right sided pleural effusion. She is not hypoxic or dypneic. She was noted to be oozing from peripharl IVs, have guiac posative stool and an INR of 1.8. She got 1 unit of FFP while on the floor [**12-6**]. Past Medical History: Recent history includes multiple admissions in [**5-7**], and [**9-9**] for confusion in the setting of lactulose noncompliance. In [**5-10**], she was diagnosed with GIB from gastric angioectasias/watermelon stomach. She was also found to have a portal vein thrombosis on ultrasound but was not anticoagulated for h/o GAVE, GIB, HIT. . OTHER PMH: - Portal vein thrombosis [**5-10**] but not anticoagulated for h/o GAVE, GIB, HIT - Type 2 diabetes. - End-stage renal disease, on hemodialysis M/W/F - Cirrhosis [**3-7**] NASH. - Gastric angioectasia with h/o GI bleeding in 4/[**2177**]. - Diastolic CHF. EF>55% by echocardiogram in 7/[**2176**]. She has a prlonged mitral deceleration time and moderate MR. - ?right sided pleural effusion: diagnosed on U/S [**11/2176**], CXR showed a small effusion - stayed stable in subsequent imaging. - Heparin-induced thrombocytopenia, Ab+ in 1/[**2176**]. - History of seizure disorder, on [**Year (4 digits) 13401**]. - History of infection in the left knee. - History of MRSA and Clostridium difficile. - History of gram-positive rod bacteremia in 4/[**2177**]. - Status post ORIF of the left distal femur fracture in 12/[**2175**]. 11. Status post ORIF of the left distal femur fracture in 12/[**2175**]. Social History: Lives with family. Given recent admissions unclear if family capable of continued care. No current EtOH, tobacco or illicit drugs. Family History: Noncontributory. Physical Exam: Vitals on transfer from ICU to floor 98.1, 56, 95/36, 17, 99%/RA; I/O +3.3L in the ICU Tele showed Sinus Brady with occassional NSVT GENERAL: comfortable, in no acute distress. [**Year (4 digits) 4459**]: sclerae icteric, OP clear, MMM, EOMI HEART: [**4-8**] holo-systolic murmur, radiating to the axilla LUNGS: Clear to auscultation bilaterally, decreased on right BACK: No CVA tenderness ABDOMEN: Obese, soft, + bowel sounds, ND NT, unable to assess for organomegaly given habitus EXTREMITIES: 2+ edema bilaterally, 2+ DP pulses, LUE AV fistula with thrill NEURO: +asterixis, strength 5/5 bilateral lower extremities, [**6-7**] grip strength Pertinent Results: ON ADMISSION: [**2177-12-5**] 11:12AM BLOOD WBC-4.0 RBC-2.83* Hgb-10.0* Hct-31.7* MCV-112* MCH-35.2* MCHC-31.4 RDW-20.7* Plt Ct-59* [**2177-12-5**] 11:12AM BLOOD Neuts-71.2* Lymphs-15.8* Monos-5.8 Eos-6.8* Baso-0.3 [**2177-12-5**] 11:12AM BLOOD PT-19.2* PTT-40.8* INR(PT)-1.8* [**2177-12-5**] 11:12AM BLOOD Glucose-175* UreaN-24* Creat-5.2* Na-140 K-4.9 Cl-102 HCO3-28 AnGap-15 [**2177-12-5**] 11:12AM BLOOD ALT-12 AST-32 CK(CPK)-39 AlkPhos-161* Amylase-38 TotBili-5.9* [**2177-12-6**] 05:25AM BLOOD Albumin-2.3* Calcium-8.9 Phos-3.4 Mg-1.9 . CARDIAC ENZYMES [**2177-12-5**] 11:12AM BLOOD cTropnT-0.04* [**2177-12-6**] 05:25AM BLOOD cTropnT-0.04* [**2177-12-6**] 01:25PM BLOOD CK-MB-NotDone cTropnT-0.04* . WORK-UP [**2177-12-5**] 11:12AM BLOOD calTIBC-157* VitB12-1565* Folate-12.8 Ferritn-212* TRF-121* [**2177-12-5**] 11:12AM BLOOD Ammonia-287* [**2177-12-7**] 09:06AM BLOOD Lactate-2.3* [**2177-12-7**] 09:06AM BLOOD O2 Sat-95 [**2177-12-7**] 09:06AM BLOOD freeCa-1.05* . ON DISCHARGE: [**2177-12-12**] 04:20AM BLOOD WBC-4.1 RBC-2.36* Hgb-8.6* Hct-26.9* MCV-114* MCH-36.4* MCHC-32.0 RDW-19.4* Plt Ct-48* [**2177-12-12**] 04:20AM BLOOD PT-18.0* INR(PT)-1.7* [**2177-12-12**] 04:20AM BLOOD Glucose-124* UreaN-20 Creat-4.4* Na-138 K-4.2 Cl-107 HCO3-25 AnGap-10 [**2177-12-9**] 05:00AM BLOOD ALT-11 AST-33 LD(LDH)-247 AlkPhos-138* TotBili-3.9* [**2177-12-12**] 04:20AM BLOOD Phos-4.1 Mg-2.1 . URINE ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R . U/S ABD No ultrasound evidence of ascites. . CXR [**12-8**]:Moderate right pleural effusion is slightly smaller today. There is no pneumothorax or left pleural effusion. Heart size is borderline enlarged. Pulmonary vasculature is engorged, but there is no edema. No pneumothorax. . [**12-6**] ECG Sinus bradycardia, rate 53. Left anterior hemiblock. Intraventricular conduction delay. Non-specific lateral repolarization changes. Compared with tracing of [**2177-12-5**] no significant change. Brief Hospital Course: 71 F with cirrhosis [**3-7**] NASH, h/o gastric angioectasia (GAVE/watermelon stomach) with GIB, DM2, ESRD on HD MWF, diastolic CHF, HIT, seizure dx on [**Month/Day (2) 13401**], with mental status changes improved after lactulose administration, was in MICU for transient hypotension responsive to fluids, transferred to floor on [**2177-12-9**]. . 1) Hypotension: now resolved; contributed initially by several BMs, hypovolemia, UTI, HD with unknown removal of fluid. She responded well to fluids. . 2) Mental status changes: most likely secondary to hepatic encephalopathy for which the patient has had repeated admissions. Patient also has positive urine culture for what is felt to be a colonizer per ID no need to treat. Patient placed on lactulose for [**4-6**] bowel movements per day, continued of rifaximin. Blood cultures negative except for one that was felt to be a contaminant. Alert and oriented * 3 at discharge. --- If additional admissions, likely will be due to noncompliance as discussion with family revealed lactulose titrated to one bowel movement daily. Family educated that patient need more bowel movements per day given her liver function. . 3) Urinary Tract Infection: Vancomycin- resistant Enterococcus felt to be colonizer due to poor urine output in this patient with End Stage Renal Disease. Patient was given 2 doses of daptomycin, but ID felt if colonizer no need to treat. . 4) Effusion: likely chronic from cirrhosis. No urgency to tap. . 5) Cirrhosis [**3-7**] NASH: increasing ascites. Continued rifaximin, ursodiol, lactulose. Stopped lasix in setting of hypotension and patient on HD for fluid control. . 6) ESRD on HD: HD on M/W/F. Continued Sevelamer . 7) GAVE and GIB: baseline Hct 30; now stable. No active bleeding. . 8) DM2: Insulin standing and ISS. . 9) Acute on Chronic Diastolic Heart Failure: CXR shows increasing R pleural effusion and worsening CHF. Patient on HD for fluid control. . 11) HIT: Avoided all heparin products. . 12) Seizure disorder: Continue [**Month/Day (2) 13401**] at home dose . 13) Coagulopathy: pt received Vitamin K 5 mg PO in the ED. INR stable at 1.7. . 14) CODE: Full . 15) Disposition: Home. Family declined VNA. Medications on Admission: Levetiracetam 500 mg PO DAILY Furosemide 40 mg PO DAILY Pantoprazole 40 mg daily Ursodiol 300 mg PO BID Sevelamer 800 mg PO TID W/MEALS Propranolol 10 mg PO BID Rifaximin 400 mg PO TID Lactulose 10 g/15 mL Syrup, 30 ML PO Q8H Insulin Glargine 100 unit/mL Solution, 12 Units SC QHS Insulin Lispro 100 unit/mL Solution Sig: as directed by sliding scale Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Insulin Regimen Please continue taking your insulin as before: Glargine 12 Units at bedtime; Lispro per sliding scale 8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Hepatic encephalopathy Hypotension Discharge Condition: Stable Discharge Instructions: Please take all your medications, particularly your lactulose and follow up with all your appointments. Please report to you doctor or come to the emergency room if you have any worsening confusion, weakness, diarrhea, fever, abdominal pain or any concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2177-12-16**] 12:00 . Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**8-12**] days.

Admission Date: [**2187-8-12**] Discharge Date: [**2187-8-29**] Date of Birth: [**2116-11-8**] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 689**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: Intubation History of Present Illness: 70 yo M with CAD, s/p CABG x2, atrial fibrillation (on coumadin at presentation) presented to an OSH (> 2 weeks ago) with 3 days of fever, hemoptysis, cough, chills, and dyspnea. CT revealed diffuse airspace disease, predominant in the R and lower lobes. His initial labs were WBC 6.6, HCT 38, Plt 199, Cr 0.6, TBili 2.7, DBili 0.7, AST 19, ALT 33. He was then treated empirically for CAP with ceftriaxone/azithromycin but had continuing hemoptysis, dyspnea, and developed [**First Name3 (LF) 5283**] abdominal pain. Patient was noted to have dropping HCT despite transfusion and worsening respiratory distress. He was then transferred to the ICU, intubated and given with additional pRBC and FFP. His TBili increased to 4.3 with a Direct Bili of 1.8 and ALT increased to 32 and AST to 63. Patient had a [**First Name3 (LF) 5283**] ultrasound and CT that were remarkable only for layering gallbladder sludge vs. small stones. GI consult suggested [**Doctor Last Name 9376**] disease. He was then transferred to [**Hospital1 18**] MICU. At the time of admission to the MICU ([**2187-8-12**]): Tmax= 102, Hct 25, INR 1.3, TBili 4.5, AST of 58, LDH 366, Lipase 92, Alb 3.0, Na 130. Flexible bronchoscopy was performed and demonstrated frank blood in all airways without any endobronchial lesions. Due to his multilobe involvement and diffuse bleeding and high temperature of 102 he was then placed on triple Abx for presumed necrotizing pneumonia: Vancomycin, Azithromycin, and ZOSYN. He was intubated for about 1 week because of hypoxemia and ARDS. Because of the bleeding both coumadin (which he normally takes for his A-fib) and aspirin were held. During [**8-12**] and [**8-13**], he was given a total of 6 u pRBC, which raised the HCT to 33 (an inappropriate increase suggesting possible hemolysis). Patient was found to be p-ANCA +. This then suggested either microscopic polyangiitis (MPA) or Churg-[**Doctor Last Name 3532**] syndrome. The findings that make Churg-[**Doctor Last Name 3532**] less likely are the absence of asthma and no eosinophilia. Consistent with MPA are the findings of hemoptysis and hematuria (with wich the patient presented). Even though the p-ANCA is nearly 70% specific for MPA, a biopsy could be used for a more definite diagnosis (specifically necrotizing inflammation of arterioles, capillaries, and venules w/o granulomas or eosin). Accordingly, Rheumatology was consulted and suggested likely MPA, with the rec of starting high dose IV steroids and Bactrim for PCP [**Name Initial (PRE) 1102**]. Patient's pulmonary function improved and he was successfully extubated on [**8-20**]. However, his elevated TBili kept increasing, following a bimodal pattern: ([**8-14**]): TBili 16 ([**8-18**]): TBili 7.2 ([**8-22**]): TBili 23 ([**8-25**]): TBili 10 with a IndirectBilli in the range of [**1-23**]. Concurrently his LFT's started increasing considerably: ([**8-19**]): ALT 60, AST 69, LDH 657, AlkPhos 93 ([**8-22**]): ALT 168, AST 147, LDH 1103, AlkPhos 164 ([**8-25**]): ALT 267, AST 100, LDH 608, AlkPhos 160, Amylase 123. Due to increasing LFTs Hepatology was consulted, and suggested that the pattern of lab abnormalities combined with the patient's clinical picture point to a drug reaction. Based on lab/imaging studies there is no evidence for viral or alcoholic hepatitis and history and imaging are not consistent with NASH. Although many medications can cause cholestatic jaundice, they suspect a reaction to Zosyn. Expected to resolve with stopping the offending [**Doctor Last Name 360**] however MRCP performed on [**8-24**] showed no evidence of intrahepatic biliary disease. A [**8-13**] [**Name (NI) 5283**] sono showed gallbladder sludge and [**Doctor Last Name 5691**], no biliary ductal dilatation and trace perihepatic free fluid. Furthermore, the increased LDH and TBilli, as well as low haptoglobin (<20) was suggestive of a delayed hemolytic anemia in the setting of multiple blood transfusion. After examining the transfused blood it was determined that 5 u pRBCs that were transfused were JK positive and the patients blood was JK antibody positive, suggestive of a transfusion reaction that would increase the IndirectBilli. Concomitantly, the presumed liver toxicity induced by zosyn and resulting intrahepatic cholestatis could potentially explain the increase in DirectBilli. On the morning of [**8-22**] the patient had a tonic-clonic seizure. While on the bed pan talking to the nurse, he suddenly gave out a yelp, his body became tense, head and eye movement turned to the right, followed by jerking of his right arm for about 1 minute. The nurse administered 2mg Ativan IV and there was a gradual resolution of movement, followed by about 15 min of confusion. There was no apparent bowel incontinence or tongue biting. The patient doesn't remember the seizure and returned to his basline mental status (AOx3). Neurology was then consulted, differential included new stroke due to vasculitis vs. cardioembolic (off coumadin) Another possiblity was re-expression of a prior stroke due to toxic metabolic infectious abnormalities. The seizure unlikely to be related to the hyperbilirubinemia. An head MRI was done on [**8-22**] showing no acute infarcts, minimal amount of chronic microangiopathic changes, and a normal MRA of the head. Past Medical History: Hyperlipidemia Hypertension Coronary Artery Bypass Grafting [**2163**] Multiple percutaneous coronary interventions Sleep apnea Restless leg syndrome Past bilateral hernia repairs Right knee arthritis Social History: Widowed, has 3 sons. lives with 2 sons in [**Name (NI) 1268**], retired but works at golf course during spring/summer season, rare ETOH. Used to work as an electrical engineer. Family History: Father 1st MI age 51, died of an MI at age 62. Physical Exam: VS- Tc 96.8, Tm 98.9, HR 79 , BP 103-140/65-89, 13, 98% RA HEENT- icteric sclerae, MMM, OP clear, no skin tenting noted LUNGS- CTA HEART- irregular irregular. + gallop; unclear if S3 or S4. + systolic murmur somewhat difficult to appreciate in setting of irregular rhythm. ABDOM- soft, ND, NT, BS+, liver nl span by percussion. No stigmata of chronic liver disease EXTRE- wwp, no edema NEURO- A*O*3 Pertinent Results: [**2187-8-12**] 03:13PM PT-14.7* PTT-34.2 INR(PT)-1.3* [**2187-8-12**] 03:13PM PLT COUNT-173# [**2187-8-12**] 03:13PM WBC-9.7 RBC-2.74* HGB-8.3* HCT-24.9* MCV-91 MCH-30.3 MCHC-33.3 RDW-14.8 [**2187-8-12**] 03:13PM NEUTS-89.1* LYMPHS-7.4* MONOS-2.9 EOS-0.4 BASOS-0.2 [**2187-8-12**] 03:13PM [**Doctor First Name **]-POSITIVE TITER-1:40 [**Last Name (un) **] [**2187-8-12**] 03:13PM ANCA-POSITIVE [**2187-8-12**] 03:13PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-2.2* MAGNESIUM-2.1 [**2187-8-12**] 03:13PM LIPASE-92* GGT-43 [**2187-8-12**] 03:13PM ALT(SGPT)-32 AST(SGOT)-58* LD(LDH)-366* ALK PHOS-82 AMYLASE-65 TOT BILI-4.5* [**2187-8-12**] 03:13PM estGFR-Using this [**2187-8-12**] 03:13PM GLUCOSE-115* UREA N-21* CREAT-0.6 SODIUM-130* POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-32 ANION GAP-7* [**2187-8-12**] 03:14PM OTHER BODY FLUID WBC-0 RBC-0 POLYS-77* LYMPHS-8* MONOS-15* [**2187-8-12**] 03:50PM freeCa-1.08* [**2187-8-12**] 03:50PM LACTATE-1.9 [**2187-8-12**] 03:50PM TYPE-[**Last Name (un) **] PH-7.35 [**2187-8-12**] 05:13PM URINE MUCOUS-FEW [**2187-8-12**] 05:13PM URINE RBC-54* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 [**2187-8-12**] 05:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5 LEUK-TR [**2187-8-12**] 05:13PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2187-8-12**] 05:13PM URINE HOURS-RANDOM CREAT-120 SODIUM-LESS THAN [**2187-8-12**] 05:40PM TYPE-ART TEMP-37.3 O2-100 PO2-245* PCO2-42 PH-7.49* TOTAL CO2-33* BASE XS-8 AADO2-444 REQ O2-74 -ASSIST/CON INTUBATED-INTUBATED [**2187-8-12**] 09:21PM HCT-25.5* [**2187-8-22**] 03:42AM BLOOD ALT-168* AST-147* LD(LDH)-1103* AlkPhos-164* TotBili-22.7* DirBili-18.9* IndBili-3.8 [**2187-8-29**] 05:20AM BLOOD ALT-218* AST-68* AlkPhos-134* TotBili-6.4* [**2187-8-29**] 05:20AM BLOOD WBC-12.7* RBC-3.64* Hgb-10.9* Hct-35.0* MCV-96 MCH-30.0 MCHC-31.1 RDW-17.5* Plt Ct-280 [**2187-8-29**] 05:20AM BLOOD PT-12.6 PTT-25.7 INR(PT)-1.1 [**2187-8-29**] 05:20AM BLOOD Glucose-129* UreaN-22* Creat-0.6 Na-133 K-4.6 Cl-98 HCO3-29 AnGap-11 [**2187-8-29**] 05:20AM BLOOD ALT-218* AST-68* AlkPhos-134* TotBili-6.4* [**2187-8-29**] 05:20AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.3 [**2187-8-12**] 03:13PM BLOOD ANCA-POSITIVE [**2187-8-12**] 03:13PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **] [**2187-8-21**] 11:41AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HAV-NEGATIVE [**2187-8-23**] 04:13AM BLOOD ALPHA-1-ANTITRYPSIN-Test [**2187-8-12**] BAL: negative for malignant cells. Blood, pulmonary macrophages - some hemosiderin-laden, and rare bronchial epithelial cells. [**2187-8-12**] CXR: Extensive right lung alveolar consolidation and rounded parenchymal opacities in left lung. Although nonspecific, the findings might represent extensive right lung hemorrhage due to vasculitis given history of hemoptysis. Differential diagnosis includes multifocal pneumonia and multiple pulmonary infarcts in the left lung with asymmetric pulmonary edema on the right. A more chronic entity such as bronchoalveolar cell carcinoma is also possible. [**2187-8-13**] Abdominal US: No focal or textural hepatic abnormality. Unremarkable Doppler interrogation of the liver. A small amount of free fluid as described. Cholelithiasis with equivocal mild gallbladder wall thickening, though clinical correlation is recommended. Left pleural effusion partially imaged. [**2187-8-15**] CXR: Endotracheal tube tip terminates about 8 cm above the carina. A nasogastric tube continues to coil in the stomach with distal tip directed cephalad, directed toward the GE junction. Diffuse air space opacities throughout the right lung and involving the left mid and lower lung appear slightly worse compared to the previous study, but may be accentuated by lower lung volumes. [**2187-8-18**] CXR: Lines and tubes unchanged. No significant change in bilateral airspace disease. [**2187-8-21**] CXR: In comparison with the study of [**8-20**], there is little change in the diffuse opacification involving most of the right lung. Areas of increased opacification are again seen at the left base. The endotracheal and nasogastric tubes have been removed. The right subclavian catheter persists with its tip in the mid superior vena cava at the level of the carina. [**2187-8-22**] ECHO: The left and right atria are moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is 11-15mmHg. The right ventricular cavity is mildly dilated. Free wall motion is good. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 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. An eccentric, inferolaterally directed jet of mild to moderate ([**11-21**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2187-8-22**] MR head w/ and w/o contrast: No acute infarcts. Minimal amount of chronic microangiopathic changes. Normal MRA of the head. [**2187-8-23**] CXR: Partial additional improvement in right lung consolidation. [**2187-8-24**] MRCP: Biliary sludge and stones without biliary dilatation or evidence of cholecystitis. No choledocholithiasis. Known adrenal calcifications, and basilar pulmonary atelectasis/effusion, and scattered pulmonary opacities. Brief Hospital Course: # Hemoptysis/Vasculitis: Patient presents to an Outside Hospital with hemoptysis, described as several teaspoons of dark red blood mixed with sputum, cough, shortness of breath, chills and a fever of Tmax=102 for the 3 days prior to admission. There, a CT scan was performed revealing diffuse alveolar disease, mainly in the Right Middle and Right Lower Lobes. He was then started on Ceftriaxone and Azithromycin. Warfarin was stopped because of persistent hemoptysis. Over the next two days his Hematocrit dropped from 38 to 29 and he was transfused 1 unit of Packed Red Blood Cells. On [**8-12**] due to his worsening hemoptysis and shortness of breath, as well as a further decrease in the Hematocrit to 27 , he was transferred to the ICU at the Outside Hospital. There he was given more blood, vitamin K, vancomycin and 2 units of Fresh Frozen Plasma. He was then intubated and transferred to the [**Hospital3 **] MICU. Due to his multilobe involvement and diffuse bleeding and fever he was then placed on triple Abx for presumed necrotizing pneumonia: Vancomycin, Azithromycin, and ZOSYN (Piperacillin and Tazobactam). During the first 48hrs in the [**Hospital3 **] MICU he was given 6 units pRBCs and his HCT increased to 33. Labs sent out: P-ANCA positive with MPO positivity, [**Doctor First Name **] positive (1:40, diffuse)) Rheumatology: High dose IV steroids and Bactrim (Trimethoprim/ Sulfamethoxazole) for PCP [**Name Initial (PRE) 1102**]. Patient's pulmonary function improved and was successfully extubated on [**8-20**] with no further episodes of hemoptysis. Based on the presentation it was believed to be a kidney-sparing microscopic polyangiitis and a treatment of steroids was continued. Rheumatology and Pulmonary felt there was no need for a lung biopsy at this time. If patient fails steroids would consider cytoxan vs. cellcept vs. methotrexate. . # Hyperbilirubinemia/LFTs: During his stay at the MICU the patient's LFTs increased drastically: ([**8-12**]): ALT 32, AST 58, LDH 366, AlkPhos 82, Tbili 4.5 ([**8-19**]): ALT 60, AST 69, LDH 657, AlkPhos 93 , Tbili 8.5 ([**8-22**]): ALT 168, AST 147, LDH 1103, AlkPhos 164, Tbili 18.9 ([**8-25**]): ALT 267, AST 100, LDH 608, AlkPhos 160, Tbili 10.7 (IndirectBili: 3-5 range) MRCP performed on [**8-24**] showed no evidence of intrahepatic biliary disease. [**Name (NI) 5283**] sono showed gallbladder sludge and [**Doctor Last Name 5691**], no biliary ductal dilatation. Hepatology was consulted and suggested Zosyn induced hepatotoxicity and Zosyn was stopped followed by gradual decrease of the Tbili. Hepatology also considering liver biopsy as outpatient. After examining the transfused blood it was determined that 5 u pRBCs that were transfused were JK positive and the patient's blood was JK antibody positive, suggesting a possible delayed transfusion reaction that could have contributed to the hyperbilirubinemia. . # Seizure: In the MICU on the morning of [**8-22**] the patient had a tonic-clonic seizure. While on the bed pan talking to the nurse, he suddenly gave out a yelp, his body became tense, head and eye movement turned to the right, followed by jerking of his right arm for about 1 minute. The nurse administered 2mg Ativan IV and there was a gradual resolution of movement, followed by about 15 min of confusion. There was no apparent bowel incontinence or tongue biting. The patient doesn't remember the seizure and returned to his basline mental status (AOx3). He was then started on Keppra. Imaging studies of the head (MR & CT) suggested no evidence of acute infarcts and no intracranial hemorrhage. CT of the head: No evidence of intracranial hemorrhage. During his stay patient has had no other seizure events and was sent home with Keppra. . # CAD: Several days prior to discharge patient reported chest pain consistent with stable agina, acute pain overnight/morning, with an unchanged EKG. He was placed on telemetry and pauses >2sec between beats occured multiple times over 24hrs. The metoprolol was decreased to 12.5mg [**Hospital1 **] (which is his home dose). MI was ruled out with negative cardiac enzymes. ASA, beta blocker were continued. Patient had no further episodes. . # Afib: The metoprolol dose was decreased to 12.5mg [**Hospital1 **] due to presence of pauses (>2sec) between beats. Due to his vasculitis the coumadin was stopped. . Medications on Admission: Protonix 40 mg daily Metoprolol 12.5 mg [**Hospital1 **] Isosorbide mononitrate 60 mg [**Hospital1 **] Simvastatin 80 mg daily Zolpidem (Ambien) 5 mg qhs Warfarin 2-4mg as directed Lorazepam 1 mg tid Aspirin 81 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 2. Outpatient Lab Work Please draw LFTs, INR, Tbili, Indirect bili, albumin, alk. phos., and CBC on [**2187-9-4**]. . Please fax results: Dr. [**Last Name (STitle) 4469**], fax: [**Telephone/Fax (1) 23978**] Dr. [**First Name (STitle) **], fax: [**Telephone/Fax (1) 44524**] Dr. [**Last Name (STitle) **], fax: [**Telephone/Fax (1) 9730**] Dr. [**First Name (STitle) **], fax: [**Telephone/Fax (1) 33403**] Dr. [**Last Name (STitle) **], fax: [**Telephone/Fax (1) 4400**] Dr. [**Last Name (STitle) **], fax: [**Telephone/Fax (1) 3341**] 3. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Calcium Citrate 950 mg Tablet Sig: One (1) Tablet PO q12hr () for 4 months. Disp:*62 Tablet(s)* Refills:*4* 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO Q12HR (). Disp:*120 Tablet(s)* Refills:*2* 9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for restless leg syndrome. 10. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*1* 11. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO qAM. Disp:*90 Tablet(s)* Refills:*2* 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual q 5min x 3 as needed for chest pain: take one under the tongue every five minutes until the pain subsides for a maximum of three nitroglycerin pills. If chest pain not resolved by then, please go to ED. Disp:*20 Tablet, Sublingual(s)* Refills:*0* 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: p-ANCA vasculitis . Secondary: 1. Coronary artery disease: s/p CABG in [**2175**] (SVG to PDA, OM-1 and jump graft to D1 and distal LAD), ostial stent placed [**2176**], LAD stent in [**2180**]. [**2180**] cath demonstrated occlusion of SVG-OM and SVG-PDA. He had re-do CABG with LIMA-LAD, SVG-OM, SVG-PDA. Last cath [**2184**] revealed proximal LAD occlusion after first septal and filled with LIMA. LCx proximally occluded and filled from graft. SVG-PDA patent, SVG-OM (86) occluded but new SVG-OM1 patent. SVG-D1-LAD from 86 CABG occluded but LIMA-LAD patent. --Last Echo: [**2-22**]: mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], RA dilated, LVSF 45%, RV wall hypokinesis. 2. Atrial fibrillation/Atrial flutter: developed post-operatively from 2nd CABG--s/p ablation for Aflutter, but now with chronic atrial fibrillation. 3. Hyperlipidemia 4. Hypertension 5. Sleep apnea 6. Restless leg syndrome 7. Past bilateral hernia repairs 8. Right knee arthritis 9. Gastroesophageal reflux disease Discharge Condition: Good Discharge Instructions: You were seen at [**Hospital1 18**] for pulmonary hemorrhage. You subsequently needed to be transferred to intensive care with intubation. You recovered in the MICU and were transferred to the general medicine [**Hospital1 **] where you continued to be stable. You were diagnosed with vasculitis and started on prednisone. You should continue on prednisone as below until you are seen by rheumatology and they advise you on medication regimen. . You have follow up as below. You should also have your labs drawn on Tuesday, [**9-4**], for which you have been provided with a prescription. . The following medications have been changed from you home regimen: - Prednisone 60mg every morning. - You were started on Keppra, 1000mg twice daily for your seizure. You should continue taking this for about a month. - You were started on sulfamethoxazole/trimethoprim SS one tab daily to guard against bacterial infections while you are on an immunosuppressant (prednisone). - You were started on calcium and vitamin D - You were given an albuterol inhaler for any shortness of breath - You were started on folic acid 5mg daily. - Your Imdur was stopped - Your simvastatin was stopped - Your ambien was stopped - your coumadin was stopped - rheumatology and pulmonology along with your primary care physician will follow up on when to restart this. - your aspirin dose was increased to 325mg/day - at some point, the liver specialists may want to hold this for 5 days for a liver biopsy. . You should return to the ED or call your primary care provider if you experience coughing or vomiting blood, blood in your urine, chest pain, abdominal pain, fever greater than 101.4 degrees F, or any other symptoms that concern you. Followup Instructions: Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-8-30**] 8:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2187-9-5**] 4:20pm . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] Phone:[**Telephone/Fax (1) 4475**] [**2187-9-6**] at 11:30am . Provider: [**Name10 (NameIs) 454**],THREE [**Name10 (NameIs) 454**] Date/Time:[**2187-9-7**] 8:00 . Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-9-7**] 9:30 . Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Rheumatology Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2187-9-11**] 8:30 . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], pulmonology. Phone:[**Telephone/Fax (1) 612**]. [**2187-9-18**] at 8:00am, please be there at 7:30 for pulmonary function tests. . Test for consideration post-discharge: Hepatitis C Virus RNA by PCR, Qualitative . Also, Dr.[**Name (NI) 19783**] office will contact you about a liver appointment in one month. Phone: [**Telephone/Fax (1) 2422**] . Dr.[**Name (NI) 10444**] office will contact you about a neurology appointment with Dr. [**First Name (STitle) **] in one month. You currently have an appointment on [**2187-11-8**] at 4pm, but they will set you up with an earlier one. Phone: [**Telephone/Fax (1) 541**] . Please call if you need to change any appointment times or if you have any questions. Completed by:[**2187-9-25**]

Admission Date: [**2201-4-30**] Discharge Date: [**2201-5-8**] Date of Birth: [**2115-1-13**] Sex: M Service: SURGERY Allergies: Indomethacin Attending:[**First Name3 (LF) 4691**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: [**2201-4-30**] 1. Exploratory laparotomy, resection of gastrojejunostomy and Billroth II anastomosis, with Roux-en-Y reconstruction. 2. Partial transverse colectomy with primary anastomosis. 3. Feeding jejunostomy. History of Present Illness: 86M with h/o gastric cancer s/p partial gastrectomy and Billroth II reconstruction [**2178**], jejunostomy tube placement in 2/[**2199**]. He also has a medical history significant for NSTEMI in [**2181**] and [**2199**] now s/p CABG as well as critical aortic stenosis s/p valvuloplasty (peak AV gradient of 10 mm Hg, and valve area of 1.1). He has been experiencing GI bleeds at the site of his gastrojejunal anastamosis, requiring multiple hospitalizations. EGD cauterization and EGD clipping were performed at the site of bleeding were performed, but were unable to control the GI bleeding. Prior EGDs concerning for gastro-jejunal anastamotic polyps and bleeding ulcers with high-grade dysplasia. These were concerning for recurrence of gastric carcinoma, and he is now s/p redo of the gastrojejunostomy with roux en y reconstruction, and resection of recurrent carcinoma, with clear margins on frozen section. On entry into the abdomen, a perforation of the transverse colon with contained abscess was discovered, and partial transverse colectomy with primary anastamosis was performed. Feeding jejunosotmy tube was placed. Past Medical History: Gastric Cancer s/p partial gastrectomy and BII [**2178**], h/o GIBs at the site of his anastamosis, recent EGDs with clipping and cauterization, severe AS s/p emergent valvuloplasty [**2201-1-8**] c/b ARDS requiring prolonged intubation leading to dysphagia, Cholangitis s/p sphincterotomy and stent [**2189**], Coronary artery disease, prior NSTEMI [**2181**] and [**2199**] ([**Month (only) **]), s/p CABG, Cerebrovascular Disease, prior stroke [**2195**], Carotid Disease, Hypertension, Dyslipidemia, BPH, Gout, Chronic Anemia Social History: Romanian-Russian. He is married lives with wife who is 84 yo. He has 2 [**Year (4 digits) **], [**Name (NI) 24006**] (HCP) that helps with care and [**Name (NI) **] . Had recent VNA which he has been refusing help and tube feeds. Has 40+ pack-year hx, quit [**2179**]. Since [**2201-1-23**] D/C (for severe ARDS requiring emergent valvuloplasty of AS) has been at [**Hospital1 1501**] and walking independently with walker and close supervision and most recent went back home post discharge. Family History: Father died of MI and age 78 Mother died of liver cancer at age 81 Physical Exam: Vitals: Pain 4 T 97.9 HR 80 BP 155/53 RR 16 SpO2 100%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, minimal TTP in lower quadrants, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: pt refused. Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2201-4-30**] 09:50PM WBC-4.4 RBC-2.94* HGB-9.9* HCT-29.3* MCV-100* MCH-33.6* MCHC-33.7 RDW-16.0* [**2201-4-30**] 09:50PM PLT COUNT-133* [**2201-4-30**] 09:50PM PT-13.9* PTT-28.0 INR(PT)-1.2* [**2201-4-30**] 09:50PM GLUCOSE-131* UREA N-23* CREAT-0.9 SODIUM-144 POTASSIUM-4.4 CHLORIDE-117* TOTAL CO2-22 ANION GAP-9 [**2201-4-30**] 09:50PM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-1.6 [**2201-5-4**] UGI : No evidence of leak at the gastrojejunostomy site. [**2201-5-5**] Video swallow : Aspiration of thin liquids with residue in the valecula and piriform sinuses. [**2201-5-6**] CT Abd/pelvis : 1. Fat- and fluid-containing right inguinal hernia without bowel content. 2. Status post recent abdominal surgery with postoperative pneumoperitoneum and fluid within the abdomen. 3. Increased bilateral moderate pleural effusions, left greater than right. 4. Status post gastrectomy and gastrojejunostomy with revision as well as partial transverse colectomy. Anastomoses appear within normal limits. 5. Previously noted upper pole left renal cyst with increased density on contrast-enhanced exam now demonstrates lower density non-contrast study. Further evaluation could be obtained with ultrasound. 6. Interval resolution of anterior abdominal wall hematoma. Brief Hospital Course: Mr. [**Known lastname 2262**] was taken to the OR on [**4-30**] for exploratory laparotomy, resection of gastrojejunostomy and Billroth II anastomosis, with Roux-en-Y reconstruction, partial transverse colectomy with primary anastomosis, feeding jejunostomy for recurrent GIB and history of gastric CA. Postoperatively, the patient was taken to the SICU for recovery. He was extubated and did well over the course of POD 0. His hematocrits were stable in the 26-27 range. His TF were started via the J tube. His NGT was to suction. On POD 1, he remained hemodynamically stable and tolerated his tube feeds however his hematocrits started to slowly decrease. He was transferred to the floor on POD 2 and given his persistent anemia with a hct of 21, he was transfused two units of PRBC. Following transfer to the Surgical floor his hematocrit remained stable in the 30-32 range. He began tube feeds via his J tube and tolerated them well. The speech and swallow service evaluated him on multiple occasions but he had frank aspiration on video swallow and therefore was given sips of nectar thick liquids for comfort. He will need this followed up. He required mineral oil via his J tube to start his bowel function and it was effective. As he is prone to constipation his narcotic pain medication was stopped and he was given scheduled Tylenol for pain. He will continue Senna and Colace as well. His Surgical wound was healing well and some of his staples were removed prior to discharge. The remaining staples will be removed at his first post op appointment. He had an abdominal CT on [**2201-5-6**] as he has had a right inguinal hernia nut had a bit more pain on palpation. The CT was done and confirmed that the hernia sac was fat and fluid filled as opposed to bowel and his pain gradually resolved. The Physical Therapy service evaluated him and recommended a stay in a short term rehab prior to returning home to increase his mobility and endurance after this hospitalization. Medications on Admission: atorvastatin 40 mg daily, metoprolol tartrate 25 mg [**Hospital1 **], lansoprazole 30 mg daily, mirtazapine 15 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime), docusate sodium 100 mg [**Hospital1 **], senna [**Hospital1 **], acetaminophen 650 prn Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) Injection TID (3 times a day). 2. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2 times a day): Hold for SBP < 110, HR < 65. 3. haloperidol 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. mirtazapine 30 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime). 6. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Colace 60 mg/15 mL Syrup [**Hospital1 **]: Twenty Five (25) ml PO twice a day. 8. atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 9. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Ten (10) ml PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: 1. Recurrent gastric cancer. 2. Colonic perforation and abscess 3. Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). 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 8-12 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 [**4-21**] 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. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**] Date/Time:[**2201-5-12**] 11:30 Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2201-5-14**] 1:30 Completed by:[**2201-5-8**]

Admission Date: [**2133-9-9**] Discharge Date: [**2133-9-15**] Service: cardiothoracic surgery. HISTORY OF PRESENT ILLNESS: Briefly, this is a 79 year old woman with a previous history of scarlet fever status post [**Last Name (un) 3843**]-[**Doctor Last Name **] mitral valve for mitral stenosis in [**2126**]. At the time of her surgery, she was found to have normal coronaries with normal aortic valve. She also had a history of atrial fibrillation which had been managed on Coumadin. In the past year, she had been complaining of fatigue and increasing shortness of breath while walking and exertion. She denied any chest pain, palpitations, dizziness or syncope. Echocardiogram revealed biatrial enlargement, severe aortic stenosis with an aortic valve area of 0.6 centimeters, concentric left ventricular hypertrophy with normal left ventricular function, moderate tricuspid regurgitation and moderate pulmonic regurgitation. The patient was taken to the Cardiac Catheterization Laboratory for evaluation of her aortic valve as well as evaluation of her coronary arteries. PAST MEDICAL HISTORY: 1. Scarlet fever. 2. Atrial fibrillation. 3. Prior transient ischemic attacks with mild carotid disease noted on recent testing. 4. Hypertension. 5. High cholesterol. 6. Obstructive pulmonary disease noted on chest x-ray. PAST SURGICAL HISTORY: 1. Hernia repair. 2. Mitral valve replacement. 3. Elbow surgery. ALLERGIES: She had no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg p.o. q. day. 2. Lipitor 10 mg p.o. q. day. 3. Toprol 100 mg p.o. twice a day. 4. Coumadin 2.5 mg Monday through Saturday and none on Sunday. 5 Fosamax one tablet a week. LABORATORY: On admission white blood cell count was 9.1, hematocrit was 38.0 and her platelets were 299. Her sodium was 140, potassium of 4.8, chloride 104, bicarbonate of 29, BUN of 24, creatinine 1.1 with an INR of 1.3. PHYSICAL EXAMINATION: On physical examination, the patient was afebrile and her vital signs were stable. Her lungs were clear to auscultation bilaterally. Her neck was supple with no jugular venous distention. Her heart was irregularly irregular with a loud systolic ejection murmur. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory and cardiac surgery consultation at that time. The patient was taken to the Operating Room on [**2133-9-10**], where an aortic valve replacement was done using a 19 centimeter pericardial valve. The patient was transferred to the CSRU postoperatively where she did well. She was slowly weaned from her ventilator and extubated, all of her drips of epinephrine and Nitroglycerin were stopped. The patient was started on beta blockers and lasix at that time. The patient was transferred to the Floor postoperatively where she continued to improve. On postoperative day number two her chest tubes were removed and her wires were removed. The patient was started back on her Coumadin for her atrial fibrillation and a chest x-ray was done which was normal, however, showed a slightly enlarged heart on x-ray. Physical Therapy was consulted at this time for testing of ambulation and it was felt that the patient could possible be able to be discharged home. The patient continued to improve and Coumadin was continued at her regular dose and was followed, and her INR was slowly increased. The patient did well with Physical Therapy and it was felt that that time that the patient could be discharged home when medically cleared. A cardiac echo performed [**2133-9-14**] showed normal LV function and good aortic and mitral prosthetic valve function. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Albuterol one nebulizer q. six hours p.r.n. 3. Lipitor 10 mg p.o. q. day. 4. Coumadin 2.5 mg p.o. q. h.s. times six days a week. 5. Percocet one to two tablets p.o. q. four hours p.r.n. 6. Zantac 150 p.o. twice a day. 7. Colace 100 mg p.o. twice a day. 8. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day. 9. Lasix 20 mg p.o. twice a day. 10. Lopressor 25 mg p.o. twice a day. CONDITION ON DISCHARGE: The patient is discharged home in stable condition. DISCHARGE INSTRUCTIONS: 1. She is instructed to follow-up with Dr. [**Last Name (STitle) **] in four weeks. 2. She is instructed to follow-up with her primary care physician in one to two weeks. 3. To follow-up with Cardiology in two to four weeks. DISCHARGE DIAGNOSES: 1. Scarlet fever. 2. Atrial fibrillation. 3. Mitral valve regurgitation status post mitral valve repair. 4. Aortic stenosis status post aortic valve repair. 5. Prior transient ischemic attacks. 6. Hypertension. 7. High cholesterol. 8. Chronic obstructive pulmonary disease on chest x-ray. The patient is discharged home in stable condition. Please see Addendum for any changes in medications and correct discharge date. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) 7148**] MEDQUIST36 D: [**2133-9-13**] 22:10 T: [**2133-9-14**] 05:02 JOB#: [**Job Number 41721**] 1 1 1 DR

Admission Date: [**2135-2-16**] Discharge Date: [**2135-2-17**] Date of Birth: [**2077-1-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8487**] Chief Complaint: respiratory distress, unresponsive, hypoxic Major Surgical or Invasive Procedure: Endotracheal intubation Femoral central line placement History of Present Illness: Mr. [**Known lastname 7710**] is a 58 year old male with a recently diagnosed T4AN2CM0 oropharyngeal squamous cell carcinoma s/p surgery with recently started XRT and soon to start chemotherapy. He has been living with his brother and was last seen normal at 8pm the evening prior to presentation. This morning his brother went to check on him and he was found in bed shallow breathing, unresponsive, and paramedics were called. He was hypoxic to the 70s in the field. . In the ED, initial vs were: P 114, BP 112/73, R 21, O2 sat 87% on NRB. Given hypoxia patient was intubated with etomidate 20 mg and succinylcholine 120 mg. Intubation was difficult, requiring a bougie, but uncomplicated. Pus? was aspirated following intubation. He was started on midazolam and fentanyl for sedation. He was noted to have copious diarrhea. He received levofloxacin, vancomycin, and zosyn for treatment of pneumonia and per report ~3L IVF. . On the floor, the patient is intubated and sedated. Past Medical History: 1. T4AN2CM0 oropharyngeal squamous cell carcinoma s/p tracheostomy, right radical neck dissection with preservation of cranial nerve [**Doctor First Name 81**], left radical neck dissection with preservation of the internal jugular vein, and cranial nerve [**Doctor First Name 81**], resection of a right palatine arch and soft palate tumor reconstruction with a pectoralis flap [**2134-12-21**], c/b R vocal cord paralysis with subsequent medialization of the R vocal cord and PEG placement [**2135-1-7**]. Recently started XRT and scheduled to start cisplatin adjuvant chemotherapy [**2135-1-17**]. 2. Hepatitis C virus 3. Hypertension? 4. Schizophrenia? 5. History of polysubstance dependence 6. Low back pain Social History: (per WXVA records) Past history of drug abuse, history of opiate dependence. Smokes 1.5 ppd x 30 years Hx of Alcoholism, sober since [**2122**] Recently discharged from [**Hospital 85897**]. Family History: (per WXVA records) Father - died of lung cancer at age 76 Mother - died of lung cancer at age 78 Siblings - one sister with liver failure adn HIV Children - none Physical Exam: Vitals: T: 101.2 BP: 105/80 P: 105 R: 20 O2: 100% General: Intubated, sedated, NAD HEENT: Sclera anicteric, pupils 3->2 with light, MMM, unable to completely visualize oropharynx but secretions are visible posteriorly Neck: supple, JVP not elevated, neck post-surgical. Right supraclavicular mass and missing tissue supraclavicularly on the left Lungs: Clear to auscultation anteriorly with a few scattered rhonchi in the right axilla. No wheezes or rales CV: Distant heart sounds, tachycardic, regular rate, no murmurs Abdomen: + BS, soft, non-tender, non-distended GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2135-2-16**] 12:15PM BLOOD WBC-10.4 RBC-4.86 Hgb-13.8* Hct-44.0 MCV-90 MCH-28.3 MCHC-31.3 RDW-14.4 Plt Ct-359 [**2135-2-16**] 06:21PM BLOOD Neuts-62 Bands-15* Lymphs-11* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2135-2-16**] 12:15PM BLOOD PT-13.2 PTT-33.9 INR(PT)-1.1 [**2135-2-16**] 12:15PM BLOOD Fibrino-610* [**2135-2-16**] 12:15PM BLOOD UreaN-30* Creat-2.3* [**2135-2-16**] 12:15PM BLOOD ALT-30 AST-39 CK(CPK)-1143* AlkPhos-98 TotBili-0.3 [**2135-2-16**] 12:15PM BLOOD CK-MB-14* MB Indx-1.2 [**2135-2-16**] 12:15PM BLOOD cTropnT-0.02* [**2135-2-16**] 12:15PM BLOOD Albumin-4.2 Calcium-9.5 Phos-8.3* Mg-2.5 [**2135-2-16**] 12:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2135-2-16**] 12:15PM BLOOD pH-7.14* Comment-GREEN TOP [**2135-2-16**] 12:17PM BLOOD Type-ART pO2-178* pCO2-65* pH-7.21* calTCO2-27 Base XS--3 [**2135-2-16**] 12:15PM BLOOD Glucose-116* Lactate-5.6* Na-138 K-6.1* Cl-90* calHCO3-29 [**2135-2-16**] 12:15PM BLOOD freeCa-1.19 [**2135-2-16**] 12:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2135-2-16**] 12:40PM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2135-2-16**] 12:40PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2135-2-16**] 12:40PM URINE CastHy-[**6-2**]* [**2135-2-16**] 12:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-POS Microbiology: Blood and urine cultures pending Legionella Urinary Antigen (Final [**2135-2-17**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2135-2-17**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 85898**] @ 3:42A [**2135-2-17**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. [**2135-2-17**] 9:42 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2135-2-17**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. Culture pending Radiology: [**2135-2-16**] AP CXR - IMPRESSION: No acute intrathoracic process. NG tube tip appears to be in distal esophagus. Please correlate and advance as necessary. [**2135-2-16**] CT Head - IMPRESSION: No acute hemorrhage. [**2135-2-17**] AP CXR - read pending, but prelim concerning for RLL pneumonia. Brief Hospital Course: Mr. [**Known lastname 7710**] is a 58 year old male with recently diagnosed squamous cell cancer of the head and neck who presented with respiratory distress and was intubated in the ED. # Respiratory failure - First ABG with acidemia and hypercarbia. Differential includes respiratory infection or mucous plugging vs. upper airway compromise from malignancy vs. narcotic overdose given home med use. Report of ?pus with intubation concerning for pneumonia which was more apparent on repeat CXR after fluid resuscitation. Suspect aspiration given altered mental status and location of infiltrate. Sputum culture pending, but with multiple organisms on gram stain. Patient initially on vancomycin, zosyn, and levofloxacin to cover for healthcare associated pneumonia and narrowed to vancomycin and zosyn (plus metronidazole for C.diff). Urine legionella antigen was negative. Ventilating very well on [**9-27**] with 50% FiO2 (tidal volumes in 800s) but extubation held given transfer to WXVA and still with significant secretions requiring suctioning. # Unresponsiveness - Likely secondary to pulmonary infection vs. mucous plugging vs. narcotic overdose given hypercarbia and respiratory distress. Hypercarbia improved post intubation. No evidence for seizure or other intoxication on serum/utox. # Diarrhea/C.diff - Stools were positive for C. difficile and patient was started on IV flagyl. # Anion gap - Likely secondary to lactic acidosis, most likely from infection. Resolved following fluid resuscitation. # Elevated CK - Possibly early rhabdo from lying immobile overnight. Cardiac biomarkers were negative x 3. CKs now trending down with IVF to maintain good urine output. # Renal failure - Baseline creatinine 0.6-0.7 per WXVA records. Likely pre-renal from dehydration in the setting of diarrhea and acute infection, now trending downward after fluid resuscitation. # Hyperkalemia - Initially 6.1 then resolved to 4.6. Likely secondary to acute renal failure. Improvement likely result of IVF and diarrhea. # Hypertension - Tachycardia could be rebound from beta-blocker withdrawal in addition to acute illness. As patient was quite ill and had the potential to become hypotensive, metoprolol was initially held and then restarted at a reduced dose the following morning. However, following first dose of metoprolol, patient systolic pressure dropped to mid 80s, so metoprolol was held. Responded back into 90s with 1.5 L IVFs in the early afternoon and has maintained in this range. # Psych history - cont. citalopram. # Chronic pain, medication dependence - Patient on narcotics and benzos at baseline and required high doses for adequate sedation while intubtated. The morning following presentation fentanyl patch and half dose methadone were restarted to facilitate later vent weaning. FEN: IVF to achieve urine output of >30cc/hr, replete electrolytes, NPO on admission and can start tube feeds. . Prophylaxis: Subutaneous heparin, aspirin, P-boots, omeprazole (home medication), holding bowel regimen d/t diarrhea. . Access: peripherals 20 gauge x2, R groin CVL placed in ED was pulled. . Code: Full . Communication: Patient Brother [**Name (NI) 892**] [**Name (NI) **]: [**Telephone/Fax (1) 85899**], [**Telephone/Fax (1) 85900**] (c) - brought pt in. HCP: Brother [**Name (NI) **] "[**Name2 (NI) 45919**]" [**Known lastname 7710**]: [**Telephone/Fax (1) 85901**] (H), [**Telephone/Fax (1) 85902**] (W) . Disposition: To WXVA. . Medications on Admission: (from WxVA discharge list [**2135-1-12**] and PCP [**Name Initial (PRE) **] [**2135-1-24**]) -Acetaminophen-oxycodone liquid [**5-7**] mL Q4H prn pain -Albuterol-ipratropium 2 puffs TID prn -ALOH-MgOH-Simethicone 10mL Q8H prn dyspepsia -Aspirin 325 mg PO daily -Bisacodyl supp 10 mg daily prn -Citalopram soln 40 mg PO daily -Diphenhydramine elixir 25 mg/10mL Q4H prn itching -Fentanyl patch 75 mcg Q72H -Gabapentin soln 300 mg PO daily -Haloperidol 5mg/1mL IM Q2H prn agitation -Heparin 5000 units sc TID -Lorazepam 1 mg PO Q6H -Methadone 10 mg PO TID -Metoprolol 37.5 mg PO Q6H -Multivitamin daily -Omeprazole susp 20 mg PO BID -Ondansetron [**Hospital1 **] prn nausea -Quetiapine 400 mg PO QHS -Sodium chloride nasal spray 2 sprays QID PRN -Tube feedings: Jevity two cans (480 ml bolus) QID Discharge Medications: 1. Midazolam 5 mg/mL Solution [**Hospital1 **]: [**1-31**] Injection TITRATE TO (titrate to desired clinical effect (please specify)). 2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (3) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Hospital1 **]: 100-500 mcg/hr Injection INFUSION (continuous infusion). 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB/Wheeze. 5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: Two (2) Inhalation Q6H (every 6 hours) as needed for SOB/Wheeze. 6. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) Injection TID (3 times a day). 9. Fentanyl 75 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): placed on [**2-17**]. 10. Methadone 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Piperacillin-Tazobactam 4.5 g IV Q8H Day 1 = [**2-16**] 13. Vancomycin 1000 mg IV Q 12H Day 1 = [**2-16**] 14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Day 1 = [**2-17**] Discharge Disposition: Extended Care Discharge Diagnosis: Primary: hypercarbic respiratory failure, aspiration pneumonia, c diff colitis, oropharyngeal cancer Secondary: depression, chronic pain, hepatitis C, hypertension Discharge Condition: Level of Consciousness: Lethargic but arousable, on sedation Activity Status: Bedbound Discharge Instructions: Dear Mr [**Known lastname 7710**], You were admitted for respiratory failure requiring intubation. You have an aspiration pneumonia and c difficile colitis. We are treating you with antibiotics and you will continue to get care at the [**Location **] with the rest of your usual providers. Followup Instructions: Pending workup and treatment at [**Location **] . Data pending at [**Hospital1 18**]: blood, sputum, urine cultures pending - please [**Telephone/Fax (1) 2756**] microbiology lab for followup. . Rads films on CD included with patient.

Admission Date: [**2159-8-12**] Discharge Date: [**2159-8-16**] Service: MEDICINE Allergies: Pneumococcal Vaccine / Influenza Virus Vaccine / Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 13386**] Chief Complaint: BRBPR and coffee ground emesis Major Surgical or Invasive Procedure: LIJ was placed Transfusion of 5 units of PRBCs History of Present Illness: [**Age over 90 **] yo F with a history of CAD, CVA, GERD, MRSA UTI, DM, and dementia (verbal but confused at baseline) presents to ED from from Heb Reb, with hypotension. She had one episode of emesis (non bloody [**8-11**]). She then reportedly complained of abd pain on the day of admission ([**8-12**]), then had 1 episode of coffee ground emesis, followed by BRBPR with clots. Her BP at the [**Hospital1 1501**] was 60/p. . On arrival to the ED her blood pressure was 80/palp. [**Hospital1 **] was 26 (was 33 on [**2158-8-9**]), lactate was 5.5, UA was grossly positive. FAST was negative. Abd CT revealed 2 cm clot vs mass in duodenum. GI and surgery were consulted. She was fluid resucutated, and initially her BP improved to 100 systolic, but then trended down to 70's. . Potassium was initially 7.6, she was given Calcium Cl 1 g, Insulin 5U. Code sepsis was called, a L IJ was placed (following a failed attempt at a R IJ). She was given 3.2L IVF, Vanco/levo/flagyl and transfused 2 units PRBCs. On transfer to the MICU she was afebrile HR 110, BP 90-100/40, satting 97% 2L NC. . ROS: unable to obtain . Past Medical History: CAD s/p angioplasty [**2143**] h/o CVA DM2 with peripheral neuropathy (HgbA1c = 6.6) CKD (b/l Cr 1.8) diverticulitis s/p partial colectomy chronic hypotension (b/l BP = 90) hyperlipidemia dementia (oriented x 1 at baseline) h/o chronic anemia h/o MRSA UTI recent CDiff (last dose [**2159-8-10**]) possible chronic renal failure GERD SLE h/o gallstone pancreatitis COPD OA h/o cystitis low back pain h/o R knee surgery s/p sympathectomy Social History: From [**Hospital 100**] Rehab, former smoker- [**12-6**] ppd x 80 years. no etoh. uses a walker. Son [**Name (NI) **] is HCP. requires assistance for adl's, Family History: NC Physical Exam: VS - Temp 97.3 F, BP 112/80, HR 102, R 18, O2-sat 96% RA GEN: sleepy but arousable--lapses back into sleep easily, oriented x1 to self only. follows simple commands, frail elderly woman, confused, moaning, very hard of hearing HEENT: [**Last Name (LF) 12476**], [**First Name3 (LF) 13775**], EOMI, anicteric , dry MM , OP clear Neck: supple, no JVD, no bruits, no LAD Heart: RRR, S1, S2, 2/6 SEM at base, no ectopy Lungs: crackles at b/l bases; no rh/wh, no accessory muscle use Abd: generally tender/no rebound/no guard. no mass; no organomegaly; obese; bruisig of skin at site of medication injection. Ext: no CCE/erythema (blanching) Rt foot; dp/pt dopplerable Skin: Stage I-II sacral decub Neuro: AA&Ox1(to name), 5/5 strength arms; 4/4 strength both legs; cn2-12 grossly normal except for left hearing loss; babinski downgoing bilat. reflexes hard to elicit. Pertinent Results: EKG: sinus tach at 108, 1st degree AV block, nonspecific stt changes . [**2159-8-14**]: Baseline artifact. Sinus rhythm. Leftward axis. Since the previous tracing the axis is more leftward. . CT pelvis w/o contrast [**8-12**]: 4 cm hyperdense collection in the duodenum is concerning Upper GI bleed(likely bleeding duodenual ulcer, but cannot rule out underlying mass). No intraperitoneal free fluid, free air or obstruction. . . [**2159-8-12**] 02:32PM GLUCOSE-251* UREA N-47* CREAT-1.7* SODIUM-137 POTASSIUM-5.5* CHLORIDE-111* TOTAL CO2-21* ANION GAP-11 [**2159-8-12**] 02:32PM CALCIUM-6.5* PHOSPHATE-4.4 MAGNESIUM-1.4* [**2159-8-12**] 02:32PM WBC-14.9* RBC-3.10* HGB-9.4* [**Month/Day/Year **]-27.2* MCV-88 MCH-30.3 MCHC-34.5# RDW-15.5 [**2159-8-12**] 02:32PM PLT COUNT-222 [**2159-8-12**] 01:07PM LACTATE-1.5 [**2159-8-12**] 11:27AM LACTATE-2.6* [**2159-8-12**] 09:45AM LACTATE-2.9* [**2159-8-12**] 09:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 [**2159-8-12**] 09:30AM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [**2159-8-12**] 09:30AM URINE RBC-[**5-15**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**2-7**] [**2159-8-12**] 08:10AM GLUCOSE-267* UREA N-46* CREAT-2.0* SODIUM-138 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-25 ANION GAP-11 [**2159-8-12**] 08:10AM estGFR-Using this [**2159-8-12**] 08:10AM ALT(SGPT)-9 AST(SGOT)-12 CK(CPK)-17* ALK PHOS-43 TOT BILI-0.3 [**2159-8-12**] 08:10AM LIPASE-16 [**2159-8-12**] 08:10AM CK-MB-NotDone [**2159-8-12**] 08:10AM ALBUMIN-1.9* CALCIUM-6.0* PHOSPHATE-4.7* MAGNESIUM-1.5* [**2159-8-12**] 08:10AM CORTISOL-27.3* [**2159-8-12**] 08:10AM CORTISOL-27.3* [**2159-8-12**] 08:10AM CRP-3.4 [**2159-8-12**] 07:19AM LACTATE-5.5* K+-7.6* [**2159-8-12**] 07:15AM cTropnT-0.03* [**2159-8-12**] 07:15AM WBC-12.7* RBC-2.93* HGB-8.1* [**Month/Day/Year **]-26.1* MCV-89 MCH-27.8 MCHC-31.2 RDW-16.8* [**2159-8-12**] 07:15AM NEUTS-81.2* LYMPHS-14.8* MONOS-3.1 EOS-0.1 BASOS-0.8 [**2159-8-12**] 07:15AM PLT COUNT-440 [**2159-8-12**] 07:15AM PT-12.9 PTT-25.7 INR(PT)-1.1 . COMPLETE BLOOD COUNT WBC RBC Hgb [**Month/Day/Year **] MCV MCH MCHC RDW Plt Ct [**2159-8-16**] 10:50AM 34.9* [**2159-8-16**] 05:55AM 7.9 3.82* 11.4* 33.7* 88 29.8 33.8 16.5* 138* [**2159-8-16**] 04:06AM 8.5 4.02* 11.7* 36.4 90 29.1 32.2 16.3* 155 [**2159-8-15**] 03:40PM 8.4 3.96* 12.1 36.1 91 30.5 33.5 16.2* 154 Source: Line-Central [**2159-8-15**] 06:10AM 8.3 4.11* 12.2 36.1 88 29.6 33.7 16.4* 188 [**2159-8-15**] 12:18AM 35.3* Source: Line-CVL [**2159-8-14**] 03:22PM 35.7* Source: Line-Central [**2159-8-14**] 05:56AM 12.3* 3.62* 11.0* 31.6* 87 30.2 34.7 16.2* 203 Source: Line-CVL [**2159-8-13**] 11:23PM 32.8* [**2159-8-13**] 07:28PM 33.9* Source: Line-central [**2159-8-13**] 04:36PM 17.1* 4.10* 11.9* 35.7* 87 29.1 33.4 16.0* 190 Source: Line-CVL [**2159-8-13**] 02:23PM 33.3* Source: Line-left ij [**2159-8-13**] 09:28AM 35.1* Source: Line- left ij [**2159-8-13**] 05:56AM 15.4* 4.17*# 12.3# 35.7* 86 29.5 34.4 15.8* 196 . . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2159-8-16**] 05:55AM 101 28* 1.3* 141 4.81 110* 19* 17 [**2159-8-15**] 06:10AM 113* 39* 1.4* 142 4.6 112* 22 13 [**2159-8-14**] 05:56AM 157* 51* 1.5* 141 4.7 112* 20* 14 Source: Line-CVL [**2159-8-13**] 04:36PM 196* 57* 1.6* 138 5.3* 109* 20* 14 Source: Line-CVL [**2159-8-13**] 02:23PM 152* 58* 1.5* 137 5.7* 111* 21* 11 Source: Line-left ij [**2159-8-13**] 09:28AM 5.7* Source: Line- left ij [**2159-8-13**] 05:56AM 177* 62* 1.6* 136 5.8* 109* 21* 12 Source: Line-central [**2159-8-12**] 02:32PM 251* 47* 1.7* 137 5.5* 111* 21* 11 Source: Line-tlc [**2159-8-12**] 08:10AM 267* 46* 2.0* 138 5.6* 108 25 11 . . . Cortisol [**2159-8-12**] 08:10AM 27.3*1 . Lactate: [**2159-8-12**] 01:07PM 1.5 [**2159-8-12**] 11:27AM 2.6* [**2159-8-12**] 09:45AM 2.9* [**2159-8-12**] 07:19AM 5.5* . ALT AST CK AlkPhos TotBili [**2159-8-12**] 9 12 17 43 0.3 . Final [**Year (4 digits) **] on discharge 34.9 . [**2159-8-15**] CATHETER TIP-IV WOUND CULTURE-PRELIMINARY INPATIENT [**2159-8-15**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2159-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2159-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2159-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2159-8-12**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI, ESCHERICHIA COLI} EMERGENCY [**Hospital1 **] [**2159-8-12**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2159-8-12**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {LACTOBACILLUS SPECIES}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] . URINE CULTURE (Final [**2159-8-15**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. 2ND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ 16 I <=2 S AMPICILLIN/SULBACTAM-- 8 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 16 I 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Brief Hospital Course: [**Age over 90 **]F presents with history of GERD, dementia, MRSA UTI admitted to MICU from [**Hospital1 1501**] with shock, UTI and GI bleed. . # Sepsis/UTI/bacteremia - initially hypotensive in ED, baseline [**Hospital1 **] per her PCP [**Last Name (NamePattern4) **] 36, down to 26 on admission, thus hypotension felt most likely hypovolemic from GI bleed, but may have had septic component as well given +UA on [**8-12**], +leukocytosis (WBC 17.1). CVP = 4. Given 3.2 L IVF, 2 units PRBC's in ED. Never required pressors in the ICU. She recieved ~4L IVF in the MICU, and 4U PRBCs. She was treated with broad spectrum abx vanc/cipro/flagyl for 1d in the ICU. She was transferred to the floor on [**2159-8-13**]. Vanco and flagyl were discontinued given the presence of gram negative rods on urine culture, and no other source of infection. Her Urine speciated E.Coli resistant to quinolones, and she was switched to oral bactrim based on sensitivities. She has a history of reported bactrim allergy. After discussion with her PCP, [**Name10 (NameIs) **] was determined that she has taken bactrim in the past in [**4-10**] without adverse reaction. She tolerated bactrim without difficulty. . Blood cultures on [**2159-8-12**] were positive for LACTOBACILLUS in 1 of 2 bottles. Subsequent cultures on [**9-8**], [**8-15**] showed no growth at the time of discharge. Left IJ catheter tip was cultured and showed no growth at the time of discharge. ID consult was obtained, and recommended clindamycin iv x 14 days to treat potential lactbacillus bacteremia starting on [**8-16**]. A PICC line was placed for this antibiotic. She was also started on a 21 day course of oral vancomycin (starting [**8-16**]) for c. difficile prophylaxis given her recent c. difficille infection. She was hemodynamically stable upon transfer to the medical floor and had no further hypotension. . She should have follow-up of her bacteremia with either her primary care physician or the gerontology service at [**Hospital 100**] Rehab. She does not require surveillence cultures. . # GIB bleed - most likely due to duodenal ulcer given CT scan. GI and surgery were consulted, and given the patient and son's desire for conservative management, it was agreed upon that no intervention would be performed unless pt developed life threatening bleed. Pt received total of 5U PRBCs last on [**8-14**]. Her [**Month/Day (4) **] was stable at 33-35 on discharge on [**8-16**]. She was tolerating a regular pureed diet with supervision given concern for aspiration while recovering from UTI. She was discharged home on omeprazole twice daily. her aspirin and plavix were discontinued. she should discuss restarting her aspirin with her primary care physician in the future. . . # Hyperkalemia - K up to 5.8 on [**8-13**], down to 4.8 on [**8-16**] without intervention. No ekg changes. some question of RTA as source of chronic hyperkalemia. potassium resolved without intervention. she will follow-up with her PCP. . . # Recent C Diff - pt finished PO Vancomycin [**8-10**]. She had melanotic stools this admission, though no diarrhea. She was started on PO vanco on [**8-16**] for 21 day course to prophylax against cdiff given that she is starting a new course of bactrim for UTI and clindamycin for bacteremia. . . # CKD: baseline Cr 1.8 per report, down to 1.3 on [**8-16**]. medications were renally dosed. no evidence of ATN. . # DM - pt was covered with sliding scale insulin while inpatient. . # gout - pt continued home regimen of allopurinol. . # anemia - baseline Hgb is approximately 12 per discussion with patients' PCP. [**Name10 (NameIs) **] down to 26 on admission consistent with GIB. At time of discharge [**Name10 (NameIs) **] 34.9. Iron supplementation was held in setting of GIB, and can be restarted as outpatient. . # CAD - given ongoing GIB as above, decision made to hold aspirin and plavix. No clear indication for continue plavix given lack of recent NSTEM, CVA, or PAD. Pt will need to discuss restarting aspirin with PCP once hematocrit has been stable. . # COPD - pt continued on her home regimen of fluticasone and spiriva. She was breathing comfortably on room air at the time of discharge. . # Access - L IJ placed in setting of hypotension in ICU. This was discontinued on [**8-15**], and tip was cultured. PICC was placed for IV antibiotics which will continue for 14 days, afterwhich time PICC can be discontinued. . # FEN - pt advanced to regular pureed diet on [**8-15**]. Pt kept on aspiration precautions given that she remains drowsy in setting of her UTI. . # CODE: pt's code status was made DNR/DNI per discussion with son, HCP in keeping with patient's wishes. Son is HCP. . # DISPO: pt being discharged to [**Hospital 100**] Rehab. Plan is to complete antibiotics as above (bactrim for UTI, clindamycin for lactobacillus bacteremia), and oral vancomycin for cdiff prophylaxis. She will readdress aspirin use as above. Medications on Admission: tylenol spiriva aspirin 81 mg feso4 daily plavix 75 mg fluticasone 220 mcg 1 puff [**Hospital1 **] milk of mag trazodone 50 HS PRN allopurinol 100 mg daily HISS prilosec TUMS [**Hospital1 **] Vit D 1000U dialy Maalox prn lactobacillus [**Hospital1 **] Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 8 days: Allegy noted. PCP said that he has never documented a reaction to it. 7. Insulin Lispro 100 unit/mL Solution Sig: One (1) units Subcutaneous ASDIR (AS DIRECTED). 8. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 9. Maalox 200-200-20 mg/5 mL Suspension Sig: One (1) PO every 4-6 hours as needed for heartburn. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 21 days: last day [**2159-9-5**]. 12. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1) 600mg Injection Q8H (every 8 hours) for 14 days: 600 mg IV q8hr, last day [**2159-8-29**]. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center Discharge Diagnosis: Primary Diagnosis: Upper GI Bleed Urinary Tract Infection Bacteremia . Secondary Diagnosis: Coronary Artery Disease Dementia Discharge Condition: You are being discharged at your baseline level of functioning. Your vital signs are stable and you have been assessed by physical therapy. Discharge Instructions: You were admitted after an ulcer in your GI tract bled enough that your vital signs become unstable and you required admission to the intensive care unit. After blood transfusions and careful monitoring, your vital signs stabilized and you were followed on the regular floors. You were also treated with antibiotics for a urinary tract infection and an infection in your blood stream. . The following changes were made to your medications" 1)You will need to take Bactrim for your urinary tract infetion. Please take 1 tablet by mouth twice a day for the next 8 days to end on [**2159-8-15**]. 2)We have discontinued your plavix, the milk of magnesia, tums, and lactobacillus. 3)Please discuss with your rehab doctors when to [**Name5 (PTitle) **] your aspirin. 4)The prilosec should now be taken twice a day by mouth. 5)Please take Clindamycin 600mg IV every 8 hours for 5 days to end [**2159-8-20**]. This is the treat the bacteria in your blood. 6)Please take Vancomycin 250mg by mouth 4 times a day for 12 days to end on [**2159-8-28**]. This is to prevent you from getting diarrhea from your other antibiotics. . You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab. . If you develop any of the following: chest pain, shortness of breath, palpataion, dizziness, nausea or vomiting, or bloody stools, please notify the doctors at Rehab [**Name5 (PTitle) **] go to your local Emergency Room. Followup Instructions: The doctors at rehab [**Name5 (PTitle) **] take care of you and will make recommendations that your should follow. Completed by:[**2159-8-16**]

Admission Date: [**2162-12-28**] Discharge Date: [**2163-1-9**] Date of Birth: [**2114-8-16**] Sex: M Service: MEDICINE Allergies: Codeine / Morphine Attending:[**First Name3 (LF) 6021**] Chief Complaint: fever Major Surgical or Invasive Procedure: Central line placement PICC line placement History of Present Illness: 48yo male with AIDS related [**Doctor Last Name 11579**] Lymphoma with CNS involvement s/p cycle 2 of R-IVAC (discharged [**12-24**]) developed chills, then checked temperature; noted fever to 100.5 at home and so presented to the ED. Denied cough, SOB, HA, urinary sx, CP, N/V/D/C. . ED Course: Febrile to 101.2, initially BP normal but fell to 70/30, HR tachycardic up to 150's. Code sepsis called. Initial labs significant for: lactate 3.3->4.3, WBC 0.1 w/ 17% PMNs, Hct 27.4, platelets 27->13. UCX, Blood Cx drawn. UA negative, CXR showed no acute cardiopulmonary process. RIJ CVL placed. CVP = 8. Given cefepime/vancomycin. Started on levophed, titrated up; eventually dopamine added. He received one unit of pRBC's. . Regarding his Burkitt's Lymphoma: Diagnosed in [**2162-10-2**] w/ BM bx [**10-18**]. CODOX and intrathecal cytarabine started on [**10-20**]. On [**10-21**], MRI demonstrated progressive CNS disease and he commenced whole brain XRT x 5 fractions of radiation (completed [**10-27**]). He was admitted from [**12-16**] through [**12-24**] for his second cycle of R-IVAC. Mr. [**Known lastname **] received rituximab on [**2162-12-16**], and his IVAC was started on [**12-17**]. He also received intrathecal liposomal cytarabine on [**2162-12-22**]. G-CSF was started on [**2162-12-23**]. During that admission he reported numbness of his left shoulder as well as bilateral fingertip numbness, thought to be due to vincristine-induced peripheral neuropathy, not a central process (MR [**First Name (Titles) **] [**Last Name (Titles) 11580**]). The patient was sent home with dexamethasone 4 mg PO bid x 2.5 days to complete a 5-day course. Plan is for 3 cycles each of CODOX (2 with Rituxan) and R-IVAC. Past Medical History: ONCOLOGIC HISTORY: He was initially admitted on [**10-14**] with ten days of increasing axillary adenopathy, fevers, chills, and night sweats. An inguinal lymph node biopsy was non-diagnostic and the diagnosis was confirmed on bone marrow biopsy performed on [**10-18**]. He was transferred to OMED service and commenced on CODOX and received intrathecal cytarabine on [**10-20**]. On [**10-21**], MRI demonstrated progressive CNS disease and he commenced WBXRT on [**10-22**]. He received five fractions of radiation and completed therapy on [**10-27**]. He developed tumor lysis with renal insufficiency following chemotherapy, but this resolved with supportive care. He has now received CODOX, R-IVAC, and R-CODOX. We are planning 3 cycles each of CODOX (2 with Rituxan) and R-IVAC. . PAST MEDICAL HISTORY: 1. Burkitt's Lymphoma as described above. 2. HIV as above, diagnosed in [**5-/2159**] thought to be contracted from an MSM contact after which he developed a viral-like syndrome. Has never been on HAART. 3. Left V1/V2 trigeminal zoster without ocular involvement in [**6-/2160**] 4. Viral orchitis in left testicle at age 15; testicle is chronically shrunken, "mushy", and tender, per patient 5. Chronic low back pain from herniated disc noted several yrs ago 6. Depression/Anxiety 7. HBcAb and HBsAb (+) (HBsAg neg) 8. s/p cholecystectomy in [**2145**] 9. Chronic anisocoria (per patient) with R>L Social History: He works for a small company doing computer programming. He denies tobacco use. Has used marijuana in the past, but denies IV drug use. He uses occasional alcohol, though none since his diagnosis. Family History: He reports that his father died of an MI in his 50s. His mother has diabetes. His sister has had zoster. Physical Exam: Physical Exam: VS - T99.0F, BP 116/61, HR 98, RR 15, Sat 99%RA GENERAL - Comfortable, no acute distress HEENT - Dry mucus membranes. Right eyelid droop. NECK - No cervical lymphadenopathy. No LUNGS - CTA bilaterally HEART - RRR normal S1/S2, no m/r/g ABDOMEN - Soft, NT, NT, + bowel sounds EXTREMITIES - Trace edema bilaterally SKIN - No rashes NEURO - Alert, oriented x 3, conversational Brief Hospital Course: ASSESSMENT/PLAN: 48yo male with AIDS related [**Doctor Last Name 11579**] Lymphoma with CNS involvement s/p cycle 2 of R-IVAC admitted with sepsis and pancytopenia. . # Sepsis/ Febrile neutropenia: GNR and methicillin resistant staph aureus on [**5-5**] blood cultures previously requiring pressors and course in [**Hospital Unit Name 153**]. Source unclear. Urine cx negative, CT sinus negative. TTE revealed no evidence of endocarditis with EF 50-55% and mild global systolic dysfunction likely secondary to sepsis. TEE not completed due to thrombocytopenia. Patient initially treated with cefepime and vancomycin. As sensitivities returned, coverage switched to Cipro and vancomycin. Vancomycin initially dosed by level in setting of acute renal failure. As renal function improved dosing switched to 1 gram q 12 hours. PICC line was placed and patient was sent home to complete 3 week course of cipro and 4 weeks total of vancomycin with follow up by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] from Infectious Disease. Given scripts to have weekly lab surveillance for Vancomycin including chemistries and vancomycin levels. . # Acute renal failure: urine lytes consistent with prerenal cause. FeNA 1%. Given IV fluids with improvement. However did not return to baseline at time of discharge. . # Altered mental status: Noted slowing and parkinsonian type features yesterday. Sent for CT head, revealed subdural hematomas. Seen by neurosx who felt evacuation not necessary. Neurology consulted also completed and felt no need for antiseizure meds at this time. Blood pressure was kept below 140 systolic and repeat CT head showed no progression. Platelets maintained above 60 and significantly improved prior to discharge. Parkinsonian features were not completely attributable to small subdural hematomas. Therefore seroquel discontinued as patient had cogwheel rigidity which can be a side effect of seroquel. . # C difficile colitis: Stool C difficile toxin positive. Started on course of flagyl for total of 14 days. However per ID curbside, patient should be treated for four weeks along with vancomycin. Therefore, Dr. [**First Name (STitle) **] was contact[**Name (NI) **] regarding appropriate duration of therapy in order to extend the total course of antibiotics. . #Pancytopenia: [**3-5**] recent chemo and complicated by sespis. Hct drifts downwards w/o transfusions, bone marrow not producing retics ANC increased with Neupogen and discontinued when count rose above 1000. . # Oral herpes: Treated with topical acyclovir. . #AIDS: Cont home ARV therapy . #Hyperglycemia: Insulin SS. Sugars improved as patient recovered from sepsis. . # Full Medications on Admission: Acyclovir 400 mg PO q12hr Ranitidine 150 mg PO BID Sertraline 100 mg daily Levofloxacin 500 mg daily x 10 days Neupogen 480 mcg daily x 10 days ATRIPLA [**Telephone/Fax (3) 567**] mg once daily Mirtazapine 15 mg PO qhs -> 7.5 since he was constantly hungry Ambien CR 12.5 mg qhs Compazine 5-10mg q 6-8 hours PRN Zofran 4 mg q 8 hrs Benadryl 50 mg qhs PRN- not taking- > nasal congestion Lorazepam 0.5-1 mg q 6 hr PRN Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous every twelve (12) hours: Last day: [**2163-1-28**]. Disp:*41 units* Refills:*0* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Last day: [**2163-1-11**] . Disp:*6 Tablet(s)* Refills:*0* 3. Outpatient Lab Work WEEKLY LABS: CBC, BUN/Cr, LFTs, Vanco trough (goal = 20) FAX to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] ([**Hospital **] CLINIC) at [**Telephone/Fax (1) 432**]. (All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 11581**] or to [**Name8 (MD) 11582**] MD in when clinic is closed.) 4. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous once a day. Disp:*30 flushes* Refills:*1* 5. Saline Flush 0.9 % Syringe Sig: [**6-10**] mL6 Injection SASH and PRN. Disp:*60 * Refills:*2* 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 7. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 13. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*5 Patch 72 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: PRIMARY: Bacteremia Hypotension Febrile neutropenia Mucositis Hyperglycemia SECONDARY: HIV/AIDS Burkitt's lymphoma Hepatitis B core/surface ab positive Anxiety Depression Eczema Low back pain/muscle spasm Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to the hospital because you had an infection in the blood. This is probably because you recently had chemotherapy and your immune system was compromised. You were treated with antibiotics and required a brief stay at the ICU for closer care and monitoring. You seem to be recovering so you will be discharged and will finish the remaining course of antiobiotics as an outpatient. You will be on Vancomycin until [**2163-1-28**]. You will be on Ciprofloxacin until [**2163-1-11**]. Remember to have your blood work checked every week while you are getting these antibiotics. Details: *** WEEKLY LABS *** CBC, BUN/Cr, LFTs, vanco trough (goal = 20) FAX'ed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] ([**Hospital **] Clinic) at [**Telephone/Fax (1) 432**]. (All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at If you have fevers or chills, please call your doctor immmediately. If you have chest pain or shortness of breath, or if there are any symptoms concerning to you, seek medical attention immediately or go to the nearest Emergency Department. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] within 1 week. Please call ([**Telephone/Fax (1) 11583**] . Please follow up with Infectious Disease Clinic: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2163-1-28**] 9:30 Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks: [**Last Name (LF) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 2393**]

Admission Date: [**2176-8-24**] Discharge Date: [**2176-8-28**] Date of Birth: [**2097-6-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: fever, UTI, hypotension Major Surgical or Invasive Procedure: None. History of Present Illness: 79 yo with h/o autonomic neuropathy c/b orthostatic hypotension, chronic foley, presents with suprapubic pain/spasma, hematuria. The patient and his wife state that yesterday, he started to have lower abdominal spasms. He denies dysuria, but does have a foley placed. HIs wife noted some hematuria and small clots as well. He has his foley changed every 3-4 weeks per his urologist. He had a UTI in [**1-19**] with klebsiella and pseudomonas. He denies chest pain or other abdominal pain. No changes in his stool. He denies melena or BRBPR. He does report some mild dyspnea. He states he felt feverish, and had some chills. He otherwise has no other complaints. In the ED, his vitals were 98.4, 106/57, 102, 16, 94% RA. Rectal temp was 103.9. He transiently became hypotnesive to 77/51 while in the ED. He has known autonomic neuropathy with hypotension, and according to the patient, his BP does go that low at home occasionally. He was given 1L NS with minimal effect, then given 2 more liters, but given his h/o SIADH, further NS was held. He was then started on peripheral norepinephrine, with improvement in his BP. He and his family refused a central line, so his levophed was stopped, and his BP remained in the mid 90s off the levophed. While in the ED, he had a positive UA, and was given Vancomycin 1 gm x 1, gentamycin 80 mg x 1, and levofloxacin 750 mg x 1. At that time, he was transferred to the MICU for urosepsis. Past Medical History: Primary autonomic failure with orthostatic hypotension and supine hypertension, diagnosed after he had a number of syncopal episodes GERD Urinary frequency; chronic foley Hx pancytopenia in [**1-17**], resolved spontaneously, negative lab w/u, has never had bone marrow bx, followed in past by Heme/Onc OSA papillary proliferation within bladder, likely urothelial neoplasm of low malig potential, followed by urology with serial cystoscopies hypothyroidism h/o hoarseness/cough, evaluated by ENT at OSH ?vocal cord dysfunction vs. reflux chronic low back pain colon polyps s/p polypectomy 5 years ago, next colonoscopy in [**2-18**]. Social History: Lives with his wife and [**Name2 (NI) 33558**], daughter also stays there. + tobacco- 5 cig/day x 10 yrs-quit [**2123**]. no EtOH currently. Family History: Father-colon CA. Mother-DM, dementia ?Alzheimer's Physical Exam: VS: 97.1 112/68 68 18 99% 2LNC GEN: elderly male, NAD, comfortable, quite voice, flat affect but pleasant HEENT: MM slightly dry CV: RRR LUNGS: decreased BS right lower base, otherwise clear ABDOMEN: soft, mild tenderness in suprapubic region but no rebound or guarding. normal BS EXT: 1+ BLE edema NEURO: A/O x 3; answers questions appropriately Brief Hospital Course: Briefly, this is a 79 yo male with h/o autonomic neuropathy c/b orthostatic hypotension, chronic foley, who presented with fevers, suprapubic pain, hematuria, and hypotension. The following problems were addressed during this hospitalization: . #. Sepsis: likely from urinary source. He presented with a positive UA, suprapubic pain, fever, and hematuria, with chronic foley. Patient has had a h/o klebsiella and pseudomonas from previous admission on a urine culture. Hypotension was attributed to a combined sepsis/baseline hypotension picture. He received fluids for pressure support, and had short course of levophed in the ED. His foley was changed in the ED. Following d/c of the pressor, SBP remained in the mid 90s. Per the patient, he has had 70s-90s at home and this is his baseline. UOP and mental status was closely monitored. He was begun on abx tx with cefepime 1 gm IV Q24. When culture sensitivities revealed an enterobacter sensitive to ciprofloxacin, the cefepime was d/c'd and replaced with ciprofloxacin, 750mg [**Hospital1 **] x14 day course. #. Hematuria. This was likely secondary to the patient's UTI. There was no evidence of foley trauma. The foley was changed in the ED. Hematuria was resolved by the time of transfer from the MICU to the floor. The patient has follow up with urology scheduled for early [**Month (only) **]. #. Autonomic neuropathy: known orthostatic hypotension. The patient was continued on midodrine and salt tabs at his outpt dose. He was given IVF cautiously as needed. PT was consulted to assist him with safe ambulation, and he was able to safely ambulate with assistance of his walker and his wife at the time of discharge. #. h/o SIADH: The patient's sodium remained wnl during the extent of his hospital course. It was noted that SIADH has lead to delerium in the past; no such delirium was noted during this hospitalization. # Pancytopenia. This patient has a history of pancytopenia which had spontaneously resolved in [**2173**], however, he was noted to be thrombocytopenic and anemic throughout this hospitalization. Further, while his leukocytes were within the typical normal range, given the extent of his bacteremia, he was noted to have a relative leukocytopenia with a peak WBC count of 6.2. All heparin products were held for the last three days of his hospital stay given the platelet nadir at 95,000. The recurrence of pancytopenia is recommended for outpatient follow up with is PCP and referral to a hematologist as necessary. Medications on Admission: Levothyroxine 50 mcg daily Citalopram 20 mg daily Midodrine 10 mg 6AM, 5 mg 11AM, 5 mg 4PM Oxybutynin 5 mg QAM omeprazole 20 mg daily Sodium Chloride tabs 2 tablets TID (8 AM, 2 PM, 8 PM) Discharge Medications: Ciprofloxacin, 750 mg [**Hospital1 **] x14days, final dose is am dose on [**2176-9-11**] Levothyroxine 50 mcg daily Citalopram 20 mg daily Midodrine 10 mg 6AM, 5 mg 11AM, 5 mg 4PM Oxybutynin 5 mg QAM omeprazole 20 mg daily Sodium Chloride tabs 2 tablets TID (8 AM, 2 PM, 8 PM) Discharge Disposition: Home With Service Facility: Preferred Home Health Discharge Diagnosis: Enterobacter sepsis Urinary tract infection Autonomic neuropathy Discharge Condition: Stable. Orthostatic hypotension and labile SBP ranging from 70s to 160s. Chronic foley in place. Tolerating po well. Ambulating with assistance. Discharge Instructions: You were admitted to the hospital because you had low abdominal pain, bladder spasms, and blood in your urine. You were found to have a bladder infection that had spread to your blood. You were treated with antibiotics. If you notice any further abdominal pain, blood in the urine, bladder spasms, fevers, chills, night sweats, falls, pain, or anything else that concerns you, please seek medical attention. Please take all of your medications as prescribed. Please follow up with your primary doctor, Dr. [**Last Name (STitle) **], on Monday, [**2176-9-2**] at 11:15am. Followup Instructions: Dr. [**First Name8 (NamePattern2) 3065**] [**Last Name (NamePattern1) **]: Monday [**2176-9-2**] at 11:15am. Phone: [**Telephone/Fax (1) 33744**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19969**], M.D. Phone:[**Telephone/Fax (1) 8139**] Date/Time:[**2176-9-26**] 1:00 Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2176-10-16**] 3:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2176-8-28**]

Admission Date: [**2199-11-19**] Discharge Date: [**2199-11-28**] Service: Cardiology HISTORY OF PRESENT ILLNESS: This is an 86 year old male with a past medical history of lung cancer, status post pneumonectomy, abdominal aortic aneurysm, aortic valve disease, history of peptic ulcer disease who presents with shortness of breath and chest pain two days prior to admission. The patient states that three days prior to admission he had difficulty sleeping secondary to general discomfort, difficulty lying flat, secondary to shortness of breath, and some stuttering right-sided chest pain. However, the patient was unable to sleep through the night. One day prior to admission, during the night again, the patient had more difficulty sleeping secondary to worsening shortness of breath when lying flat and more frequent episodes of right-sided chest pain. He states that he sat up in bed for most of the night and could not sleep at all the night prior to admission. He denies any nausea or vomiting, no diaphoresis, no palpitations. The day of admission, the patient states that after returning from the grocery store the patient thought he was going to collapse. He states his whole body felt weak, extremely short of breath and he noted a small amount of hemoptysis. The patient presented to the Emergency Room in a taxi cab. In the Emergency Room, the patient was noted to be short of breath, he was speaking in short sentences. His respiratory rate was 36 and oxygen saturation was 71% on room air. His blood pressure at that time was 164/103. His heartrate was 126. He was noted to have coarse breathsounds throughout. The patient was placed on 100% nonrebreather face mask. Electrocardiogram showed a sinus tachycardia to 115 with some J point elevations in leads V2 through V3 as well as incomplete left bundle branch block. He was given Lasix 80 mg intravenously times two, nitroglycerin drip was started and he was also given some Morphine 2 mg intravenously and Lopressor 2.5 mg intravenously times two. In the Emergency Room his creatinine kinase was 1209 with an MBI of 19, troponin was 2.7. The patient was started on heparin. His blood pressure decreased to 115/70. The patient was unable to wean off of 100% nonrebreather mask. The chest x-ray was consistent with pulmonary edema. After receiving the Lasix in the Emergency Room, the patient was feeling much better. The patient has denied shortness of breath and denies chest pain. PAST MEDICAL HISTORY: Lung cancer, status post partial pneumonectomy. Abdominal aortic aneurysm. History of peptic ulcer disease. Aortic valve disease. Gout. MEDICATIONS ON ADMISSION: 1. Aspirin 2. Lipitor 3. Allopurinol ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco use, no alcohol use. The patient lives with his daughter in the [**Name (NI) 1426**] [**Name (NI) 26498**]. PHYSICAL EXAMINATION: Physical examination on admission revealed temperature 98.2, heartrate 81, blood pressure 110/71, respiratory rate 32, oxygen saturation was 95% on 100% nonrebreather facemask. In general the patient appeared comfortable, lying in bed at an angle of 30 degrees on a nonrebreather mask. Head, eyes, ears, nose and throat: His right pupil was cloudy. His left pupil reactive to light. Sclerae anicteric. Oropharynx clear. Moist mucous membranes. Cardiovascular examination: Regular rate and rhythm, he has a normal S1 and S2. No murmurs, rubs or gallops audible. His abdomen was soft, nontender, nondistended with active bowel sounds. His lungs, coarse breathsounds throughout. Extremities, no edema. LABORATORY DATA: On admission his white blood cell count was 13.1, hematocrit 35.9, platelets 153. His MCV was 110, sodium 141, potassium 4.8, chloride 107, bicarbonate 20, BUN 54, creatinine 3.8, and glucose 257. His creatinine kinase on admission was 1209 with an MB of 328, MB index of 19 and troponin of 2.71. Urinalysis on admission: Yellow, clear, 1.025, 100 protein, 0-2 red blood cells, 3 white blood cells, rare bacteria, [**3-27**] epithelial cells. Chest x-ray showed a pulmonary edema with a left pleural effusion. HOSPITAL COURSE: The patient was admitted to the Medical Floor after his respiratory status improved after receiving Lasix in the Emergency Department. Over night the patient remained stable, however, the next morning the patient was noted to be more hypotensive and to be in increasing respiratory distress. In addition, the patient had a traumatic Foley catheter insertion and developed some significant hematuria. The Urology Service was consulted and the patient was started on continuous bladder irrigation with resolution of the hematuria. Due to his worsening respiratory status, the patient was taken immediately to catheterization for evaluation of possible blockage, given that the patient ruled in for myocardial infarction. The patient was then transferred to the Intensive Care Unit post catheterization. Catheterization showed left main coronary artery disease with a 20% ostial stenosis. Left anterior descending artery has a 90% mid stenosis involving D2, as well as 60% ostial/proximal stenosis. There was also 80% left circumflex stenosis and 80% proximal right coronary artery stenosis. PTCA and stenting was performed during catheterization, on the left circumflex and on the mid left anterior descending. During the catheterization, the patient was emergently intubated for worsening respiratory status. It was thought the patient was in cardiogenic shock secondary to an anterolateral myocardial infarction. The patient was started on Dopamine drip. He was also started on Natrecor drip to diurese. In the Intensive Care Unit the patient was noted to have acute renal failure with creatinine increasing to 5.1. It was thought this likely secondary to the dye load from the catheterization in the setting of chronic renal insufficiency. The patient was also noted to have a temperature spike to 101 degrees F. The patient received Vancomycin times one and was started on Levofloxacin and Flagyl. The patient was slowly weaned off of Dopamine and extubated on [**2199-11-22**]. The patient was continued on a heparin drip on transfer to CCU. The patient developed a hematocrit drop from 35.9 to 27 to 23. The heparin was discontinued and the patient was transfused 2 units of red blood cells with improvement of his hematocrit to 30.8 prior to transfer out of the Intensive Care Unit. While in the unit the patient continued to demonstrate congestive heart failure. The patient was treated with Hydralazine and Isordil as well as Lasix intravenously prn urine output. The patient had a renal ultrasound which documented no hydronephrosis bilaterally. The ultrasound did show that the renal cortices were thin and that the kidneys were overall small in size suggestive of some element of chronic renal disease. The patient was transferred out of the Intensive Care Unit on [**2199-11-25**]. At the time of transfer, the patient was afebrile, his heart rate was 93, his blood pressure was 124/55. Respiratory rate was 18 and he was sating 95% on 4 liters nasal cannula oxygen. In terms of his cardiovascular disease, the patient was continued on his Aspirin, Plavix, statin as well as Carvedilol on transfer to the Medicine Floor. The patient remained chest pain free throughout the remainder of the hospital stay. In terms of his congestive heart failure, the patient was noted to have an ejection fraction of less than 15% with global severe hypokinesis to akinesis. He appeared euvolemic on transfer to the Medical Floor, however, he was noted to have some coarse crackles at the base bilaterally. The patient was diuresed with Lasix intravenously. In addition, the patient's Hydralazine was increased to 25 t.i.d. with a goal dose being 75 mg p.o. t.i.d. He was also continued on his Isosorbide which was increased to 20 mg t.i.d. with a goal dose being 40 t.i.d. The medications were increased as blood pressure permitted with a goal systolic blood pressure of greater than 90. Given the patient's decreased ejection fraction, the patient should have an electrophysiology consult as an outpatient regarding implantable cardioverter defibrillator placement. Concerning the patient's renal failure, his acute renal failure was secondary to dye load during catheterization and was noted to improve from a creatinine 5.2 on transfer to 3.6 prior to discharge. The patient was able to maintain good urine output throughout the remainder of the hospitalization. It was felt that this renal function would likely continue to improve. In terms of his fluids, electrolytes and nutrition, the patient was continued on pureed, soft/solid diet and slowly advanced to solids, 2 gm sodium-restricted diet. The patient was also continued on Boost t.i.d. per Nutrition recommendations. The patient was noted to become hypernatremic and slightly hyperchloremic with Lasix diuresis and Lasix was appropriately decreased. The patient was also encouraged to drink free water. In addition during the hospital stay the patient was noted to have increased blood sugars that were likely secondary to the stress of acute illness. He was maintained on insulin sliding scale after transferred out of the Intensive Care Unit to the Medical Floor. The patient's blood sugars should be followed and the patient may need to be started on oral hypoglycemic agents in the future if his blood sugar does not improve. By [**2199-11-27**], the patient's mental status had much improved, respiratory status was stable, his creatinine was improving and it was thought the patient was stable for transfer for further rehabilitation and physical therapy at [**Hospital3 **]. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSIS: 1. Acute myocardial infarction complicated by cardiogenic shock 2. Congestive heart failure 3. Anemia 4. Mild aortic stenosis 5. Acute renal failure 6. Chronic renal failure DISCHARGE STATUS: To home with services. The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] his primary care physician within the next month, and with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] for his cardiovascular and electrophysiologic issues. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Atorvastatin 10 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. 4. Insulin sliding scale 5. Ipratropium bromide nebulizer 1 neb q. 6 hours prn 6. Carvedilol 3.125 mg p.o. b.i.d. 7. Lansoprazole 30 mg p.o. q.d. 8. Isosorbide dinitrate 20 mg p.o. t.i.d. 9. Hydralazine 50 mg p.o. q. 6 hours 10. Lasix 10 mg p.o. q.d. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2199-11-27**] 21:38 T: [**2199-11-27**] 22:48 JOB#: [**Job Number 26499**] cc:[**Hospital3 26500**]

Admission Date: [**2144-8-25**] Discharge Date: [**2144-9-11**] Date of Birth: [**2063-8-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Cardiogenic shock. Major Surgical or Invasive Procedure: Intra-aortic Balloon pump placement Impella - Left Ventricular Assist Device Cardiac catheterization PICC placement Left Groin Central Venous Catheter. SWAN catheter placed, Left groin History of Present Illness: This is an 81 year old gentleman with a past history of coronary artery disease (CAD), status-post coronary artery bypass grafting (CABG) (SVG to OM, SVG to RCA and LIMA, [**7-/2140**]) who underwent elective right total hip replacement on [**2144-8-25**]. His post-operative course was complicated by anginal symptoms during physical therapy ([**2144-8-26**]). The patient was noted to have dynamic ECG changes and CK 667, MB 12, Trop 0.11. Conservative management, including heparin was initiated, with plan for possible catheterization and some future point. Over the course of the day, the patient remained borderline hypotensive and was noted to have a decrease in urine output. Urine electrolytes suggested a pre-renal etiology. The patient received several litre boluses on the floor. Subsequently, the patient continued to have low blood pressures and was transferred to the [**Hospital Unit Name 153**], where he continued to received IV fluid boluses. He was later found to have a fall in his hematocrit from 29 to 24 and was transfused 2 units PRBC. The patient continued to become progressively hypotensive to systolic in 50s, despite running saline through 2 IVs as well as PRBCs through a third. He became progressively distressed, diaphoretic, and began complaining of substernal chest discomfort. Code blue was called and patient was intubated. Prior to intubation, patient had a large emesis that he was witnessed to aspirate. He received a total of 9 litres fluid, and had progressively escalating vasopressor requirement, needing maximum doses of first dopamine, then neosynephrine, then levophed. This maintained his blood pressure in systolic of 90s. ECG initially was similar to prior tracings earlier in the day, but the patient subsequently evolved a rhythm that appeared to be accelerated idioventricular with RBBB morphology. Cardiology was called and bedside echocardiogram was performed. This demonstrated some focal wall motion abnormality and possibly some evidence of right-heart strain. Bedside LENIs were obtained to assess for source of possible source of PE, and these were negative. Decision was made to transfer the patient to the cardiac catheterization laboratory for further evaluation and management. Past Medical History: - CAD, status-post CABG X 3 '[**40**], - Hypertension, - Hypercholesterolemia - Chronic Renal Insufficiency, - Gallstone pancreatitis status-post cholecystectomy [**6-11**], - Status-post lumbar laminectomy (L4-5) in [**2140-2-4**] for - spinal stenosis. - R-hip degenerative arthritis s/p elective total hip replacement [**2144-8-25**] - Benign prostatic hyperplasia - Gastroesophageal reflux disease. - History of a difficult intubation. - History of torn cartilage in the right knee. Social History: Patient lives with wife, has 3 children. He is retired and his previous occupation was as a mens' apparel businessman and CFO for his son's construction buisiness. No tobacco, rare social EtOH, and no other drug use. Family History: Father: 1st MI early 60's; Mother: CVA; No siblings with CAD Physical Exam: T: 33 C, HR 94, BP 105/55 (IAMP: systoly 98, augmented diastoly 109, IABP mean 80), respiratory on AC 550/26 PEEP 20 witgh an ABG 7.19/40/75/15 SPO2 78 General: intubated and sedated, pupils areactive and at 2mm Neck: difficult to assecc JVD Lungs: clear anteriorly Heart: soft s1, RRR, no holosystolic murmur appreciable Abdomen: distended and w/o bowelsounds Extremities: patient warm as on heating blanket, pulses dopplerable, trace edema Pertinent Results: Labs on admission: [**2144-8-26**] 07:00AM BLOOD WBC-12.1*# RBC-3.12* Hgb-9.9* Hct-29.3* MCV-94 MCH-31.8 MCHC-33.8 RDW-13.4 Plt Ct-173 [**2144-8-27**] 06:55AM BLOOD Neuts-85* Bands-10* Lymphs-4* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2144-8-27**] 01:30AM BLOOD PT-18.8* PTT-150* INR(PT)-1.7* [**2144-8-26**] 07:00AM BLOOD Glucose-156* UreaN-25* Creat-1.4* Na-136 K-4.7 Cl-103 HCO3-23 AnGap-15 [**2144-8-27**] 01:30AM BLOOD ALT-15 AST-49* LD(LDH)-152 CK(CPK)-667* AlkPhos-42 TotBili-0.4 [**2144-8-26**] 07:00AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.7 [**2144-9-1**] 06:37AM BLOOD calTIBC-129* Ferritn-858* TRF-99* [**2144-9-2**] 04:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2144-8-25**] 05:52PM BLOOD Glucose-112* Lactate-1.5 Na-137 K-4.3 Cl-105 Labs on discharge: [**2144-9-11**] 05:42AM BLOOD WBC-8.4 RBC-2.91* Hgb-8.8* Hct-26.6* MCV-92 MCH-30.4 MCHC-33.2 RDW-14.9 Plt Ct-438 [**2144-9-6**] 06:53AM BLOOD Neuts-81.1* Lymphs-11.7* Monos-4.8 Eos-1.9 Baso-0.4 [**2144-9-11**] 05:42AM BLOOD PT-33.7* PTT-43.4* INR(PT)-3.5* [**2144-9-11**] 05:42AM BLOOD Glucose-113* UreaN-52* Creat-2.3* Na-138 K-3.8 Cl-102 HCO3-30 AnGap-10 [**2144-9-11**] 05:42AM BLOOD Calcium-7.8* Phos-3.9 Mg-2.3 Cardiac enzymes: [**2144-8-29**] 05:49AM BLOOD CK-MB-51* MB Indx-2.1 cTropnT-6.58* [**2144-8-28**] 12:49PM BLOOD CK-MB-186* MB Indx-4.7 cTropnT-9.19* [**2144-8-27**] 09:18PM BLOOD CK-MB-GREATER TH cTropnT-7.29* [**2144-8-27**] 05:04PM BLOOD CK-MB-GREATER TH cTropnT-6.58* [**2144-8-27**] 06:55AM BLOOD CK-MB-343* MB Indx-19.6* cTropnT-1.42* [**2144-8-27**] 01:30AM BLOOD CK-MB-55* MB Indx-8.2* cTropnT-0.36* [**2144-8-26**] 07:21PM BLOOD CK-MB-17* MB Indx-2.5 cTropnT-0.11* Cardiac cath #1 on [**2144-8-27**]: COMMENTS: 1. Selective coronary angiography in this right dominant system revealed three vessel coronary disease. The LMCA had a 50% in the midsegment. The LAD had a mid-vessel occlusion with a 70% diag1 lesion. The proximal LCX had a 60% lesion, a 70% mid lesion and an 80% OM1 stenosis with diffuse disease noted. The RCA was not engaged but was known to be occluded. 2. Selective conduit arteriogrpahy revealed a patent LIMA to LAD with good collaterals to the RCA. 3. Venous conduit angiography was not performed as the SVG to RCA and SVG to OM were known to be occluded from prior cardiac catheterization. 4. Resting hemodynamics revealed systemic hypotension with SBP of 109 mmHg on three IV pressor agents. Right sided and left sided filling pressures were elevated with RVEDP of 29 mmHg and mean PCWP of 46 mmHg. There was pulmonary arterial hypertension with PASP of 57 mmHg. Cardiac index was preserved with CI of 3.88 l/min/m2. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA to LAD. 3. Elevated right and left sided filling pressures 4. Successful insertion of IABP. Cardiac cath #2 on [**2144-8-27**]: COMMENTS: 1. Pulmonary angiography of the right and left pulmonary artery demonstrated normal filling of contrast with no obvious flow limiting pulmonary emboli. 2. Selective angiography of the abdominal arteries demonstrated a patent celiac, superior mesenteric artery and inferior mesenteric artery - no obvious source for mesenteric ischemia. 3. Successful placement of the Impella cardiac support unit following successful removal of the intraortic balloon pump. 4. Towards the conclusion of the case the patient experienced an PEA cardiac arrest and was successfully resuscitated. 5. Limited resting hemodynamics demonstrated elevated right and left heart filling pressures along with depressed cardiac output with an index of 1.8 L/min/m2. 6. Pt with increasing ventilator requirements with poor oxygenation. Switched from oxygen to nitric oxide with improved oxygenation. FINAL DIAGNOSIS: 1. No evidence of pulmonary emboli. 2. No evidence of mesenteric emboli. 3. Cardiogenic shock requiring multiple pressors along with placement of an Impella cardiac support pump. Removal of the IABP. 4. PEA cardiac arrest with successful resuscitation. Lower ext. ultrasound [**2144-8-27**]: IMPRESSION: No deep vein thrombosis in bilateral lower extremity. Please note that right common femoral could not be evaluated due to line and bandages. ECHO [**2144-9-1**]: The left and right atrium are moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF 45%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. A small vegetation on the non-coronary leaflet cannot be fully excluded (clip #[**Clip Number (Radiology) **]). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2144-8-28**], bitventricular systolic function has markedly improved and mild pulmonary artery systolic hypertension is now identified. Trace aortic regurgitation is also now seen (the aortic valve was previously distorted and is better defined on the current study). Brief Hospital Course: 81 year old male with extensive cardiac hx on POD1 c/o of CP/back pain, who came in for Right total hip repalcement and on POD#1 from Right Total hip replacement He started having chest pain and hypotension with ECG changed consistent with an NSTEMI. he was started on a heparin drip and his blood pressure medications were held. His urine output decreased and he was transferred to the MICU. His condition continued to worsen, he became more hypotensive and required intubation for respiratory support. His hematocrit also dropped and he required 2 units of blood. An ECHO showed an EF of 25% and he was taken to the cath lab. There was no obvious cardiac lesion. A balloon pump was placed to maintain cardiac output, he was started on pressors and he was transferred to the CCU. He developed a fever and was started on broad spectrum antibiotics. He was cathed again and the intra-aortic balloon pump was exchanged for an Impella device. There was no evidence of a pulmonary embolism. He developed cardiogenic shock and went into a PEA arrest requiring CPR. He had another PEA arrest a few hours after and was again resuscitated. He required three pressors for blood pressure support. His pressures improved and the impella device was removed. His blood cultures grew out Vancomycin resistant enteroccocus and he was started on Linezolid. His swan was pulled and a PICC was placed. His blood pressures normalized and he was weaned off of pressors. He begain to improve and was able to be extubated. He tolerated PT well over the next few days and was able to be tranfered to the general medical floor. He was stable on room air at rest, although he did require O2 (2L nasal cannula) when ambulating. He is stable for discharge. On discharge his Imdur and doxasosin were held. He requires coumadin for 6 weeks for his hip replacement with an INR goal of [**3-7**].5. He was resumed on his home medication regimine. His staples will need to come out between [**Date range (1) **]. This can be done at a rehabilitation hospital or PCP [**Name Initial (PRE) 3726**]. Medications on Admission: Milk of Magnesia 30 ml PO Multivitamins 1 CAP PO DAILY Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP 150 mEq Sodium Bicarbonate/ 1000 mL D5W Continuous at 150 ml/hr for [**2136**] ml Order date: [**8-27**] @ 0815 19. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP 60 Allopurinol 300 mg PO DAILY Piperacillin-Tazobactam Na 2.25 g IV Q8H Aspirin 325 mg PO DAILY Atorvastatin 40 mg PO DAILY Ranitidine 150 mg PO BID Calcium Carbonate 500 mg PO TID Senna 1 TAB PO BID:PRN Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days DOPamine 5-20 mcg/kg/min IV DRIP TITRATE TO MAP 60 Docusate Sodium 100 mg PO BID Famotidine 20 mg PO BID Vancomycin 1000 mg IV Q48H Ferrous Sulfate 325 mg PO DAILY Vitamin D 1000 UNIT PO DAILY traZODONE 50 mg Insulin SC Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four times a day. 6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 10. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for pain. 11. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**] Discharge Diagnosis: Cardiac Arrest Acute on Chronic Renal Failure VRE Bacteremia Acute Respiratory Failure Cardiogenic Shock Ileus Status-post total right hip replacement [**2144-8-25**] Discharge Condition: Vital signs stable. afebrile. Ok to go to rehab. Discharge Instructions: You had an infection in your blood and acute respiratory and kidney failure that is now resolving. You are still receiving an oral antibiotic to treat the blood infection. You had a catheterization that showed some moderate blockages in your coronary arteries but they were not severe enough to get a balloon procedure or a stent. Your bowel function slowed because of your illness, however there is no evidence of infection in your stool. Medication changes: Please stop taking Imdur and Doxazosin. Your staples will need to come out between [**9-20**] and [**9-23**]. This can be done at your [**Hospital **] Hospital or at your primary care phycisian's office. Please adhere to your follow-up appointments. They are important for managing your long-term health. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Orthopedic surgery: Provider: [**First Name8 (NamePattern2) 4599**] [**Last Name (NamePattern1) 9856**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2144-9-22**] 4:00 Cardiology: Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) 122**], MD Phone: [**Telephone/Fax (1) 5068**] Date/Time:Thursday [**9-24**] at 11:00am Primary Care: Provider: [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**], MD Phone: [**Telephone/Fax (1) 3329**] Date/Time: Wednesday [**10-14**] at 11:30am. Opthamology: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2144-11-10**] 10:00

Admission Date: [**2174-12-17**] Discharge Date: [**2174-12-29**] Date of Birth: [**2095-2-8**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: coronary artery bypass grafts (LIMA-LAD, SVG-OM1, SVG-OM2,SVG-DG) [**12-21**] left heart cathaterization and coronary angiography History of Present Illness: This is a 79 year-old male with a history of hypertension, hyperlipidemia, PVD, malignant melanoma and non-hodgkins lymphoma who presents for evaluation of chest pain. The pain has felt squeezing in nature, does not radiate, is not associated with other symtpoms and has been episodic for the past 5 days. It typically had resolved quickly but when it did not resolve last night after several minutes he came to the hospital. No nausea, diaphoresis, or shortness of breath. There is no history of exertional dyspnea, PND, orthopnea, presyncope, syncope, or palpitations. In the ED his EKG was WNL but cardiac enzymes were positive and this was felt to be a NSTEMI. A head CT ruled out brain metastasis and the patient was started on a heparin infusion, aspirin 325, metoprolol 25mg. He was admitted for cardiac catheterization. Past Medical History: Diabetes Dyslipidemia Hypertension h/o Stage IIIB melanoma h/o B-cell non-Hodgkinds lymphoma History of basal cell carcinoma. benign prostatic hypertrophy. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He is a retired schoolteacher and administrator. He has been married for more than 50 years. He has two children and five grandchildren. . Family History: Family history significant for father who had heart disease and possible anemia. Mother died of heart disease. He has a brother who is healthy, sister died from complications of obesity, likely heart disease. His children are healthy. He has one grandchild with celiac disease. Physical Exam: Discharge: Awake and alert. Has advanced to soft diet as directed by speech pathology evaluation. Lungs- clear Cor: NSR at 80. Extremeties- warm, without edema Wounds- clean and dry. Stable sternum (PT does rarely complain of clicking, but it is lateral to sternum) 122/65. Wt 99kg (v.100 preop) Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 15423**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 15424**] (Complete) Done [**2174-12-21**] at 1:52:25 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] Information Date/Time: [**2174-12-21**] at 13:52 Interpret MD: [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW33-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 45% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Arch: *3.2 cm <= 3.0 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 15 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 10 mm Hg Aortic Valve - Valve Area: *1.3 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Moderate symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferiolateral walls. EF is approximately 50%. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Left and right ventricular function is preserved. The aorta is intact. The remainder of the examination is unchanged. Dr.[**Last Name (STitle) 914**] was notified of the results in person at the time of the study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2174-12-22**] 15:02 FInal Report STUDY: Carotid series complete. FINDINGS: Duplex evaluation was performed of bilateral carotid arteries. There is mild plaque seen in the proximal ICAs bilaterally. On the right, peak velocities are 90, 90, and 123 cm/sec in the ICA, CCA, and ECA respectively. This is consistent with less than 40% stenosis. On the left, peak velocities are 104, 101, and 83 cm/sec in the ICA, CCA, andECA respectively. This is consistent with less than 40% stenosis. There is antegrade vertebral flow bilaterally. IMPRESSION: Bilateral less than 40% carotid stenosis. Brief Hospital Course: This 79 year old male presented to the emergency room with a complaint of chest pain. His EKG showed no acute changes but his cardiac bio markers were elevated. He was admitted and diagnostic cardiac catheterization showed severe coronary artery disease. Cardiac surgery was consulted for evaluation for revascularization. He was brought to the operating room on [**2174-12-21**] and underwent 4-vessel CABG. Please see operative note for full details. The surgery was uncomplicated and he weaned from bypass on neosynephrine. He was transferred to the cardiac surgical ICU post-operatively for invasive hemodynamic monitoring. He was extubated on POD 1. He required intravenous nitroglycerine for several days to control his blood pressure. He was gently diuresed towards his pre-operative weight and was transferred to the step-down floor on POD 5. He failed speech and swallow on POD 5 and had a video-swallow study on POD 6 he was able to take a ground solids/thin liquids diet. This was tolerated and advanced to soft on [**12-28**]. He remained stable and was ready for transfer to rehabilitation for further recovery prior to return home. Discharge instructions, medications and follow up instructions were outlined with the transfer information. Medications on Admission: Lipitor 10mg po daily Terazosin 5mg po daily Diovan 160mg daily Atenolol 50 mg po daily Aspiring 81mg po daiily Discharge Medications: 1. Influen Tr-Split [**2174**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Tablet(s) 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale Injection ASDIR (AS DIRECTED): 120-160-2units SQ 161-200-4units SQ 201-240-6units SQ 241-280-8units SQ. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass graft benign prostatic hypertrophy noninsulin dependent diabetes mellitus hyperlipidemia h/o B cell nonHodgkins Lymphoma peripheral vascular disease hypertension h/o melanoma Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 131**] in 1 week ([**Telephone/Fax (1) 133**]) Dr. [**Last Name (STitle) 1016**] in 2 weeks please call for appointments Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2174-12-28**]

Admission Date: [**2182-9-7**] Discharge Date: [**2182-9-18**] Service: MEDICINE Allergies: Aspirin / Adhesive Tape Attending:[**First Name3 (LF) 1436**] Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: -Cardiopulmonary resuscitation -Endotracheal intubation History of Present Illness: 89F CAD, Afib, DM2 felt "strange" around 9pm last night with malaise. Denies CP or SOB. Presented to [**Hospital3 4107**] ED, where her HR was in 150s with question of SVT. She was given IV dilt and HR came back to SR 60/min. Patient reported feeling much better. She denied any CP this time. She uses a walker to ambulate but denied DOE. No N/V. Her ECG in at OSH showed ST elevations in V2-V5 and III, w/ Q waves V2-V4,inferior. She was transferred to [**Hospital1 18**] for further management. Past Medical History: Coronary Artery Disease s/p MI 15y ago s/p angioplasty Afib on coumadin Hypertension Hypercholesterolemia Upper GI [**Last Name (un) **] 10y ago Osteoarthritis (primarily affecting knees) Social History: Lives on her own in [**Hospital1 **], has family nearby, mostly independent & takes care of herself, no tobacco, occ EtOH Family History: non-contributory Physical Exam: VS: T97.1 , BP 114/66 , P86 , SaO298%2L at RR22 GENERAL: No apparent distress HEENT: PERRLA, MMM NECK: no JVD CHEST: CTAB CVS: irreg, 1/6 SEM ABD: +BS. soft, NT/ND. EXT: Warm, without edema. SKIN: no rash NEURO: AO3, moving all spontaneously Pertinent Results: Admission Labs: [**2182-9-7**] 07:50AM WBC-6.2 RBC-3.73* HGB-11.4* HCT-35.7* MCV-96 MCH-30.6 MCHC-32.0 RDW-14.6 PLT COUNT-156 [**2182-9-7**] TSH-1.9 [**2182-9-7**] CK-MB-24* MB INDX-15.7* cTropnT-1.23* [**2182-9-7**] CK(CPK)-153* [**2182-9-7**] GLUCOSE-146* UREA N-33* CREAT-1.3* SODIUM-142 POTASSIUM-5.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14 . Discharge Labs: [**2182-9-18**] WBC-6.2 RBC-3.26* Hgb-9.8* Hct-31.2* MCV-96 MCH-30.1 MCHC-31.4 RDW-15.2 Plt Ct-269 [**2182-9-18**] PT-20.5* INR(PT)-2.0* [**2182-9-18**] Glucose-99 UreaN-22* Creat-1.2* Na-140 K-4.8 Cl-106 HCO3-27 AnGap-12 [**2182-9-12**] -32 AST-40 LD(LDH)-199 AlkPhos-122* TotBili-0.9 [**2182-9-12**] CK-MB-NotDone cTropnT-0.37* [**2182-9-17**] Calcium-8.4 Phos-3.0 Mg-2.2 Imaging: [**2182-9-18**] CXR - FINDINGS: In comparison with the study of [**9-12**], there is again acute enlargement of the cardiac silhouette. Although the retrocardiac area is poorly seen, there does appear to be some increased opacification that would be consistent with atelectatic change. Mild prominence of the right hilar vessels, though no definite increase in pulmonary venous pressure is appreciated. . [**2182-9-9**] TTE: EF 30%. The left atrium is mildly dilated. The right 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 severe regional left ventricular systolic dysfunction with septal, anterior and distal LV akinesis. No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: 89yo F w/ CAD s/p MI, Afib, DM2, transferred to [**Hospital1 18**] here w/ wide complex tachycardia and elevated CEs. * Wide complex tachycardia: On admission, pt was thought to have supraventricular tachycardia with right bundle branch block. She was given adenosine; however, the adenosine did not break rhythm. The rhythm lasted for a few hours and broke spontaneously. The pt was hemodynamically stable during the event. She noted only a mild discomfort in her interscapular area. Approximately 24hr after the rhythm broke she went into it again, w/o hemodynamic compromise or symptoms. Again, the rhythm broke spontaneously after a few hours--metoprolol was given during the event without apparent effect. EP was consulted (Dr. [**Last Name (STitle) **] was initially EP attending, then Dr. [**Last Name (STitle) **]. They determined that the rhythm was actually a narrow, monomorphic ventricular tachycadia with RBBB and an inferior axis, likely arising in/near the septum. (Of note, the official EKG readings in OMR do not describe the rhythm as VT--see EKG from [**2182-9-7**] at 4:23 for an example of the VT.) Pt had a third episode of VT, during which she was given lidocaine with good response. Discussion was had between the team, the pt, and the pt's family about whether the pt should undergo an EP study or start amiodarone empirically without an EP study. Given the patient's overall clinic picture and wishes, amiodarone was started, no EP study was done. She was loaded with approximately 6grams of amiodarone. She was then continued on 200mg daily for maintenance. The patient had no further episodes of ventricular tachycardia after starting the amiodarone. Of note the patient had normal thyroid & liver function prior to starting amiodarone. She is scheduled to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at his [**Hospital1 **] office on [**2182-10-15**] at 2:40pm. She will likely need baseline pulmonary function tests, ophthomalogic exam, and repeat thyroid & liver function tests. * PEA arrest: After the patient's third episode of VT broke, she had a severe coughing fit, and became hypoxic with 02 into the 70s. She then went into PEA arrest, presumably from hypoxia, as no other cause was found. CPR was performed for less than 5 minutes before a spontaneous rhythm was achieved. However, the patient was intubated given concern over her ability to proctect her airway. The patient was intubated for less than 48hr. * Coronary artery disease: Pt has a remote history of an MI approximately 15yr, at which time she underwent angioplasty. Prior to transfer to [**Hospital1 18**], she had diffuse ST elevations on EKG at OSH. These had resolved by time of admission here. Pt was without chest pain. CE were elevated on admission & trended down. Her EKGs from OSH were reviewed and it was questioned whether the ST elevations were from ischemia vs. repolarization change or pericarditis. Given her lack of CP and overall clinical picture, it was felt that she did not need to go for cardiac catheterization. She was continued on her statin. Her b-blocker (coreg) was given until she was started on amiodarone, at which time it was stopped due to bradycardia occasionally into the 40s (without symptoms). She is being discharged off of coreg. Caution should be used with b-blockers given she has first degree AV block and is on amiodarone. The pt refuses aspirin due to prior bleeding with it. * Atrial fibrillation: Rate controlled with amiodarone. Coreg discontinued due to bradycardia (hr 40-50s on amio). Coumadin dose decreased to 1.5mg daily (from 2.5mg) after starting amiodarone. INR on day of discharge was 2. This should be rechecked on [**2182-9-20**] and coumadin adjusted as necessary. * Congestive heart failure: acute on chronic systolic heart failure. Echo during this stay showed an EF of 30% with moderate mitral regurgitation moderate to severe tricuspid regurgitation. She was diuresed with IV lasix as necessary and continued on home dose of lasix 20mg daily. On day of discharge, pt received a dose of 20mg IV lasix for slight volume overload. Her aldactone (25mg daily) was also restarted on [**2182-9-18**]. An ACEi or [**Last Name (un) **] was not started during this hospital stay due to relatively low BP (90-100); though pt would likely benefit from one of these agents in future. * Cough: Pt had a dry cough on admission, which ecame more severe during hospital stay. No clear pneumonia on imaging. Pt thought to likely have viral lower respiratory tract infection. She was treated with standing anti-tussives and ipratropium nebulizer (avoided albuterol because of arrythmias). If cough persists, consider further evaluation with her primary care doctor. * Acute renal failure: pt had episode of pre-renal failure early in her hospital stay that was thought to be from dehydration. Baseline crt unknown, though was as low as 1.2 and peaked at 1.5. Discharge crt 1.2. * LE ulcers: stable & appear to healing slowly. Pt received 7d course of abx for possible infection of LE ulcer. Pt has two ulcers, one on left leg & the other on the R leg. Left lower leg is a traumatic ulcer approx 1.5 x 1 cm. The wound bed is 80% pink, 20% yellow. The wound edges are irregular. The periwound tissue is intact with resolving cellulitis. Right lower extremity full thickness ulcer is present on anterior tibialis, approx 7 x 5.5 cm, and the wound bed is 60% yellow, 20% black, 20% pink. There is a moderate amount of serosanguinos yellow drainage with no odor. The periwound tissue is discolored, dark purple. Pt seen by wound care nurse and plastic surgery. * DM: type II, on low dose glipizide at home. Was treated with insulin sliding scale. Sugars well controlled. [**Month (only) 116**] continue insulin sliding scale at rehab; however, pt can likely resume home regimen in near future. * PPx: Therapeutic INR * Code: Full Medications on Admission: lasix 20 daily aldactone 25 daily lipitor 10 daily MV protonix 40 daily coreg 25 [**Hospital1 **] detrol 2 [**Hospital1 **] coumadin 2.5 daily glipizide 5 daily cranberry caps daily keflex q6h start [**9-2**] for 7 days Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) for 7 days: Con't for 1 week or until cough resolves. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): [**Month (only) 116**] stop when cough resolves. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAILY16 (Once Daily at 16). 12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every 4 hours) as needed for cough: pt may refuse; discontinue once cough resolves. 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 15. Aldactone 25mg daily (restarted on [**2182-9-18**]) Discharge Disposition: Extended Care Facility: [**Hospital **] health care center Discharge Diagnosis: Primary: - Monomorphic ventricular tachycardia with right bundle branch block - Cardiac arrest from pulseless electrical activity (in setting of hypoxia) - Bronchitis - Lower extremity ulcers Secondary: Coronary artery disease s/p MI 15years ago s/p angioplasty Atrial fibrillation on coumadin Hypertension Hypercholesterolemia UGIB 10y ago Osteoarthritis (primarily affecting knees) Discharge Condition: Good, ambulating with assistance, 02 saturation 97% on 2L NC. Afebrile, BP 110-120/50-60s, HR 50-80s in atrial fibrillation. No BM for 4 days--got suppository today ([**2182-10-18**]) Discharge Instructions: You were admitted with ventricular tachycardia. You were started on a new medication for this called amiodarone. You will need to have pulmonary function tests and an eye exam now that you are on a new medication called amiodarone. Additionally, you will need to have your liver function tests followed from time to time. Please discuss this with your cardiologist and, or your primary care doctor. Your dose of warfarin was decreased to 1.5mg. Your new medication amiodarone may cause your coumadin level to increase, so your blood should be monitored closely and your coumadin dose adjusted as needed. Please call your doctor or 911 if you develop fever, chills, shortness of breath, chest pain, lightheadedness, or any other concerning change in your condition. Followup Instructions: Please call your PCP [**Name9 (PRE) 61898**],[**Name9 (PRE) 278**] [**Name Initial (PRE) **]. at [**Telephone/Fax (1) 61899**] to schedule appointment . You have an appointment scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], cardiologist and electrophysiologist, on [**2182-10-15**] at 2:40pm at his [**Hospital1 **] office. See address below. [**Hospital3 **] Internal Medicine Address: [**Street Address(2) **]. # 300 [**Hospital1 **], [**Numeric Identifier 4474**] Phone: ([**Telephone/Fax (1) 24747**]

Admission Date: [**2139-1-14**] Discharge Date: [**2139-1-24**] Date of Birth: [**2083-2-26**] Sex: M CHIEF COMPLAINT: Ascites, scrotal swelling, shortness of breath and lower extremity edema. HISTORY OF PRESENT ILLNESS: This is a 55 year old male with infarction times two, status post four vessel coronary artery bypass graft in [**2135-3-6**], hypercholesterolemia, hypertension, and congestive heart failure, who reports he has had increased swelling of his abdomen and legs with swelling of the scrotum which has progressed over two to three weeks' time. He also has had associated and frequent shortness of breath and inability to move. He was transferred from [**Hospital1 **] [**Hospital1 **] where he was admitted on the [**3-9**]. There, he was assumed to have biventricular failure as the cause of his edema. He received Zaroxolyn and Bumex, but his BUN and creatinine elevated. An abdominal ultrasound showed splenomegaly and a renal consult thought patient was pre-renal and therefore, the patient's diuresis was withheld except for Spironolactone. ACE inhibitor was held as well. A cardiac ultrasound was attempted but the study was limited by obesity and Cardiology there recommended a MUGA Scan which showed a left ventricular ejection fraction of 60%, good biventricular function. A paracentesis was done on [**1-11**], of two liters. The studies showed 400 white blood cells, 520 red blood cells, no polys, 41 lymphocytes, 59 monocytes, glucose 126, total protein 3.9, LDH 110 and Enterococci grew out which was treated with Ampicillin one gram q. eight hours. For a hematocrit of 25 he was transfused two units of packed red blood cells. Repeat paracentesis on [**1-13**] drew off five liters; this was done only for the patient's comfort and no studies were sent. A BUN and creatinine on discharge were 127 and 3.8. PHYSICAL EXAMINATION: Vital signs were 97.9 F.; 140/72; 56; 20; 97 on room air; 170 kilograms. On examination, the patient was in no apparent distress. Oropharynx clear. Mucous membranes were moist. Heart showed regular rate and rhythm. Normal S1, S2. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, distended with splenomegaly. Extremities with two plus edema bilaterally. LABORATORY: Chem 7 as follows: 137, 5.7, 102, 27, 127, 3.8, 153 glucose. Calcium 8.9, iron 53, TIBC 298, hemoglobin A1C 7.3, TSH 17. Ascites with Enterococci sensitive to Ampicillin and sensitive to Vancomycin. HOSPITAL COURSE: This is a 55 year old male with a history of insulin dependent diabetes mellitus, significant coronary artery disease, but good ejection fraction on a recent MUGA scan, obesity, hypertension, and lower extremity edema with shortness of breath times two to three weeks. He had his first paracentesis in an outside hospital recently with unclear etiology of his edema. A Cardiology consultation was obtained and a repeat echocardiogram was done to work-up the cause of his edema. This study was extremely limited and the left ventricular ejection fraction could not be estimated, but the systolic function of the left ventricle did not seem to be severely depressed. The right ventricle was not well seen. Thickened aortic and mitral leaflets, and a right ventriculogram could be done if further quantification was to be done. In addition, the patient had an ultrasound of his right upper quadrant to determine whether flow was abnormal. This showed a diffusely increased echogenicity in the liver consistent with fatty liver. Portal venous flow with hepatopetal direction and a normal hepatic reflow. The spleen was mildly enlarged. There were mild ascites but no other abnormality on this ultrasound. The patient had paracentesis of five liters of fluid in-house which was clear and yellow. The fluid showed 310 white blood cells, total protein of 3.2, albumin of 1.7, glucose 162, LDH 100, amylase 26, gram stain negative and a culture was pending. Hepatitis serologies were also sent to determine whether there was some evidence of liver dysfunction accounted by Hepatitis. HIV negative, Hepatitis B surface antibody negative. The patient was maintained on a cardiac low-salt diet of less than 2 grams per day and diuretics were initially held secondary to the question of prerenal azotemia. The Renal Service was consulted regarding this patient and acute renal failure was thought to be secondary to ACE inhibitors plus diuretics plus/minus infection, with the intention to restart Bumex 2 twice a day once the patient's creatinine reached its baseline. A right heart catheterization was performed while the patient was in-house to find the etiology of his symptoms as well as transfer to Liver biopsy. The catheterization showed equalization of pressures consistent with a constrictive physiology. He was aggressively diuresed with Lasix overnight while in the Cardiac Care Unit. The patient had increased right and left heart pressures as well as cirrhosis. He was continued on a regimen of Lasix 40 twice a day and Aldactone 100 q. day, aiming for minus 1.5 liters off per day. It was decided that creatinine could be tolerated as high as 2.5. There were no further recommendations from renal at this time, and the patient was cleared for discharge. Ampicillin was also given in-house while the patient had an Enterococcus in his prior peritoneal fluid. DR [**First Name (STitle) **] [**Name (STitle) **] 12.899 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2139-5-20**] 15:12 T: [**2139-5-20**] 16:13 JOB#: [**Job Number 10472**] 1 1 1 R

Admission Date: [**2132-4-19**] Discharge Date: [**2132-4-26**] Date of Birth: [**2057-5-11**] Sex: F Service: MICU/[**Location (un) **] Admitted to MICU on [**2132-4-20**], and transferred back to C-Medicine on [**2132-4-26**]. HISTORY OF PRESENT ILLNESS: The patient is a 74 year old female with a past medical history of 4+ mitral regurgitation, severe bronchiectasis after childhood pertussis, [**Doctor First Name **], pulmonary infection and chronic resistant pseudomonas colonization of her lungs, who presented to the MICU for increasing hypoxemia. The patient has a complicated recent past medical history for issues of fatigue and dyspnea. She has been followed by Dr. [**Last Name (STitle) 6770**] and Dr. [**Last Name (STitle) 120**]. She recently had a DDD pacer placed, followed by arterial blood gases, noted ablation on [**2132-3-6**], for supraventricular tachycardia, atrial fibrillation/atrial flutter, started on Amiodarone, did not improve significantly. She was diuresed with Lasix and also started on chemotherapy for [**Doctor First Name **] on [**2132-3-31**], without improvement after this diuresis and pacer. She was anticoagulated for her atrial flutter. Two to three days prior to arrival to the hospital, she began having worsening shortness of breath, intermittent chest pain, came into the Emergency Department and was given a liter of normal saline due to decreased sodium, and admitted to C-Medicine to rule out for myocardial infarction. She was initially saturating decently in the 80s in room air, actually up to 96% on three liters. Her hypoxia gradually worsened. She had a blood gas of 7.43/43/71 and was transferred to the MICU for hypoxemia. PAST MEDICAL HISTORY: 1. Bronchiectasis secondary to childhood pertussis, chronic secretions. 2. [**Doctor First Name **], started on Rifampin, Ethambutol and Biaxin on [**2132-3-31**]. 3. She had an echocardiogram in [**2132-2-16**], that showed an ejection fraction of greater than 55%, 4+ mitral regurgitation with moderate pulmonary hypertension. 4. Paroxysmal atrial fibrillation/flutter, status post ablation and DDD pacer, on Amiodarone. 5. Hyperparathyroidism. 6. Partial hysterectomy, appendectomy and bilateral salpingo-oophorectomy. ALLERGIES: Aspirin, Motrin and Bactrim. MEDICATIONS ON ADMISSION: 1. Humibid. 2. Fluticasone. 3. Ethambutol. 4. Rifampin. 5. Clarithromycin. 6. Etidronate. 7. Losartan. 8. Amiodarone. 9. Celexa. 10. Salmeterol. SOCIAL HISTORY: She does not drink alcohol or use drugs. She has a remote tobacco abuse history. She is a rabbi [**First Name (Titles) **] [**Last Name (Titles) 109496**]. PHYSICAL EXAMINATION: On admission, heart rate 80, blood pressure 137/68, respiratory rate 30, oxygen saturation 100% on BiPAP. In general, she is a thin female with moderate respiratory distress. She is anicteric in the eyes, clear oropharynx with no jugular venous distention. Cardiovascular - She has an irregularly irregular rhythm, S1 and S2 with a V/VI holosystolic murmur loudest at the apex and left axilla. Pulmonary - She has mild wheezes and crackles throughout, the crackles more prominent at the bases. The abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities - no cyanosis, clubbing or edema. No calf tenderness. Neurologically, she is alert and oriented times three, mentating well. LABORATORY DATA: On admission to the MICU, her chemistries were unremarkable. Her white blood cell count was 17.3, hematocrit 37.3. Her coagulation studies showed an INR of 3.8 and partial thromboplastin time of 31.0. Her troponin was less than 0.3 times two. CKs were 58 and 55. She had had numerous microdata in the past from [**2132-4-19**]. She had a urinalysis which showed no signs of infection. Her chest x-ray on admission showed worsening right upper lobe infiltrate, bilateral chronic lung changes. HOSPITAL COURSE: While in the Intensive Care Unit, the patient was gently diuresed and nearly intubated initially. However, she was started on BiPAP ventilation which in combination with diuresis improved her respiratory status and she avoided intubation. She received a repeat echocardiogram which showed mainly a decreased ejection fraction of 35% and newly found left ventricular hypokinesis and akinesis in essentially all areas except for the base of the heart. She still had 4+ mitral regurgitation and flail leaflet. The patient also had consultation from endocrinology for a relatively low TSH although within normal range. Her other thyroid functions were checked and she was deemed not to be in thyrotoxicosis. The patient had her Vitamin D level checked which was within normal limits. In terms of infectious disease, the patient was initially on [**Doctor First Name **] and antipseudomonas coverage. Her antipseudomonas coverage was discontinued when her respiratory failure was viewed to be more attributed to her cardiovascular fluid status. The patient's white blood cell count remained elevated but stable at around 16.0. Her differential did not show bandemia. This white blood cell count remained stable even after cessation of antibiotics. Her [**Doctor First Name **] treatment was stopped as well secondary to risks being greater than benefit in terms of affecting her transaminases. While in the unit, the patient's Amiodarone was stopped and an attempt to overdrive pacer atria was attempted and failed. Cardioversion was considered but ultimately deemed not prudent at this time. The patient's hematocrit remained stable while in the unit. During evaluation, the patient's liver function tests were noted to be normal. She had elevated transaminases and alkaline phosphatase. Her ASTs were in the 1000s and ALTs in the [**2128**]. After cessation of her [**Doctor First Name **] chemotherapy, her liver enzymes resolved on a daily basis although still are above the normal range. On [**2132-4-26**], the patient was deemed stable to be transferred to the C-Medicine unit under telemetry. She was actually deemed stable for transfer one to two days before this. The ultimate plan for the patient is to have her undergo a right and left cardiac catheterization fairly in close proximity to possible cardiac surgery and mitral valve repair. There is some delay in proceeding with this course as the surgical and cardiac services want the patient's liver function tests to resolve and they are following her white blood cell count. The patient also was seen by physical therapy while in the Intensive Care Unit and had great difficulty with simple movements such as getting from bed to chair as she was felt to be quite deconditioned at this point. CONDITION ON DISCHARGE: Stable and improved from admission to the MICU. DISCHARGE DIAGNOSES: 1. Chronic pulmonary disease. 2. Congestive heart failure with fluid overload. MEDICATIONS ON DISCHARGE: 1. Fluticasone inhaler. 2. Losartan 25 mg p.o. once daily. 3. Celexa 20 mg p.o. once daily. 4. Salmeterol inhaler. 5. Guanethidine Codeine Phosphate. 6. Albuterol Ipratropium inhalers. 7. Protonix 40 mg a day. 8. Sodium Chloride Nasal Spray p.r.n. 9. Ambien 5 mg p.o. q.h.s. 10. Subcutaneous Heparin 5000 units twice a day. 11. Valium 1 mg p.o. q.h.s. p.r.n. 12. Colace. The patient is discharged to the C-Medicine unit for further workup. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**MD Number(1) 4062**] Dictated By:[**Last Name (NamePattern1) 2215**] MEDQUIST36 D: [**2132-4-26**] 20:10 T: [**2132-4-29**] 20:53 JOB#: [**Job Number 109497**]

Admission Date: [**2178-11-12**] Discharge Date: [**2178-11-25**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: 81 y.o. man with PMHx significant for perforated diverticulum and iliopsoas abscess presented with 2 day history of fever. Major Surgical or Invasive Procedure: CT-guided percutaneous drain placement of diverticular abscess. History of Present Illness: Pt. presented to the [**Hospital1 18**] ED from [**Hospital1 102355**]. The patient had been diagnosed with diverticulitis and left iliopsoas abscess in [**2178-8-31**]. The abscess was drained; culture of abscess fluid revealed ampicillin-sensitive enterococcus. He subsequently developed sepsis syndrome warranting redrainage of the abscess in [**10-5**]; culture of abscess fluid at this time revealed VRE, citrobacter, and C tropicalis. After the appropriate antibiotic course, the patient was discharged to [**Hospital **] Rehabilitation. The drain was removed on [**2178-11-4**] once CT revealed resolution of the abscess. The patient returned on [**11-12**] with a 2 day history of fevers to 102.8F. He complained of nausea/vomiting times 2 at presentation but denied bloody emesis. He denied pelvic/abdominal pain, chills, shakes, loss of consciousness, shortness of breath, bright red blood per rectum, or melena. He was transferred from [**Hospital1 **] for evaluation and suspected recurrence of the abscess. Past Medical History: CAD, HTN, hyperlipidemia, diverticular abscess, atrial fibrillation, bilateral DVT/PE, rheumatoid arthritis, GI bleed. Social History: No etoh, no tob, resided at [**Hospital **] Rehabilitation, previously lived w/ wife (who is unofficial HCP). Family History: Noncontributory. Physical Exam: T: 102.8 HR 115 BP 122/75 RR 33 O2sat 97 Constitutional: Pt. lying down. In mild respiratory distress. AOx4. HEENT: PERRL, decreased right lateral rectus muscle function, NCAT. Decreased neck ROM (unable to fully turn neck to right secondary to stiffness). No pain on palpation. Non-tender nodes. Question of yellow fungal growth on tongue. Chest: bilateral rales in lower lobes; decreased breath sounds. CV: No JVD, no carotid bruits detected, 1-2/6 midsystolic murmur, otherwise nl S1, S2 Abdomen: Nontender, nondistended, normal bowel sounds. GU: No pelvic pain, flank/CVA pain on palpation. Closed wound at left flank. No erythema, no pus. MSK: Non-erythematous. No pedal edema. Skin: Petechiae on lower extremities bilaterally. Neuro: CN II-XII grossly intact. Pertinent Results: [**2178-11-12**] 06:18PM PT-13.7* PTT-25.3 INR(PT)-1.3 [**2178-11-12**] 06:18PM PLT COUNT-199 [**2178-11-12**] 06:18PM ANISOCYT-2+ MACROCYT-3+ [**2178-11-12**] 06:18PM NEUTS-84.7* LYMPHS-11.3* MONOS-2.9 EOS-0.7 BASOS-0.3 [**2178-11-12**] 06:18PM WBC-12.3*# RBC-3.78* HGB-12.3* HCT-36.1* MCV-96 MCH-32.6* MCHC-34.1 RDW-20.2* [**2178-11-12**] 06:18PM GLUCOSE-137* UREA N-61* CREAT-1.4* SODIUM-137 POTASSIUM-5.8* CHLORIDE-102 TOTAL CO2-23 ANION GAP-18 [**2178-11-12**] 06:40PM LACTATE-3.2* [**2178-11-12**] 07:30PM URINE HYALINE-0-2 [**2178-11-12**] 07:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2178-11-12**] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2178-11-12**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2178-11-12**] 11:57PM K+-5.5* Brief Hospital Course: Mr. [**Known lastname 50388**] was admitted to the Crimson Colorectal Surgery Service after transport from ED and was evaluated as a candidate for colostomy and colectomy. He was placed on telemetry, and was kept NPO with intravenous administration of linezolid, metronidazole, levofloxacin, and fluconazole. On HD 2, he underwent CT-guided placement of a pigtail catheter in his left lower abdominal quadrant and drainage of 50 cc from the recurrent iliopsoas abscess; cultures subsequently revealed pseudomonas, coagulase negative staph aureus, and probable enterococcus. He was restarted on a regular diet on HD 3. On HD 5, the patient spiked a fever to 103.6, with tachycardia to the 80's, occasional PVC's, and hypotension (SPB 100-120). He was immediately transferred to the Surgical Intensive Care Unit; subsequent blood culture grew enterococcus in 1 of 3 bottles. Cardiology work-up on HD 6 revealed an evolving apical MI. At this time, the patient was deemed an inappropriate surgical candidate and his surgery was cancelled. He was transferred off the SICU on HD 6 with continued drainage of fluid from his pigtail catheter. The drain was repositioned by IR on HD 8, and upsized on HD 12 to expedite drainage. The patient will be discharged to [**Hospital **] Rehabilitation on HD 14 with a PICC line for long-term IV antibiotic administration. Medications on Admission: ASA 325, Protonix 40, Prednisone 5, Lopressor 25 [**Hospital1 **], Lasix 20, NPH 4 QAM/SSIR, Nitroglycerin prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO BID (2 times a day). 9. Methylprednisolone Sodium Succ 1,000 mg/8 mL Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours). 10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 11. Morphine 2 mg/mL Syringe Sig: One (1) ml Injection Q4H (every 4 hours) as needed for pain. ml 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 13. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 14. Sodium Chloride 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous DAILY (Daily) as needed: Peripheral IV flush as needed. 15. Insulin Regular Human 100 unit/mL Solution Sig: One (1) per attached Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Diverticulitis Discharge Condition: Stable. Discharge Instructions: Please call or return if you have a fever >101.4, severe pain, persistent nausea, vomiting, diarrhea, or constipation. Followup Instructions: Please see Dr. [**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 2981**] for an appointment. Please follow up with your primary care doctor as directed. Completed by:[**2178-11-25**]

Admission Date: [**2159-3-18**] Discharge Date: [**2159-3-24**] Date of Birth: [**2159-3-18**] Sex: M Service: NB HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 6955**], delivered at 37-0/7 weeks gestation with a birth weight of 3175 grams and was admitted to the Newborn Intensive Care Unit from labor and delivery for management of respiratory distress. Mother is a 30 year-old gravida II, para I, now II mother with estimated date of delivery of [**2159-4-8**]. Prenatal screens included blood type A positive, antibody screen negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen, and group B strep negative. The pregnancy was uncomplicated. She presented in labor with ruptured membranes. There was a rapid second stage. There was no maternal fever, a fetal tachycardia. Membranes were ruptured for clear fluid around 4 hours prior to delivery. The delivery was by spontaneous vaginal delivery with a loose nuchal cord. The infant emerged vigorous with a good cry. Apgar scores were 9 at 1 minute and 9 at 5 minutes. Around 1/2 hour of age he developed grunting that improved for a short time and then reoccurred prompting this admission to the Newborn Intensive Care Nursery. PHYSICAL EXAMINATION: On admission weight 3175 grams (75th to 90th percentile), length 50 cm (75th to 90th percentile). Head circumference 33.5 cm (50th to 75th percentile). On examination a term appropriate for gestational age male with grunting and retracting. Pink with free flow oxygen. Anterior fontanelle soft, flat, nondysmorphic. Intact palate. Breath sounds with poor aeration, mild retracting. Intermittent grunting. Regular rate and rhythm with soft murmur, normal pulses and perfusion. Abdomen soft, with a 3 vessel cord. No hepatosplenomegaly. Normal male genitalia with testes descended bilaterally. Patent anus. No hip clicks. No sacral dimple. Normal tone and activity. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The infant was initially on free flow oxygen on admission. Due to persistent oxygen requirement and grunting was placed on continuous positive airway pressure, 5 cm requiring around 25% oxygen with decrease in his retracting and grunting. Around 24 hours of age he was intubated for worsening respiratory distress associated with a left sided pneumothorax. This was treated with needle thoracentesis. The patient received a total of 2 doses ofsurfactant for respiratory distress syndrome and was extubated around 44 hours of age to a nasal cannula. He weaned to room air on day of life 4 and has remained in room air since with a comfortable work of breathing, respiratory rates in the 30s to 50s. CARDIOVASCULAR: He has been hemodynamically stable throughout hospital stay. A murmur was noted on admission that was resolved by day of life 3. At discharge there is no murmur. His heart rate ranges in the 140s to 160s. A recent blood pressure was 74/51 with a mean of 50. FLUIDS, ELECTROLYTES AND NUTRITION: He was initially NPO and maintained on IV fluid. He started feeds after extubation on day of life 2 and ad lib feeding with Enfamil 20, breast milk or is breast feeding when mother visits. [**Name2 (NI) **] is doing well on feeds, wetting and stooling appropriately. Discharge weight: 3005 Length: 21 inches Head circumference: 33.5 cm GASTROINTESTINAL: Peak bilirubin was total 5.5, direct .3. HEME: Hematocrit on admission 42.7%. INFECTIOUS DISEASE: A CBC and blood culture was drawn on admission due to respiratory distress. He was placed on Ampicillin and Gentamicin. He received it for 48 hours with a normal CBC. Blood culture was negative. Respiratory distress was due to surfactant deficiency. No infection. NEUROLOGIC: Examination was age appropriate. SENSORY: Hearing screening was performed with automated auditory brain stem responses. Baby passed both ears. CONDITION ON DISCHARGE: Stable term infant, feeding well. DISCHARGE DISPOSITION: Discharged home with parents. Name of primary pediatrician is Dr. [**First Name (STitle) 11894**] Shaft at [**Hospital **] Pediatrics. CARE RECOMMENDATIONS: FEEDS: Ad lib feeds with breast feeding or bottle feeding per mom's desire. MEDICATIONS: None. CAR SEAT POSITION SCREENING: Pending. STATE NEWBORN SCREEN: Was done on [**2159-3-21**] and is pending. IMMUNIZATIONS RECEIVED: Hepatitis B immunization on [**2159-3-23**]. Circumcision was performed on [**2159-3-23**]. FOLLOW UP APPOINTMENTS: Follow up appointment recommended with pediatrician on Monday, [**2159-3-26**]. Mother to make appointment. DISCHARGE DIAGNOSES: 1. Term appropriate for gestational age male. 2. Respiratory distress syndrome, resolved. 3. Sepsis ruled out. 4. Left pneumothorax, resolved. 5. Physiologic jaundice. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2159-3-23**] 18:43:56 T: [**2159-3-23**] 21:22:10 Job#: [**Job Number 65757**]

Admission Date: [**2147-4-7**] Discharge Date: [**2147-4-11**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 783**] Chief Complaint: Fever, atrial fibrillation with RVR Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 77816**] is an 84 yoM w/ hx of AD, Afib, BPH, HTN, Anemia, Disphagia, Gastric ulcers and hx of DVT/PE, admitted from a NH in setting of hypotension and diltiazem being held for five days due to hypotension. By report, NH stopped his Diltiazem on [**4-2**] for low BP, and noted to have systolics in 60s mmHg today. No reported fevers, cough, chest pain, or abdominal pain. . On arrival to ED, BP 100/70 and HR 130. Initially afebrile but spiked to 101R. Received 1 g CTX for UTI, tylenol, 1 L NS, and total of 20mg IV Diltiazem, but Hr remained 110-130. In the MICU patient received 2.5L of NS resucitation, received another dose of Ceftriaxone and placed on diltiazem gtt, eventually converted to PO diltiazem currently at 60mg QID. He is being transferred to the medicine floor for further management. . On the floor VS were 97.8F 108/60 72 16 98% RA. Patient was unable to answer ROS questions reproducibly, but denies any pain or discomfort. Pt seen with son, HCP, who states that he is at his baseline in terms of mental state. Past Medical History: Alzheimer's dementia Depression Restless leg syndrome Atrial fibrillation Lung mass-- right, paratracheal; picked up incidentally on chest CT in [**Month (only) 547**]; bx deferred ? CHF HTN Syncope BPH Anemia Dysphagia ? Necrotizing Enterocolitis Abd surgeries for ulcer disease 25 & 55 years ago Pulmonary embolism - unclear circumstances; happened years ago per son DVTs PVD per son. Social History: Lives [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 583**] Gardens of [**Location (un) 1411**]. Son is HCP. Requires [**Name2 (NI) 77819**] with all ADLs. Does not ambulate independently and is a risk for falls. Family History: Noncontributory Physical Exam: ADMISSION EXAM VS on arrival to the ED: 98.4, 100/70, 78, 24, 98% 2L NC VS on arrival to the MICU: 98.6, 116/88, 116, 22, 99% on 2L NC General: elderly male, pale, frail appearing; NAD HEENT: PERRL; dry mucous membranes LUNGS: diminished bilaterally CARDIO: tachycardic, no m.r.g. appreciated ABD: midline abd scar EXTREMITIES: 1+ pedal pulses SKIN: skin tear on L hand NEURO: sleepy but arousable; oriented to self (baseline per son); answers questions though non-specifically; intension tremor in hands b/l; CN II - XII grossly in tact; moving all limbs; gait deferred. . EXAM on transfer to the floor; . VS 97.8F 108/60 72 16 98% RA. General: elderly male, frail appearing; NAD HEENT: PERRL; dry mucous membranes, no OP lesions LUNGS: nl breath sounds b/l, cracles at left base. CARDIO: nl rate, [**Last Name (un) 3526**]/[**Last Name (un) 3526**], no m.r.g ABD: midline abd scar, slightly distended, soft. EXTREMITIES: Trace pedal pulses, SKIN: skin tear on L hand, dressed. No edema. Hallux deformity b/l. warm LE. NEURO: Awake and alert; oriented to self (baseline per son); answers questions but not goal directed. intention tremor in hands b/l, signficant cogwheeling rigidity in UE b/l; CN III - XII grossly in tact; moving all extremities; gait deferred. Foley catheter in place. Pertinent Results: Labs on admission: . [**2147-4-7**] 05:30PM BLOOD WBC-15.4*# RBC-3.09* Hgb-10.3* Hct-30.7* MCV-99* MCH-33.4* MCHC-33.6 RDW-16.4* Plt Ct-223 Neuts-84.1* Lymphs-11.6* Monos-4.0 Eos-0.1 Baso-0.1 [**2147-4-7**] 05:30PM BLOOD Glucose-123* UreaN-65* Creat-2.5*# Na-143 K-4.4 Cl-110* HCO3-22 AnGap-15 [**2147-4-7**] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2147-4-8**] 01:05AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2147-4-7**] 05:30PM BLOOD CK(CPK)-44 [**2147-4-8**] 01:05AM BLOOD CK(CPK)-50 [**2147-4-8**] 01:05AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 [**2147-4-9**] 03:45AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0 [**2147-4-8**] 01:05AM BLOOD TSH-2.1 [**2147-4-7**] 06:05PM BLOOD Lactate-2.8* [**2147-4-8**] 05:07PM BLOOD Lactate-0.8 [**2147-4-8**] 12:21AM BLOOD freeCa-1.13 IMAGING CHEST (PORTABLE AP) Study Date of [**2147-4-7**] 6:11 PM Portable AP upright chest radiograph is obtained. Cardiomegaly is again noted. The known right upper lobe paraspinal mass is not clearly seen. The remainder of both lungs appears unchanged without evidence of overt CHF or pneumonia. Patient is slightly rotated to the left. Bones appear somewhat demineralized. Clips project over the left heart border. There are defects in the left posterior rib cage which appear unchanged. IMPRESSION: Cardiomegaly without acute findings to explain patient's symptoms. . Labs on dischrge: . [**2147-4-10**] 07:35AM BLOOD WBC-9.9 RBC-2.94* Hgb-9.6* Hct-30.0* MCV-102* MCH-32.8* MCHC-32.2 RDW-16.3* Plt Ct-254 [**2147-4-10**] 07:35AM BLOOD Neuts-83.3* Lymphs-12.7* Monos-2.7 Eos-1.2 Baso-0.1 . [**2147-4-10**] 07:35AM BLOOD PT-14.6* PTT-28.6 INR(PT)-1.3* [**2147-4-10**] 07:35AM BLOOD Glucose-112* UreaN-32* Creat-1.4* Na-147* K-3.6 Cl-118* HCO3-19* AnGap-14 . [**2147-4-8**] 01:05AM BLOOD CK(CPK)-50 [**2147-4-7**] 05:30PM BLOOD CK(CPK)-44 [**2147-4-8**] 01:05AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2147-4-7**] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.04* . [**2147-4-10**] 07:35AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.9 Iron-PND [**2147-4-9**] 03:45AM BLOOD TSH-2.2 [**2147-4-8**] 05:07PM BLOOD Lactate-0.8 . Urine Cx: . URINE CULTURE (Final [**2147-4-10**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R . Blood Cx - pending at time of discharge. . Brief Hospital Course: 85M with AF with RVR, in setting of fever and urosepsis with Afib with RVR. # Sepsis: Upon admission, patient was febrile with leukocytosis, left shift, lactate 2.8. UA positive as a likely source. CXR obtained and negative for infiltrate. Additionally, his abdomen was soft, non-tender, and guaiac negative. He was treated with IV resuscitation 4L and lactate normalized. Started on Ceftriaxone 1g q24H with plan to add Vancomycin if clinical deterioration. He did not require pressors or central line placement. As BPs improved to > 100mmHg systolic, patient was transefered to medical floor for further management. He was noted to have a urine culture positive to Proteus and sensitive to cephalosporins. He was initially started on Cefpodoxime but was then changed to cefuroxime as the mirco-organism was sensitive to this. Per discussion with family, his mental status returned to baseline by HD#3. He was discharged on 200mg [**Hospital1 **] of cefpodoxime for an additional 7 days, which may be switched to 250mg [**Hospital1 **] of Cefuroxime for an additional 7 days if permitted by pharmacy supplies. His Blood cultures will require follow up at [**Hospital1 18**], as they were pending at time of discharge. He will also require follow up of CBC and LFTs due to start of the cephalosporin. # Atrial Fibrillation with RVR: In the setting of sepsis and fever, was felt to be a compensatory rather than primary cardiac, although patient has not received Diltiazem for 5 days due to reported hypotension at nursing home. Given IV fluids as above. Started on 30mg TID Diltiazem dosing and a Diltiazem gtt. Diltiazem was uptitrated to 60mg QID upon discharge from ICU and patient remained stable on this during floor stay with HR in 70-90 range. This may be uptightrated back to 75mg QID as HR and BP tolerate. . He was not on anticoagulation (stopped after recent admission with epistaxis as per discussion with PCP). Given CHADs score of 3, this was readressed with PCP and was noted that he had frequent falls at NH, thus would not be a good candidate for coumadin at this time. He was started on 81mg ASA daily for primary prevention of CVA and CAD. # Acute Renal Failure and Mild Hypernatremia: Initially some concern for pre-renal as pt appeared dry, vs possible ATN in setting of prolonged hypotension at NH. Baseline creat 1.1. FeNa = 1.5 initially suggestive of a likely intrinsic renal pathology, however Fena was 0.3% on HD3, thus not as reliable. Cr improved to 1.3 from peak of 2.5 on HD#5. Patient was provied with IVF resuscitation with D5W given hypernatremia to 147. All medications were renally dosed. Na at time of discharge was 141. # Anemia: Hct 30.7 and at baseline. Guaiac negative on admission. Last Fe studies from [**2146**], consistent w/ Fe defficiency anemia, however anemia is macrocytic and patient on B12 supplementation. TSH was wnl. This will require outpatient follow up with B12, Folate measurements. Patient was continued on iron. # Troponin leak: Patient had troponins of 0.07 in the past and noted to have 0.04-0.05 in setting of ARF. Likely a leak in setting of rapid rate. Enzymes were trended and rate control was pursued as above. # Aspiration risk. Patient noted to have bibasilar opacifications on CXR preliminary read on [**2147-4-10**] concerning for possible aspiration. He was evaluated by speech and swallow, including video swallow, which did not note overt aspiration, but deemed high risk due to penetration and however was recommended PO diet of nectar thick liquids and soft solids with 1:1 supervision, with crushed pills in pure. CONTACT: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 77816**] [**Telephone/Fax (1) 77817**] (HCP); [**Location (un) 583**] Gardens of [**Location (un) 1411**] [**Doctor Last Name **] [**Telephone/Fax (1) 47057**]; daughter [**Name (NI) 41356**] [**Telephone/Fax (1) 77818**] is also HCP CODE: DNR/DNI (confirmed with son, paperwork in chart) Patient was dicharged in a stable condition, normotensive and afebrile. Medications on Admission: (per NH list) Iron sulfate 325 mg Omeprazole 20 mg QD Lexapro 15 mg QD Vitamin B12 100 mg QD Folic acid 1 mg QD MVI Ensure TID Ropinerole 0.25mg one [**Hospital1 **] Tylenol 1000 mg [**Hospital1 **] + PRN Seroquel 200 mg [**Hospital1 **] Aricept 10 mg QD Senna Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection 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. Lexapro 5 mg Tablet Sig: Three (3) Tablet PO once a day. 4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 7. Diet Ensure TID 8. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day) for 1 days. 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 16. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 17. Outpatient Lab Work CBC, Chem 10 and LFTs on [**2147-4-14**], results to be forwarded to PCP [**Name9 (PRE) **],[**Name9 (PRE) 77820**], [**Name9 (PRE) **] MEDICAL ASSOCIATES, INC., Phone: [**Telephone/Fax (1) 8506**], Fax: [**Telephone/Fax (1) 77821**] 18. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary: Urosepsis, Atrial fibrillatin with rapid ventricular response. Secondary: Alzhemier's disease, Atrial fibrillation, Anemia, Dysphagia Discharge Condition: Stable, normal heart rate and normal blood pressure. Discharge Instructions: You were admitted to [**Hospital1 18**] with low blood pressure (hypotension), urinary tract infection (UTI) and high heart rate (atrial fibrillation with rapid ventricular response). You hypotension was felt to be due to a severe UTI (urosepsis). Your high heart rate was felt to be due to the infection as well as not having received your diltiazem at the nursing home. For your infection, you were treated with intravenous fluids and antibiotics in the intensive care unit. You improved significantly and your medicaion was switched to be be taken by mouth. Your blood pressure returned to [**Location 213**]. For you high heart rate, you were treated with fluids and your cardizem was restarted. With this treatment, your heart rate improved significantly. Due to your atrial fibrillation and risk of stroke, you were started on a low dose aspirin, 81mg daily. Because of your dementia, you were also evaluated by our speech and swallow specialists. Because of possible aspiration, you were advised with a diet of nectar thick liquids and soft solids, with your medications crushed with puree. You may take occasional regular soid foods with supervision. The following changes were made to your medications: - Started Aspirin 81mg daily - Started on Cefpodoxime 200mg twice daily for 7 days, this may be switched to Cefuroxime 250mg twice daily for 7 days if preferred by rehabiliation staff. - Restarted on Diltiazem at 60mg four times daily. Should you experience any further lower blood pressures, confusion, fevers, chills, changes in urination, bleeding with stool, shortness of breath, or any other symptom concerning to you, please call your primary care doctor or go to the emergency room. Followup Instructions: Please call your primary care doctor, [**Doctor Last Name **],SREELEKHA [**Telephone/Fax (1) 8506**], to make an appointment within a week. She will accomodate an appointment with you whenever it is convenient for you. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2147-4-11**]

Admission Date: [**2114-7-4**] Discharge Date: [**2114-7-11**] Date of Birth: [**2053-1-31**] Sex: M Service: NEUROLOGY Allergies: Shellfish Derived / Zocor Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 61-year old man with known history of hypertension, hypercholesteromia presents with being found unresponsive this morning. Patient was initially reported by [**Location (un) **] to have been last seen well at 9pm last night. However, upon speaking to son on his arrival (initially not answering his cell as was driving here), he was seen walking to get a glass of water this morning between 5am and 7am. However, later this morning he was found in the basement on the ground, unresponsive and non-verbal. EMS was called and noted that he would open his eyes to verbal stimuli and seemed to withdraw to painful stimuli. There was no speech. He appeared hot and diaphoretic. SBP was 170/100 on the scene. He was given Narcan with no response. Patient was taken to [**Hospital3 7571**]Hospital where his exam remained stable and in addition it was noted that he was not moving his right side. He was thought to be outside of the window for any acute intervention, and transferred to [**Hospital1 18**] for further management. Past Medical History: Hypertension Hypercholesteromia Right knee menisceal repair in [**5-7**] with arthroscopic methods Social History: lives with son, son's wife, and [**Name2 (NI) 12496**] tob: remote, quit etoh: [**1-31**] drinks per week currently drugs: never Family History: father with stroke at 65 (ultimately four strokes total); otherwise no family history of neurological disease or strokes or MI younger than 50. Physical Exam: T 98.2 P 60 BP 152/77 RR 16 O2 100% HEENT: Overweight, NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, No nuchal rigidity Pulmonary: + Transmitted upper airway sounds. Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: small abrasion on right knee. Neurologic: -Mental Status: Somnolent but arousable to voice though then closing his eyes; not following midline or appendicular commands, no verbalization but grunts with painful stimuli, attends to visual and tactile stimuli on left greater than right CN I: not tested II,III: no blink to threat on right, does blink to threat on left, pupils 4mm->2mm bilaterally III,IV,V: eyes conjugate and midline, with full lateral movement, slight left gaze preference VII: right facial droop VIII: responds to verbal stimuli IX,X: weak gag, palate elevates symmetrically, uvula midline XII: tongue protrudes midline Motor: Increased tone in RLE; normal bulk Moves -left: left upper and lower extremities spontaneously at least [**4-2**], tactile stimulation elicits grip on left upper extremity [**5-2**] -right: no spontaneous movement; moves right upper and lower extremity at least [**2-2**] only to painful stimuli and in stereotyped fashion Reflexes: -left 3+ at biceps, triceps, brachioradialis, 2+ at patella and achilles, toe goes down -right 4+ at biceps, 3+ at brachioradialis, 2+ at triceps, 2+ at patella and achilles, toe goes UP -Sensory: left: withdraws to pain on left purposefully in upper and lower right: localized pain on right but does not withdraw, rather pain elicits stereotyped movement -Coordination: unable to assess -Gait: unable to assess Pertinent Results: [**2114-7-11**] 05:50AM BLOOD WBC-10.1 RBC-5.05 Hgb-15.3 Hct-44.6 MCV-88 MCH-30.2 MCHC-34.2 RDW-13.6 Plt Ct-231 [**2114-7-11**] 05:50AM BLOOD Glucose-106* UreaN-25* Creat-0.9 Na-146* K-3.9 Cl-109* HCO3-27 AnGap-14 [**2114-7-11**] 05:50AM BLOOD ALT-75* AST-32 LD(LDH)-227 AlkPhos-83 TotBili-1.3 [**2114-7-9**] 08:45AM BLOOD ALT-96* AST-40 AlkPhos-88 [**2114-7-5**] 01:52AM BLOOD Triglyc-118 HDL-46 CHOL/HD-4.9 LDLcalc-154* [**2114-7-5**] 01:52AM BLOOD %HbA1c-5.5 eAG-111 CTA head and neck on [**2114-7-4**] IMPRESSION: 1. Extensive left middle cerebral artery distribution infarct, without evidence of hemorrhage at this time. 2. Complete occlusion of left internal carotid artery along its entire course, from the carotid bifurcation to the left MCA, with extensive clot burden. 3. Near complete occlusion of left M1 and M2 branches, reconstituted more peripherally. Very minimal flow in the left M1 segment via the circle of [**Location (un) 431**]. 4. Atherosclerotic disease at the right carotid bifurcation, with minimal stenosis. Brief Hospital Course: 61-year old man with known hypertension, hypercholesterolemia, recent arthroscopic knee surgery presents with being found unresponsive with no verbal output and no spontaneous movement on right, currently exam notable for not following any commands, non-verbal, inattentive to right, with right facial droop and hemiparesis. Head CT from OSH shows possible left MCA hyperdense sign and hypodensity in L MCA territory all consistent with L MCA infarct. inital CT scan demonstrated extensive left middle cerebral artery distribution infarct, without evidence of hemorrhage at this time. Complete occlusion of left internal carotid artery along its entire course, from the carotid bifurcation to the left MCA, with extensive clot burden. Near complete occlusion of left M1 and M2 branches, reconstituted more peripherally. Very minimal flow in the left M1 segment via the circle of [**Location (un) 431**]. Atherosclerotic disease at the right carotid bifurcation, with minimal stenosis. Patient was admitted to the Neuro ICU as no step-down beds available and patient will need close monitoring for airway protection and possible hemorrhagic conversion or edema of potentially large infarct. Patient was kept on telemetry and stabalized. - A follow up head CT 2 days later showed. Further evolution of left MCA infarct, with slight increase in mass effect on the anterior [**Doctor Last Name 534**] of the left lateral ventricle. No herniation. Then the following day a CT demonstrated: Continued evolution of a left middle cerebral artery territorial infarct. Mild mass effect on the frontal [**Doctor Last Name 534**] of the left lateral ventricle is unchanged. No evidence of transtentorial herniation. No hemorrhage detected. MI was ruled out with negative cardiac enzymes. Patient was started on Aspirin 325 mg PO daily. On [**2114-7-11**] patient was started on coumadin with an aspirin bridge. Patient was started on coumadin 5 mg PO daily. Goal [**1-31**]. Patient's PCP's office was contact[**Name (NI) **]. [**Name2 (NI) **] should follow up with PCP for INR monitoring after leaving rehab center. PREVENTATIVE: [**2114-7-5**] 01:52AM BLOOD Triglyc-118 HDL-46 CHOL/HD-4.9 LDLcalc-154* [**2114-7-5**] 01:52AM BLOOD %HbA1c-5.5 eAG-111 Labs demonstrated HLP and therefore patient was started on Zocor. Patient's LFTs then rose to the peak on [**2114-7-9**]. [**2114-7-11**] 05:50AM BLOOD ALT-75* AST-32 LD(LDH)-227 AlkPhos-83 TotBili-1.3 [**2114-7-9**] 08:45AM BLOOD ALT-96* AST-40 AlkPhos-88 Patient was then d/c from zocor. Zetia was started the next day for lipid managment. LFT's continued to trend downward with d/c levels listed above. BP was initally allowed to autoregulate with goal SBP < 180, and was treated with PRN hydralazine if needed. Patient's cardiac echo. No PFO, ASD, or cardiac source of embolism seen. Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Mild pulmonary hypertension. Video swallow recs 1. PO diet: ground solids, nectar thick liquids 2. PO meds crushed in puree 3. TID oral care 4. 1:1 supervision with meals to assist with self-feed and maintain standard aspiration precautions. 5. Nutrition f/u for oral vs. non-oral supplements as needed 6. Repeat swallowing evaluation on Fri for possible diet upgrade 7. Intensive speech-language f/u in rehab setting for global aphasia. Patient was discharged to rehab for further recovery from his large stroke. patient will follow up with his stroke neurologist Dr. [**Last Name (STitle) **] and with his PCP. Medications on Admission: none Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO TID (3 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Left MCA stroke Hypertension Hypercholesteromia Right knee menisceal repair in [**5-7**] with arthroscopic methods Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - sometimes. Discharge Instructions: You suffered an extensive left middle cerebral artery distribution infarct (Stroke), without evidence of hemorrhage at this time. You were found to have complete occlusion of left internal carotid artery along its entire course, from the carotid bifurcation to the left MCA, with extensive clot burden. Very minimal flow in the left M1 segment via the circle of [**Location (un) 431**]. You were initially admitted to the Neuro ICU. 2 follow up imaging did not show any hemorrhagic conversion. You were started on Aspirin 325 mg PO daily. On [**2114-7-11**] you were started on coumadin 5 mg daily with an aspirin bridge. Goal INR [**1-31**]. Your PCP's office was contact[**Name (NI) **]. [**Name2 (NI) **] will need to make an appt after leaving the rehab center and have your INR checked and faxed to her. You were found to have high cholesterol. You were initially started on a medication called Zocor. This raised your liver enzymes. You should not take this medication in the future. We therefore switched your medication to Zetia. Swallow instructions: 1. PO diet: ground solids, nectar thick liquids 2. PO meds crushed in puree 3. TID oral care 4. 1:1 supervision with meals to assist with self-feed and maintain standard aspiration precautions. 5. Nutrition f/u for oral vs. non-oral supplements as needed 6. Repeat swallowing evaluation on Fri for possible diet upgrade 7. Intensive speech-language f/u in rehab setting for global aphasia. Your cardiac imaging (echo): was within normal limits. You are now taking a blood thinner coumadin. No dangerous activity. If fall or any injury seek medical attention immediately. Continue to monitor your INR through your PCP. Followup Instructions: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Pager: Office Phone: ([**Telephone/Fax (1) 7394**] : Make appointment for after leaving Rehab center. PCP:[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] S. Location: APPLEWORKS Address: [**Location (un) 18204**] ROUTE 110, [**University/College **],[**Numeric Identifier 17035**] Phone: [**Telephone/Fax (1) 18203**] Fax: [**Telephone/Fax (1) 71989**] Make appointment with PCP [**Name Initial (PRE) 151**] 10 days after rehab center. Have your INR (lab slip attached) taken 2 days after leaving rehab center and have the results faxed to your PCP so they may adjust your comadin accordingly. Completed by:[**2114-7-11**]

Admission Date: [**2197-6-7**] Discharge Date: [**2197-6-12**] Date of Birth: [**2112-10-10**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3531**] Chief Complaint: Seizure/sepsis Major Surgical or Invasive Procedure: CVL, intubation History of Present Illness: Ms. [**Known lastname **] is an 84 yo female with PMH of DM, resident of a nursing home, who presented to [**Hospital3 4107**] after being found at her nursing home with periods of unresponsiveness of facial twitching. Per her daughter, she was talking and in her normal state of health at her evening meal on [**6-6**]. She had a repeat of these periods at [**Hospital1 **]. Per report, there was no generalized tonic-clonic component but possibly some tonic head turning and upper extremity shaking. There, she was also noted to be hypotensive with systolic BP in the 80s and as low as 50/p and hypothermic to 95. She was intubated for airway protection in the setting of possible status and also for hypotension. She had a negative head CT as well as a CT thorax which was unremarkable. She was given phosphenytoin, vancomycin 1g, possibly levo, ativan, cerebryx and sent to [**Hospital1 18**] because there was no neurologist there. . She has had a big decline over the past year cognitively. She suffered a fall last year and has since been in a nursing facility. She has had dementia diagnosed. She also has had two heel ulcers in the last year, the latest over the past four months last requiring antibiotics 2 months ago. She has also lost 15lb in the last 2 months with decreased appetite. . Initial vitals in the ED: T 95 HR 73 110/60 RR18 intubated, sedated with fentanyl/versed, on dopamin (10-15mcg). Her pupils were reactive and her neck supple. She was noted to have pyuria > 50, + nitrite, WBC 20 with 90% neutrophils, and a heel ulcer that looked infected. Cefepime was added to the vanc she already had. An IJ was attempted for access, but was not successful, so a right femoral line was placed. She was given 2L IVF rapidly, but her SBP remained in the 80s if the dopa was taken off. They did however get her dopa down to 5mcg with the fluid and reduction of her sedation. Neurology was consulted who recommended keppra 1g IV. Her lactate was 1.5, down to 0.7 on repeat. ABG showed pH 7.40/34/312. . Upon arrival, she is on 7.5mcg of dopa. . Past Medical History: DM neuropathy gout PVD cervical CA age 49 s/p hysterectomy chronic heel ulcers Social History: [**11-3**] yr smoking history, quit in her late 30s. No alcohol. Retired bookkeeper. Lives in a nursing home. Husband died in his late 60s. Family History: no history of seizure disorder Physical Exam: vitals: 110/56 86 100% 50% FiO2. AC 500/12 gen: intubated sedated. Not responding to voice or painful stimuli. heent: ncat, mmm. pupils pinpoint 2 to 1 mm reactive to light. neck: JVD 10-12 CM pulm: CTA anteriorly. no w/r/r cv: HRRR, 1/6 SEM throughout. quiet S1/S2. abd: NT/ND. hypoactive BS neuro: intubated, sedated, not responding to voice or painful stimuli. Not following commands. Extremities: dressing on right heal ulcer. No C/C/E. Non dopplerable LE peripheral pulses, 2+ in UEs. Pertinent Results: [**2197-6-7**] 05:49PM CEREBROSPINAL FLUID (CSF) PROTEIN-50* GLUCOSE-96 [**2197-6-7**] 05:49PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-27* POLYS-3 LYMPHS-46 MONOS-50 ATYPS-1 [**2197-6-7**] 04:20PM TYPE-ART PO2-236* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 [**2197-6-7**] 04:20PM LACTATE-1.5 [**2197-6-7**] 04:10PM WBC-14.2* RBC-3.47* HGB-9.1* HCT-28.7* MCV-83 MCH-26.3* MCHC-31.7 RDW-18.0* [**2197-6-7**] 04:10PM PLT COUNT-483* [**2197-6-7**] 04:10PM PT-12.6 PTT-24.1 INR(PT)-1.1 [**2197-6-7**] 04:10PM FIBRINOGE-596* [**2197-6-7**] 05:09AM GLUCOSE-141* LACTATE-0.7 [**2197-6-7**] 05:06AM GLUCOSE-177* UREA N-18 CREAT-0.9 SODIUM-141 POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16 [**2197-6-7**] 05:06AM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-207* TOT BILI-0.5 [**2197-6-7**] 05:06AM CALCIUM-7.5* PHOSPHATE-3.8 MAGNESIUM-1.9 [**2197-6-7**] 05:06AM WBC-17.2* RBC-3.39* HGB-9.1* HCT-28.3* MCV-83 MCH-26.9* MCHC-32.3 RDW-17.6* [**2197-6-7**] 05:06AM NEUTS-89.8* LYMPHS-6.5* MONOS-3.5 EOS-0.1 BASOS-0.1 [**2197-6-7**] 05:06AM PLT COUNT-349 [**2197-6-7**] 01:18AM TYPE-ART RATES-[**12-26**] TIDAL VOL-500 PEEP-5 PO2-312* PCO2-34* PH-7.40 TOTAL CO2-22 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED [**2197-6-7**] 12:59AM GLUCOSE-185* LACTATE-1.5 K+-4.0 [**2197-6-7**] 12:50AM UREA N-22* CREAT-1.2* [**2197-6-7**] 12:50AM LIPASE-35 [**2197-6-7**] 12:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2197-6-7**] 12:50AM URINE HOURS-RANDOM [**2197-6-7**] 12:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2197-6-7**] 12:50AM WBC-20.0* RBC-4.08* HGB-10.5* HCT-34.1* MCV-84 MCH-25.7* MCHC-30.8* RDW-17.6* [**2197-6-7**] 12:50AM NEUTS-90.9* LYMPHS-5.0* MONOS-3.7 EOS-0.1 BASOS-0.3 [**2197-6-7**] 12:50AM PLT COUNT-415 [**2197-6-7**] 12:50AM PT-12.3 PTT-23.6 INR(PT)-1.0 [**2197-6-7**] 12:50AM FIBRINOGE-666* [**2197-6-7**] 12:50AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2197-6-7**] 12:50AM URINE BLOOD-LG NITRITE-POS PROTEIN-300 GLUCOSE-100 KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-LG [**2197-6-7**] 12:50AM URINE RBC-21-50* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**6-29**] [**2197-6-7**] 12:50AM URINE AMORPH-MOD CT head from [**Hospital1 **]: There is no evidence for midline shift. There is no CT evidence for an acute infarct or intracranial hemorrhage or for hydrocephalus. Moderate white matter disease and volume loss are identified. The sinuses, mastoids and orbits appear normal. There is no evidence for an acute fracture or malalignment. Impression: There are no acute concerning abnormalities. . CT chest/abd/pelvis from [**Hospital1 **]: There is no evidence for aortic dissection or for a pericardial effusion on these noncontrast images. It is not possilbe to assess for pulmonary embolus on these noncontrast images. The tip of the endotracheal tube is approximately 3.5cm above the carina. There is no signficant adenopathy. There is probable atelectasis/scar in the lungs. There is a small right pleural effusion. Tehre is no pneumothorax. Degenerative change i identified in the spine. There is no evidence for acute fracture or malalignment. There has been a cholecystecomy. there is no evidence for pancreatitis. There is no evidence for renal calcifications or for hydronephrosis. The urteters appear normal in caliber where visualized. Hypodenisities in the kidney are too small to definitiely characterize although statistically they most likely represent benign cysts. there is a large amount of stool in the rectosigmoid colon suggesive of constipation. there is no significant bowel dilation. Bowel evaluation is limited on these noncontrast images. No bowel mass is seen. Degenerative change is identified in the spoine. There is no evidence for acute fracture or malalignment. there is no evidence for abdominal or pelvic adneopathy by CT size criteria. Impression: There is a large amount of stool in the rectosigmoid colon suggestive of constipation. There is a small right pleural effusion. There is no pneurmothorax. . CXR [**2197-6-6**]: endotracheal 2.7 cmabove advanced OG tube gastric distension streaky opacity likely atelectasis no consolidation. . EEG: IMPRESSION: Abnormal portable EEG due to the disorganized and slow background and bursts of generalized slowing, a few with triphasic or sharp appearances. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. Sharp features appear to be more likely part of the encephalopathy. There were no simple spike or sharp and slow wave discharges. An abnormal cardiac rhythm was noted, but this would be assessed better through routine ECG tracings. . MRI HEAD: IMPRESSION: 1. No evidence of acute infarct, mass or hemorrhage. 2. Diffuse enlargement of the ventricles, including the temporal horns indicating brain and medial temporal atrophy. Brief Hospital Course: # Sepsis: Originally she met SIRS criteria with WBC 17-20 and temp 95F, and most likely sources urinary +/- skin (right heel). She also has septic shock with low UOP and seizures possibly related to her sepsis. Pulmonary source less likely with negative CXR. CNS source had to be considered since she had seizures. A femoral line was placed because of collaps of her IJ during insertion, suggesting still significant volume depletion. Lactate wnl and Cr wnl. Intubation did not appear to be for respiratory failure, but for airway protection and sepsis. She was weaned off pressors after agressive IVF resuscitation. She was initially started on broad spectrum abx to cover meningitis, urinary sources, and heel ulcers as these were thought most likely causes of her septic shock. Eventually urine culture grew out Ecoli sensitive to Ceftriaxone (resistant to Cipro), LP was negatve, and blood cultures were no growth so patient's antibiotics were weaned to just Ceftriaxone for a planned 14-day course. Her femoral line was replaced with a midline prior to discharge to the floor. On transfer to the floor, she was changed to oral antibiotics (Cefpodoxime) with plan to take 8 days as outpatient to complete 14 day course. On discharge, she was afebrile and hemodynamically stable. Midline IV was pulled prior to discharge. # Seizures: No known seizure history. Differential includes primary CNS vs related to septic process. She does have a remote history of cervical CA at age 49. CT head from OSH not suggesting primary CNS source. Seen by neuro in the ED and started on keppra. MRI of the head was unrevealing with only age-related changes. LP was performed and was negative. Abx were tailored to treat UTI only from meningitis coverage (originally with vancomycin and ceftriaxone at 2gm to ceftriazone only). Neurology continued to follow. Keppra was discontineud and eeg off keppra showed no seizure activity. Neurology recommended she follow-up with a neurolgist as an outpatient. Should Mrs. [**Known lastname **] decide to follow-up at [**Hospital1 18**], the number has been provided. Ultram was not continued on discharge due to potential to lower seizure threshold. # Right Heel Pressure Ulcer - Present on admission and originally concerned for possible source of infection. Wound consult was obtained and pressure ulcer was cared for per wound care recommendations. # DM: Controlled with humalog insulin sliding scale. Discharged on sliding scale without restarting standing Novolin N. Nursing home facility can restart Novolin N pending evaluation of PO intake and blood sugars. # Dementia: Restarted dementia medications after CNS infeciton ruled-out. Medications on Admission: per Nursing Home Allopurinol 100 mg daily Lidoderm patch daily R cervical spine MVI with minerals Prilosec 40 mg daily KCl 20 mEq daily Lopid 600mg [**Hospital1 **] Namenda 10 mg [**Hospital1 **] Ultram 25 mg [**Hospital1 **] Zyprexa 2.5 mg po BID ES Tylenol 1000mg Q8H Aricept 10 mg QHS Melatonin 1mg QHS Glucerna health Novolin N 12U SC QAM before breakfast FS 6:30AM, 4:30pm ISS with regular insulin 70-130 0 180 2 240 4 300 6 350 8 400 10 >400 12 PRN Glucagon Discharge Medications: 1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days: LAST DAY [**2197-6-20**]. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): To right cervical spine. Apply for 12 hours then remove for 12 hours prior to placing next patch. 4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for sedation. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 13. Humalog 100 unit/mL Solution Sig: 0-10 Subcutaneous three times a day: Per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 13990**] Discharge Diagnosis: Primary Diagnosis: - Sepsis - Respiratory Failure - Urinary Tract Infection - Hypotension - Seizure - Right Heel Pressure Ulcer (present on admission) Secondary Diagnosis: - Diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a very serious infection that affected many organs. You required antibiotics, medicaiton to raise your blood pressure and a machine to temporarily breath for you. The source of the infection was felt to be from an untreated urinary tract infection. You also had a seizure at the emergency room prior to transfer to [**Hospital1 **] Hospital. You were temporarily placed on medication to help prevent seizures while the neurologists evaluated you and felt you did not need to continue the medication, but should be evaluated by neurologist after discharge. CHANGES IN MEDICATIONS: START - Cefpodoxime 200 mg by mouth twice a day for 8 days STOP - Ultram STOP - Novolin N (may restart once PO intake improved) STOP - Potassium Chloride HOLD - Glucerna (may restart once evaluated in nursing home) Please take all other medication as previously prescribed. Followup Instructions: Please follow-up with a Nuerologist as an outpatient. An appointment should be arranged at your earliest convenience. If you choose to see a Neurologist at [**Hospital1 1170**], please call [**Telephone/Fax (1) **]

Unit No: [**Numeric Identifier 66299**] Admission Date: [**2196-11-25**] Discharge Date: [**2196-11-28**] Date of Birth: [**2196-11-25**] Sex: M Service: NB [**First Name4 (NamePattern1) **] [**Known lastname 17811**] is born at 41-1/7-weeks gestation to a 31-year- old gravida 1, para 0 now 1 woman. The mother's blood type is A-positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, and group B Strep positive. The mother's past medical history is remarkable for irritable bowel syndrome treated with fiber and dicyclomine. The mother was evaluated with abdominal CT with contrast on [**2196-3-2**] for evaluation of abdominal pain to rule out appendicitis. She was discharged without surgery in good condition. She had a concerning triple screen for trisomy 21 which led to an amniocentesis which showed 46 X,Y with 1/10 colonies showing a cell with trisomy 14; therefore, a pseudomosaicism. A fetal survey showed right pyelectasis and choroid plexus cyst, both which resolved on follow-up ultrasound. The remainder of her antepartum course was benign. Artificial rupture of membranes occurred 4 hours prior to delivery. The mother received greater than 4 hours of intrapartum prophylaxis for group B Strep colonizaiton. The infant delivered vaginally under epidural anesthesia. Apgars were 8 at 1 minute and 9 at 5 minutes. The birth weight was 3,375 grams (50th percentile), birth length 52 cm (75-90th percentile), and head circumference 37.5 cm (greater than 90th percentile). The admission physical exam is remarkable for a full-term infant in no distress. Anterior fontanel: Soft and flat. Brachycephaly, sagittal sutures mobile, thick ridge along coronal sutures, mild macrocephaly, low set posteriorly rotated ears, high-arched palate, long thorax, no grunting, flaring, or retracting, clear breath sounds, no murmur, present femoral pulses, flat, soft, and nontender abdomen, normal phallus, no testes in scrotum, but mobile masses palpable high in both canals. Long limbs and fingers. Difficult to abduct hips, no clunks, normal tone with positive head lag, symmetric Moro, and normal spontaneous movement. NICU COURSE BY SYSTEMS: Respiratory status: He has remained in room air throughout his NICU stay. On day of life 1, he did have some transient upper airway congestion and stridor with feeding which resolved spontaneously by day of life #2. He does have some mild nasal stuffiness. His lung bases are clear and equal. Cardiovascular status: He has remained normotensive throughout his NICU stay. His heart has a regular rate and rhythm, no murmur. He has had evaluation by [**Hospital3 18242**] cardiology department. An EKG has been done and the results are pending, and an echocardiogram is planned prior to discharge as part of evaluation for his multiple dysmorphic features. The echocardiogram shows patent foramen ovale, no significant ventricular septal defect, trace aortic regurgitation, mild mitral and tricuspid regurgitation, right ventricular hypertension, qualitatively good biventricular systolic function (i.e., basically no significant structural heart disease). Fluid, electrolytes, and nutrition status: At the time of discharge, his weight is 3,160 grams. Electrolytes done on [**2196-11-27**] were sodium 145, potassium 4.0, chloride 107, and bicarbonate 26. He has been eating orally 20 calories per ounce Enfamil or breast feeding. He has had some difficulty latching onto the breast. Mother is currently using a nipple shield and will need some further lactation support after discharge. He has remained euglycemic throughout his NICU stay. A renal ultrasound to evaluate anatomy and assess for pyelectasis that was seen on prenatal ultrasound showed a normal left kidney and generous renal pelvis on the right but otherwise normal morphology. Follow up renal ultrasound is recommended at 3-4 months of age. Gastrointestinal status: His bilirubin on [**2196-11-27**] was total 8.5, direct 0.2. He never required phototherapy. Genitourinary status: His testes are undescended. A scrotal ultrasound revealed normal testes at the top of the inguinal canal. They are expected to descend with time. Hematology: The infant has received no blood products during his NICU stay. Infectious disease: There are no infectious disease issues. Neurology: Due to the macrocephaly, a head CT scan was done on [**2196-11-25**]. The preliminary report is a normal [**Location (un) 1131**] without evidence of hydrocephalus or craniosynostosis. We are awaiting a final report from [**Hospital3 1810**] neuroradiology. Audiology: Hearing screening was performed with automated auditory brainstem responses and the infant passed in both ears. Genetics: Chromosome studies for karyotype was sent on [**2196-11-25**]. [**Doctor Last Name **] was evaluated by [**Hospital3 18242**] genetics service, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 60775**]. A signature chip was sent prior to discharge. The genetics service also requested a babygram to evaluate vertebral bodies that was done. There were no definite vertebral anomalies seen. The ossification centers of the proximal femurs are present which would be unusual in a newborn infant. Psychosocial: Parents have been very involved in the infant's care throughout his NICU stay. Infant is discharged in good condition. Infant is discharged home with his parents. Primary pediatric care will be provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 60051**] of [**Hospital 620**] Pediatrics, [**Last Name (NamePattern1) 40688**], [**Location (un) 620**], [**Numeric Identifier 63538**], telephone number [**Telephone/Fax (1) 37814**]. RECOMMENDATIONS AFTER DISCHARGE: Feedings: Breast and formula feeding. Mother will need further support with breast feeding. The infant is discharged on no medication. The infant has passed a car seat position screening test. A state newborn screen was sent on [**2196-11-28**]. He received his 1st hepatitis B vaccine on [**2196-11-27**]. RECOMMENDED IMMUNIZATIONS: 1. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1. Born at less than 32 weeks, 2. Born between 32 and 35 weeks with 2 of the following: Daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school- age siblings, or 3. With chronic lung disease. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. Followup for this infant includes [**Hospital3 1810**] genetics, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66300**], telephone number [**Telephone/Fax (1) 66301**]. He should be seen at 1 month of age. Parents will call for an appointment. Dr. [**Last Name (STitle) 60051**] on [**11-30**]. Lactation consult on [**11-29**]. DISCHARGE DIAGNOSES: 1. Male term newborn. 2. Trisomy 14 pseudomosaicism on amniocentesis prenatally. 3. Bilateral undescended testicles. 4. Multiple dysmorphic features. 5. Macrocephaly. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2196-11-28**] 02:33:35 T: [**2196-11-28**] 06:23:01 Job#: [**Job Number 66302**]

Admission Date: [**2187-4-26**] Discharge Date: [**2187-4-27**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 112130**] is a [**Age over 90 **]F s/p recent admissions hip fracture [**2187-3-20**] and pneumonia requiring a MICU stay in mid-[**Month (only) 116**] who was brought from her long-term care facility for hypotension. She began to have diarrhea 6-7d ago. Labs [**4-23**] notable for WBC 25, cdiff positive, and Cr 0.6. She started metronidazole yesterday for C diff per LTC facility and family. She was noted to be hypotensive today and so was brought in for evaluation. In the ED, initial VS were: 97.4, 86, 76/54. Exam was notable for diffuse abdominal pain. CT in the ED showed pancolitis. Labs in ED notable for WBC 74, Cr 2.2, albumin 2.5, lactate 2.5. Got 2L IVF, Zosyn, and Flagyl in ED. Pressures improved to 80s-90s prior to transfer. Goals of care were discussed with the family, and they do not want central lines or pressors. SW was consulted for pt and family support. On arrival to the MICU, patient's VS T 98.1, BP 83/39, RR 23, 99% 2L . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies arthralgias or myalgias. No edema. Past Medical History: Past Medical History (per family, NH notes): - Recent admission for pneumonia, requiring an ICU stay for sepsis at [**Hospital 47**] Hospital [**Date range (1) 112131**] - HTN - pacemaker (placed in [**2180**], V demand pacing) - fall with femoral fracture ([**3-/2187**]), was not repaired - abnormal LFTs - demand ischemia - orthostatic hypotension - anxiety Social History: Moved back to Mass from [**State 108**] in 4/[**2186**]. Prior to her hip fx in [**3-/2187**], was living independently and managine most of her ADLs. Her husband of 72 years recently passed away in mid-[**Month (only) 116**]. Rare EtOH, quit smoking 30 years ago. Family History: No significant family Hx per daughter. Physical 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, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Discharge Exam: Expired. Pertinent Results: [**2187-4-27**] 02:21AM BLOOD WBC-79.0* RBC-4.03* Hgb-12.0 Hct-38.7 MCV-96 MCH-29.6 MCHC-30.9* RDW-14.7 Plt Ct-356 [**2187-4-26**] 02:35PM BLOOD WBC-74.0* RBC-3.81* Hgb-11.3* Hct-36.9 MCV-97 MCH-29.8 MCHC-30.7* RDW-14.3 Plt Ct-357 [**2187-4-26**] 02:35PM BLOOD Neuts-87* Bands-0 Lymphs-6* Monos-0 Eos-1 Baso-0 Atyps-0 Metas-5* Myelos-1* [**2187-4-27**] 02:21AM BLOOD Glucose-90 UreaN-36* Creat-2.0* Na-139 K-4.0 Cl-109* HCO3-17* AnGap-17 [**2187-4-26**] 02:35PM BLOOD Glucose-82 UreaN-37* Creat-2.2* Na-137 K-3.8 Cl-103 HCO3-20* AnGap-18 [**2187-4-26**] 02:35PM BLOOD ALT-17 AST-19 AlkPhos-104 TotBili-0.2 CXR ABDOMENL: FINDINGS: There is no evidence of free air. Bowel gas pattern is nonspecific. Scoliosis is noted. Degenerative changes are seen within the spine, better evaluated on the CT abdomen and pelvis from two days earlier. Fixation rod is noted in the left femoral head. Better seen on the same day chest radiograph are pacer leads and additional wires. IMPRESSION: No good evidence of free air or obstruction. CXR: Aside from a small region of atelectasis at the left base, lungs are clear. There may be a new small left pleural effusion. Heart size is normal. Thoracic aorta is tortuous and generally large but not focally aneurysmal. No pneumothorax. Tranvenous right atrial and right ventricular pacer leads are in place, but their course is not standard and would require at least conventional views for assessment. Brief Hospital Course: [**Age over 90 **]yo s/p recent admissions for hip fx and pneumonia complicated by sepsis at [**Hospital 47**] Hospital who presents from her rehab facility with hypotension, diarrhea, pronounced leukocytosis with left shift, c/w + C diff. # Severe C diff, hypotension: Per [**Hospital1 18**] guidelines has severe C diff based on presence of: WBC > 15, Hypoalbuminemia (< or = 2.5 mg/dl), Serum Cr increase of 1.5 x baseline, and pan-colitis on imagine. Given ICU transfer, would be classified as severe complcated C diff. Normally, surgery consult would be appropriate for this severity of disease, but this is not within the goals of care of this patient (discussed with HCP). We initially started her on the treatment protocol for severe C diff. Patient was DNR/DNI per discussion with family. Patient's blood pressure continued to trend down into 80s despite fluid rescucitation. Over the course of the day on [**2187-4-27**] patient lost bowel sound and continued to complain of abdominal pain. Discussion with family resulted in converting patient to comfort measures only and her dose of morphine was increased to every hour PRN for comfort. The family was at bedside on her last day of hospitalization and requested that no more fluids were given to her, and that she was allowed to pass away in comfort. Time of death was 8:33 pm. The family, attending were notified. Chief cause of death was reported as Severe C diff, immediate cause was reported as sepsis. Medications on Admission: atenolol 25mg daily docusate 100mg [**Hospital1 **] dorzolamide 2% eye drops both eyes [**Hospital1 **] enalapril 20mg daily ferrous sulfate elixer 220mg/mL, 7.25mL q12 flagyl 500mg po TID fludicortisone 0.1mg qAM Heparin 5000 units TID melatonin 3mg qHS Mucinex extended release 600mg [**Hospital1 **] omeprazole 20mg at 8am and 4:30pm NaCl 1g [**Hospital1 **] timolol 0.25% drops both eyes [**Hospital1 **] acetaminophen 1g TID dlucolax PR daily PRN Fleet enema daily PRN MoM daily PRN tramadol 50mg TID PRN Xanax 0.25mg [**Hospital1 **] PRN Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired Completed by:[**2187-4-27**]

Admission Date: [**2124-7-17**] Discharge Date: [**2124-7-26**] Date of Birth: [**2048-6-14**] Sex: M Service: CHIEF COMPLAINT: Epigastric pain and bloating. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old gentleman with a history of coronary artery disease (with a history of an inferior wall myocardial infarction in [**2093**]; status post coronary artery bypass graft in [**2093**] and a redo coronary artery bypass graft in [**2111**]) who was admitted on [**2124-7-17**] for three days of persistent epigastric discomfort. At this point, the patient denied any chest pain, shortness of breath, headaches, visual changes, nausea, vomiting, diarrhea, constipation, fevers, chills, or sweats. The patient complained of increased bloating and belching which was not similar to anginal pain he had experienced in the past. He denied having chest pain for the past 12 years. On [**2124-7-19**], the patient was awoken from sleep when he had [**10-13**] anginal chest pain. Electrocardiogram was without evidence of ST segment elevations. Initial cardiac enzymes were negative on admission; however, now are significant for a troponin T elevation from 0.54 to 0.85. However, his creatine phosphokinase of 129 was trending down. An echocardiogram was performed, and the patient was found to have an ejection fraction of 25%, paced at 58 (which was elevated) and a new 4+ mitral regurgitation. The patient was then referred for a cardiac catheterization. In the Catheterization Laboratory, angiography revealed a 90% stenosis of the proximal saphenous vein graft to the right coronary artery and 80% stenosis of the distal ramus. A stent was placed in the proximal region of the saphenous vein graft with no evidence of residual stenosis and resultant TIMI-III flow. The patient was started on Integrilin and milrinone and transferred to the Coronary Care Unit. PAST MEDICAL HISTORY: 1. Coronary artery disease. (a) The patient had an inferior myocardial infarction in [**2093**]. (b) Status post coronary artery bypass graft with left internal mammary artery to first diagonal, saphenous vein graft to left anterior descending artery, saphenous vein graft to right coronary artery. (c) Status post redo coronary artery bypass graft in [**2111**]. (d) The patient also had a catheterization on [**2122-1-20**] showing patent grafts with 50% touchdown of left internal mammary artery occlusion. Noted to have a pressure gradient across his left subclavian artery. 2. Peripheral vascular disease; status post coronary artery bypass graft on [**2124-6-13**] with left renal stent placed for renal artery stenosis; [**2124-6-14**] bilateral iliac stents placed. 3. Hypercholesterolemia. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Gastroesophageal reflux disease. 7. Congestive heart failure; echocardiogram from [**2124-6-19**] showed an ejection fraction of 25%, 4+ mitral regurgitation, 3+ tricuspid regurgitation, akinetic left ventricular wall motion, and dilated right ventricle. 8. Bilateral carotid endarterectomies. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg by mouth once per day. 2. Lipitor 10 mg by mouth once per day. 3. Cardura 4 mg by mouth once per day. 4. Cardizem 240 mg by mouth once per day. 5. Toprol 200 mg by mouth once per day. 6. Diovan 160 mg by mouth once per day. 7. Lasix 40 mg by mouth once per day. 8. Potassium chloride 10 mEq by mouth once per day. 9. Niacin 1000 mg by mouth once per day. 10. Prilosec 20 mg by mouth every day. 11. Fish oil 4000 units by mouth every day. ALLERGIES: SOCIAL HISTORY: The patient quit smoking approximately 20 years ago. Occasional alcohol use. No drug use. FAMILY HISTORY: Mother deceased from a cerebrovascular accident at 50 years of age. Father deceased from congestive heart failure at the age of 80. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Coronary Care Unit revealed vital signs with a temperature of 97 degrees Fahrenheit, blood pressure was 95/39, heart rate was 68, respiratory rate was 20, and oxygen saturation was 100% on 2 liters nasal cannula. Pulmonary artery diastolic pressure was 10. Generally, the patient was lying in bed and calm. In no acute distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light and accommodation. Positive bilateral carotid bruits. Elevated jugular venous pulsation. Cardiovascular examination revealed a regular rate. Normal first heart sounds and second heart sounds. A [**3-9**] holosystolic murmur at the apex and left sternal border. Lung examination revealed decreased breath sounds bilaterally. Crackles noted at the anterior bases bilaterally. Abdominal examination revealed positive bowel sounds. Soft, nontender, and nondistended. Extremity examination revealed pulses were 2+. No edema. Right femoral line in place. ASSESSMENT AND PLAN: The patient is a 76-year-old male with coronary artery disease now with elevated troponin levels and occlusion of the saphenous vein graft to the right coronary artery, status post stent placement, with no evidence of residual stenosis. The patient was started on a milrinone drip for afterload reduction, and fluid status was monitored. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was continued on the milrinone drip for afterload reduction understanding that the mitral regurgitation may decrease. 1. ISCHEMIA ISSUES: In terms of his ischemia, the patient denied any further chest pain. No electrocardiogram changes were noted. The patient was continued on his aspirin and Plavix. The patient was noted to have ectopic beats on the milrinone drip. Therefore, the drip was titrated down, and the patient was started on captopril 6.25 mg three times per day. The patient also received one unit of packed red blood cells for a drop in his hematocrit from 25.8 which corrected to 31.6. On admission to the Coronary Care Unit, the patient's chest x-ray showed pulmonary vasculature congestion. He received 100 mg of intravenous Lasix for diuresis as well as being continued on captopril for afterload reduction. The patient was initially on a high oxygen requirement, requiring a nonrebreather face mask; however, after the patient was diuresed and afterload reduced, the patient's oxygen requirement decreased until the patient was 100% on room air. 2. RHYTHM ISSUES: In terms of his rhythm, the patient converted between atrial fibrillation and a normal sinus rhythm and demonstrated evidence of paroxysmal atrial flutter as well as premature atrial contractions. However, the patient's rhythm corrected on its own. The patient is currently in a normal sinus rhythm. However, due to his current ischemia, and dilated left atrium, the patient was started on Coumadin to prevent thrombus formation. 3. RENAL ISSUES: In terms of the patient's renal function, his creatinine was elevated to 2.2 on admission to the Coronary Care Unit with afterload reduction, increased perfusion of the kidneys, and appropriate diuresis the patient's creatinine trended down to 1.6 and is currently improving. The patient also complained dysuria; however, a urinalysis was negative for leukocyte esterase and nitrites. The patient was not started on antibiotics but was given a trial of Pyridium for symptomatic relief. The patient will not be started on antibiotics unless urine cultures are positive. Urine cultures currently pending. A repeat echocardiogram showed a dilated left atrium with a diameter of 5.7 cm. The left ventricular wall showed basal and mid inferior akinesis, dilated left ventricular and right ventricular (which was larger than previous examination), 4+ mitral regurgitation, 2+ tricuspid regurgitation, and without significant change. Ejection fraction was 20% to 25%. PLANS FOR THIS PATIENT: 1. CARDIOVASCULAR: (a) Coronary artery disease; status post percutaneous coronary intervention of his saphenous vein graft to the right coronary artery. The patient was to be continued on aspirin, Plavix, and Lipitor. (b) Pump: Ejection fraction of 25%, 4+ mitral regurgitation, dilated left ventricle and right ventricle, and dilated left atrium. The patient was at increased risk for atrial fibrillation given left atrial size and ischemia. The patient was to be continued on warfarin and continued on an ACE inhibitor for afterload reduction. (c) Rhythm: As stated before, the patient was to be continued on his Coumadin for the risk for atrial fibrillation and atrial flutter and was to be sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor on discharge. 2. GOUT: The patient had an episode of pain consistent with gout in his left big toe which was relieved with colchicine 0.6 mg by mouth as needed. Currently, the patient with no complaints of pain. The patient has had a diagnosis of gout in the past and has been successfully treated with Indocin; however, at the time of treatment the patient's kidney function was not at baseline. Therefore, nonsteroidal antiinflammatory drugs could not be initiated. The patient has been treated successfully with colchicine treatment. 3. RENAL: Urinalysis was negative for leukocyte esterase or nitrites. Dysuria was likely secondary to inflammation or trauma from the Foley catheter. The patient was given a prescription for Pyridium for his dysuria, and symptomatic relief was noted. The patient's creatinine decreased from 2.2 to 1.6 (currently) and was trending down. The patient was started on Lasix 40 mg once per day and may be sent home with this medication as the patient is likely to have dietary indiscretion as an outpatient. DISCHARGE DISPOSITION: The patient was to be sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor. The patient was not likely to require home services. The patient was to be followed in the [**Hospital3 **] for frequent INR checks. The patient was to follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] in approximately one month. The patient was to be scheduled for an echocardiogram prior to his Cardiology follow-up appointment. CURRENT CONDITION AT DISCHARGE: Condition on discharge was stable. CURRENT MEDICATIONS ON DISCHARGE: 1. Atorvastatin 10 mg by mouth once per day. 2. Coumadin 5 mg by mouth once per day. 3. Plavix 75 mg by mouth every day. 4. Lisinopril 10 mg by mouth twice per day. 5. Toprol-XL 100 mg by mouth once per day. 6. Colchicine 0.6 mg one tablet by mouth q.1-2h. as needed (for gouty pain). 7. Aspirin 81 mg by mouth once per day. 8. Prilosec 20 mg by mouth every day. 9. Fish oil capsules. 10. Niacin 1000 mg by mouth once per day. 11. Lasix 40 mg by mouth once per day. 12. Potassium chloride 10 mEq by mouth once per day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Dictator Info 21090**] MEDQUIST36 D: [**2124-7-26**] 10:57 T: [**2124-8-3**] 08:26 JOB#: [**Job Number 21091**]

Admission Date: [**2145-5-7**] Discharge Date: [**2145-5-20**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1390**] Chief Complaint: 89 year old female presenting with nausea, vomiting, diarrhea and abdominal pain. Major Surgical or Invasive Procedure: [**5-13**] Lysis of adhesions and enterotomy x2. History of Present Illness: [**Age over 90 **]F s/p multiple abdominal operations including incisional hernia repair x3 with a known recurrent ventral hernia, who presents with a 1-day history of abdominal pain, nausea/vomiting. Pt has been followed by Dr. [**Last Name (STitle) **] for her hernia with non-operative management given her prior lack of obstructive symptoms. Approximately 3 months ago, patient began having intermittent episodes of nonbloody diarrhea associated with mild cramping. On [**5-6**], she experienced increasing abdominal pain, initially in a band-like distribution across her upper abdomen and later over her large hernia. The pain is intermittent and associated with a bloating and firmness of her hernia during severe epioShe had 2 episodes of nonbloody, nonbilious emesis with associated subjective fevers/chills. Last bowel movement was [**5-6**] and was loose; last flatus [**5-6**] early evening. She presented to the ED for evaluation, and a surgical consult was requested. Past Medical History: HTN Hepatitis CHF s/p CCY ('[**12**]) Incarcerated hernia s/p abd surgery Fibroid s/p TAH Social History: Russian-speaking. Lives in [**Location 86**] alone. Moved to US 2 years ago. Family History: (-) Tobacco/EtOH/IVDA Physical Exam: On Admission: Vitals: 97.8 112 131/99 16 97% GEN: NAD. Alert, oriented x 3. HEENT: No scleral icterus. Mucous membranes mildly dry. CV: RRR PULM: Unlabored breathing ABD: Very large ventral hernia with significant loss of domain. Soft but very distended with mild tenderness to palpation. No R/G. RECTAL: Normal tone. No masses. No gross blood. Heme-occult negative. EXT: Warm trace pitting edema of LLE. No calf tenderness, warmth, or pain with passive ankle flexion. On Discharge: Vitals: T 98.8, HR 88, 140/64, RR 14, 98% on 2 liters NC Neuro: AAO x 3. No pain. No acute distress. Strength 4/5 in all distal extremities, [**1-25**] in proximal extremities. CV: S1 S2, no m/r/g. Pulm: Clear in upper lobes bilaterally, diminished in bases bilaterally. GI: Positive BS. Obese, softly distended. Slightly tender over areas of prior herniations. Mid-line incision closed with surgical staples, CDI. No exudate or signs of infection. GU: Voiding. Incontinent at times. Extrem: Warm with 2 - 3+ edema.UEs cool. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. Pulses 2+ in all extremities. Pertinent Results: [**2145-5-7**] 05:05PM BLOOD WBC-3.9* RBC-5.00 Hgb-13.6 Hct-41.7 MCV-83 MCH-27.2 MCHC-32.6 RDW-18.3* Plt Ct-245 [**2145-5-7**] 03:55AM BLOOD WBC-4.6 RBC-5.32 Hgb-14.6 Hct-44.3 MCV-83# MCH-27.5 MCHC-33.0 RDW-18.3* Plt Ct-241 [**2145-5-7**] 05:05PM BLOOD Glucose-125* UreaN-16 Creat-0.7 Na-136 K-3.9 Cl-101 HCO3-25 AnGap-14 [**2145-5-7**] 03:55AM BLOOD Glucose-158* UreaN-18 Creat-0.8 Na-132* K-6.4* Cl-98 HCO3-21* AnGap-19 [**2145-5-7**] 05:05PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2 [**2145-5-7**] 05:59PM BLOOD Lactate-1.4 [**2145-5-7**] 04:07AM BLOOD Lactate-1.8 K-3.6 [**2145-5-7**] 03:55AM NEUTS-71.5* LYMPHS-20.9 MONOS-6.5 EOS-0.6 BASOS-0.5 [**2145-5-7**] 03:55AM ALBUMIN-3.6 [**2145-5-19**] 10:35AM BLOOD CK-MB-1 cTropnT-<0.01 [**2145-5-20**] 05:25AM BLOOD WBC-6.0 RBC-3.63* Hgb-9.7* Hct-30.3* MCV-84 MCH-26.7* MCHC-31.9 RDW-18.4* Plt Ct-175 [**2145-5-20**] 05:25AM BLOOD Plt Ct-175 [**2145-5-20**] 05:25AM BLOOD Glucose-125* UreaN-10 Creat-0.3* Na-135 K-3.4 Cl-97 HCO3-28 AnGap-13 [**2145-5-20**] 05:25AM BLOOD Calcium-7.3* Phos-1.3* Mg-1.8 [**2145-5-7**]: CT abdomen/pelvis Large, [**Hospital1 **]-lobed ventral hernia contains multiple small bowel loops. There is evidence of incarceration, with mesenteric kinking and multiple areas of abrupt narrowing at the entry and exit points of the hernia. Loops within and proximal to the hernia are dilated up to 5-6 cm, with air-fluid levels. Several regions of circumferential wall thickening, mucosal hyperemia, and surrounding fluid raise concern for ischemia. There is no pneumatosis, pneumoperitoneum, or portal/mesenteric venous gas. [**2145-5-8**] KUB: Within this limitation, dilated small bowel loops in the left lower quadrant are noted, likely representing the dilated obstructive loop of bowel present in prior study. NG tube tip is in the stomach. [**2145-5-18**] ECG: Sinus rhythm. Left axis deviation with possible left anterior fascicular block. Borderline voltage criteria for left ventricular hypertrophy. Modest ST-T wave changes that are non-specific. Compared to the previous tracing of [**2145-5-14**] ventricular premature contraction is absent. Otherwise, no other significant diagnostic change [**2145-5-19**] CXR (AP): Mild pulmonary edema with small to moderate bilateral pleural effusions. Brief Hospital Course: Ms. [**Known lastname 44910**] was admitted to the Acute Care Surgery service on [**2145-5-7**] for management of her abdominal pain secondary to a small bowel obstruction/incarcerated ventral hernia. Given the large size of her [**Hospital1 **]-lobed ventral hernia, in addition to Ms. [**Known lastname 44911**] poor surgical candidacy, she was treated conservatively via bowel rest, IVF, and nasogastric decompression via NGT. Her labs, most notably, her lactate and WBC were trended throughout her hospital stay and were noted to be within normal limits. Ms. [**Known lastname 44910**] gradually responded well to this treatment, and was noted to be much less distended and tender to palpation by HD#2. She self-dc'ed her NGT overnight on HD#2 without worsening of her symptoms. On HD#3, her abdominal exam remained improving, and she was given a bowel regimen to which she responded well. On [**5-11**], the patient was advanced to clears but did not tolerate that well and was again made NPO. Because of concern for increasing abdominal pain and worsening SBO, the patient was taken to the OR for an exploratory laparotomy, lysis of adhesions, and small bowel resection with primary anastomosis. See operative note for details. Her skin and subcutaneous tissue were closed. She was transferred to the TSICU post-op. ICU course: Neuro: The patient remained sedated while intubated. Once sedation was weaned, she responded appropriately in terms of mental status. Her pain was controlled. CV/Pulm: Her cardiovascular status was stable and she was continued on b-blockers while in the ICU. She has a history of congestive heart failure and her volume status was monitored closely. She was edematous and diuresed with lasix [**Hospital1 **]. Her IVFs were discontinued as well in order to improve her edema, and instead albumin was given. She remained intubated post-op and was able to be weaned and extubated on [**5-15**]. GI: Post-op, she had an NGT in place and was NPO. Her NGT was removed on [**5-16**] and she was advanced to sips on [**5-17**]. Her abdominal wound was covered with dry sterile dressing and an abdominal binder was kept on at all times. Her incision remained c/d/i. GU: She had a foley in place. She had intermitent episodes of low UOP and was bolused gently as needed, with goal of 15-20 cc/hr of urine. Heme: Her hematocrit remained stable throughout her ICU course ID: she was given clotrimazole cream for a fungal infection Prophy: She received subcutaneous heparin for DVT prophylaxis. She was also continued on a H2 blocker. Dispo: she was stable and ready for transfer to the floor on [**2145-5-17**]. Once transferred to the surgical floor, Mrs.[**Known lastname 44912**] course by system is as follows: Neuro: She's been oriented x 3 including the reason for her admission. Her pain has been treated with tramadol and oxycodone PRN. She has intermittent minor pain as expected post-operatively. Cardio: Beta blockers have been continued. She has been hemodynamically stable with adequate rate control (70 - 90s). Generalized edema 2 - 3+ persists. Continue furosemide treatment as discussed below. The patient did describe chest pain (as translated by her daughter) and shortness of breath on [**5-19**]. An ECG was obtained and showed no acute changes when compared to prior tracings this admission. Troponin levels were drawn and were found to be flat. She has not described further chest pain after its spontaneous resolution. Pulm: A chest x-ray taken on [**5-18**] showed likely bilateral pleural effusions. She remains on supplemental oxygen via nasal cannula. She has described feeling short of breath at times. Albuterol and atrovent nebulizer treatments have been administered with good results. Furosemide therapy is continued. With a fluid balance goal of 1 - 2 liters negative per day, her dose was increased on [**5-19**] to 20mg PO BID. Our recommendation is to continue this dosing for approximately five days and then decrease the dose back to her previous home dose of 20mg PO daily. Of course, further clinical exams are warranted to determine effectiveness and titration of diuretic therapy. GI: Mrs.[**Known lastname 44912**] abdominal incision has been well-approximated with no signs of infection. There have been no issues of constipation or diarrhea. She is tolerating a mechanical soft, regular diet. GU: Daily fluid balances have been closely monitored due to Mrs.[**Known lastname 44912**] history of congestive heart failure and current (likely) bilateral pleural effusions. She has diuresed well from daily Lasix. Her foley catheter was discontinued on [**5-19**]. She has since voided without issue, although frequently incontinent. Lines: A right brachial PICC line was in place for prior IV therapy. The line was discontinued on [**5-19**]. Endocrine: Although Mrs. [**Known lastname 44910**] is noted to have a history of diabetes, her pre-prandial blood glucose levels have been well controlled. In general, she has not required an exogenous insulin secondary to hyperglycemia while recouperating post-operatively. Per prior medical records, she not taking any oral diabetic agents. At this time, Mrs. [**Known lastname 44910**] is hemodynamically stable and ready to be transferred to rehab. Medications on Admission: -Iodoquinol HCl 1% topical cream to affected area [**Hospital1 **] -Furosemide 20mg daily -Metronidazole 1% topical gel to affected area [**Hospital1 **] -Metoprolol tartrate (unknown dose) -Glyburide (unknown dose) Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze 2. Clotrimazole Cream 1 Appl TP [**Hospital1 **] fungal skin infection apply to affected area of skin 3. Furosemide 20 mg PO BID 4. Metoprolol Tartrate 12.5 mg PO BID Hold for sbp<110 or HR<60 5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5-1 Tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 6. Acetaminophen 325 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital because of a small bowel obstruction. You were treated with bowel rest, IVF, and nasogastric decompression via an NGT. You responded well to this treatment and did not require surgical intervention to correct your small bowel obstruction. You may continue with your regular diet. You should continue with your home medications. You should continue to wear your abdominal binder at home while walking around for comfort. You should seek immediate medical attention if you develop abdominal pain, nausea/vomiting, inability to take in food/water, or any other symptoms which are concerning to you. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2145-6-8**] at 2:00 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2145-5-20**]

Admission Date: [**2124-1-24**] Discharge Date: [**2124-3-8**] Service: CARDIOTHORACIC Allergies: Percocet Attending:[**First Name3 (LF) 165**] Chief Complaint: Increasing SOB Major Surgical or Invasive Procedure: [**2124-1-27**] cardiac catheterization [**2124-2-3**] Redo sternotomy, MVR (#31 [**Company **] mosaic tissue valve), TV Repair (#32 CE band) [**2-25**] Trach/PEG [**3-3**] Tunneled Left subclavian HD Cath History of Present Illness: HPI: 85 yo M w/MMP including CAD s/p CABG, CRI, HTN presents with SOB. Pt was recently in the hospital on [**12-28**] [**1-14**] to mechanical fall. He was d/c and sent to rehab. At rehab, pt states feeling well until the end of last week when he felt he was "full of fluid." He described having to stop after 40 feet walking b/c of SOB (baseline >80 feet), requiring O2 during night time (pt able to sleep with one pillow), an sense of increased abd distention, and increased lower extremity edema. . While in the EMED, he received a total of 80 mg of IV lasix and had a total of 1000 cc of Uop at noon. . He denies, PND,denies cough, fever, fatigue, chest pain, dizziness, HA, or sick contacts. . Of note, he had a LLL PNA diagnosed in [**12-17**], and he just finished treatment with augmentin for 14 days. Past Medical History: 1. CAD s/p MI - CABG [**2106**] and 2 vessel redo in [**2113**]. - [**10-16**] PMIBI: No anginal symptoms.No significant interval change. oderate fixed inferior wall defect and moderate apical defect with a small amount of reversibility. Inferior wall hypokinesis. Calculated ejection fraction of 56%. 2. Ischemic cardiomyopathy - TTE [**10-16**] TTE: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated, symm LVH, EF >55%, aortic root mildly dilated, trace AR, 3+ MR, mild PA sys HTN 2. Endocarditis [**2114**] Strep salivarius 3. 2:1 Wenckebach block s/p v-pacer 4. BPH 5. Pseudocyst L knee 6. s/p hernia repair, x3 surgeries 7. s/p appy 8. HTN 9. CRI (baseline 1.6-1.8) 10. LLE cellulitis 11. Gout 12. Emphysema 13. R colon cancer s/p colectomy 14. Parkinson's disease (followed by Dr. [**Last Name (STitle) **] 15. PVD w/ claudication symptoms 16. Chronic venous stasis 17. Hypercholesteroemia. Social History: Lives with son although has been in and out of inpatient rehab facilities over past 2 months. remote 1 year history of cigar use, quit. Drinks occasional alcohol, 1 small glass of wine per night, can go days without drinking etoh. Denies other drug use. Works 3hours/week in insurance. . Family History: brother-80 YO deceased, MI two sisters have CAD Physical Exam: PE: on admission VS: Tm: 96.1 Tc 96.1 BP: 118/72 HR: 88 O2sat: 94% on 2L Weight [**1-24**]: 251.1 lbs General: Aox3. In NAD. Pulm: bibasilar crackles. Decreased breath sounds L>>R. CV: holosystolic murmur best heard at the apex. nl S1/S2. JVP is at the jaw line ~ 11 cm. GI: distended. Nl BS+. No tenderness. Ext: 3 + pitting edema. Redness over both lower extremities, consistent with venous stasis. Skin: redness over sacral region and scrotum. Pt getting daily washing with saline and nystatin powder on scrotum, and xeroderm over sacrum. PE prior to leaving medicine floor: General: Aox3. In NAD. Pulm: Bibasilar crackles. CTAB anteriorly CV: holosystolic murmur best heard at the apex. nl S1/S2. GI: soft and non-tender. GU: 3+ scrotal edema. Foley in place ([**1-27**]). Ext: 2 + pitting edema. Redness over both lower extremities, consistent with venous stasis. Skin: redness over sacral region and scrotum. Pt getting daily washing with saline and nystatin powder on scrotum, and xeroderm over sacrum. R femoral dressing is intact, no hematoma, no drainage, no pus, no erythema (cath done on [**1-27**]). Pertinent Results: [**2124-3-8**] 01:30AM BLOOD WBC-10.5 RBC-2.96* Hgb-8.8* Hct-27.7* MCV-94 MCH-29.8 MCHC-31.8 RDW-16.7* Plt Ct-237 [**2124-3-7**] 02:52AM BLOOD WBC-11.4* RBC-2.96* Hgb-8.9* Hct-27.8* MCV-94 MCH-30.1 MCHC-32.1 RDW-16.9* Plt Ct-267 [**2124-3-8**] 01:30AM BLOOD Plt Ct-237 [**2124-3-8**] 01:30AM BLOOD PT-14.3* PTT-30.7 INR(PT)-1.3* [**2124-3-8**] 01:30AM BLOOD UreaN-35* Creat-3.0*# Na-143 K-3.6 Cl-105 HCO3-30 AnGap-12 [**2124-3-7**] 02:52AM BLOOD Glucose-115* UreaN-64* Creat-4.6* Na-138 K-4.7 Cl-103 HCO3-25 AnGap-15 [**2124-3-1**] 04:15AM BLOOD ALT-9 AST-18 LD(LDH)-210 AlkPhos-195* Amylase-104* TotBili-0.5 Portable chest [**2-28**] Tracheostomy tube remains in standard position. Permanent pacemaker is unchanged in position, with proximal coiling of one of the leads in the right supraclavicular area. Heart is enlarged but stable in size. Pulmonary vascular engorgement and perihilar haziness are unchanged. Multifocal areas of atelectasis show slight improvement, particularly in the right lower lobe. Left retrocardiac opacity and adjacent left pleural effusion are unchanged. Small right pleural effusion is also stable. [**2-28**] CT Head w/o contrast IMPRESSION: 1. No hemorrhage or mass effect. 2. Chronic microvascular ischemia. 3. Paranasal sinus mucosal disease. 4. Unchanged expansion of the diploic space of the left parietal bone which may be secondary to Paget's disease. [**3-2**] EEG IMPRESSION: This is an abnormal EEG due to the independent, at times synchronous, frontocentral slowing with broad-based phase reversals, as well as the slow and disorganized background and bursts of generalized slowing. This suggests bilateral frontocentral subcortical dysfunction, as well as similar regions of cortical irritability. The slow and disorganized background and bursts of generalized slowing suggest an encephalopathy, which may be seen with infections, toxic metabolic abnormalities, ischemia or medication effect. Brief Hospital Course: Mr. [**Known lastname **] was admitted with a CHF exacerbation. He was diuresed and began feeling better. CT surgery was consulted for his MR and TR. Cardiac cath on [**1-27**] showed severe 3VD with a patent LIMA-LAD, severe disease in SVG->OM and occluded SVG->RCA. He was placed on cipro for a UTI. Dental medicine cleared him for surgery. He awaited improving creatinine before going to the operating room on [**2124-2-3**] where he underwent a redo, redo-sternotomy, MVR with #31 [**Company **] mosaic tissue valve & TV Repair with 32 mm CE band. He was transferred to the CSRU in critical but stable condition on epinephrine, levophed, vasopressin, and propofol. His epi was weaned off and he was started on natrecor for diuresis. He was extubated on POD #2. The remaining vasoactive drips were weaned to off on POD #3 and he was diuresed with lasix. He continued to be followed by cardiology. He was seen by speech and swallow who recommended pureed solids and thin liquids with PO meds. He was transferred to the floor on POD #5. He was cdiff positive on [**2-9**] and was started on flagyl. He was readmitted to the CSRU on [**2-9**] for respiratory distress and decreased urine output. He was treated with nebulizers with little result and required reintubation. He was seen by mephrology later that same day for anuria and rising creatinine. He was started on vasopressin and neosynphrine for hypotension. His neo and vasopressin weaned to off on [**2-11**]. His creaintine and urine output continued to improve. He was again extubated on [**2-12**]. On [**2-14**], he had recurrent ATN, required reintubation for suspected aspiration and pressors again. He also had afib. He was started on CVVH. He was seen by ID and was started on cefepime and vanco. On [**2-21**] he was again extubated and his CVVH was dc'd. A dobhoff tube wsa placed and he was started on tube feeds. PICC line placed [**2-22**]. Antibiotics (vanco/cefepime) for presumed hospital acquired pneumonia dc'd on [**2-23**]. He completed his course of flagyl. Urine output continued to wax and wane and he was again seen by renal, repiratory status [**Last Name (un) **] began to deteriorate. He was seen by thoracic surgery for consideration of trach and PEG which were placed n [**2-25**]. He was seen by neurology on [**2-27**] for stiffness which ws thought to be metabolic. Head CT was negative. He was restarted on dialysis on [**3-1**] and an HD cath was placed on [**3-3**]. He was last dialyzed on [**3-7**] and will need HD on [**3-9**]. Medications on Admission: 1. Aspirin 81 mg Tablet2. 2. Allopurinol 100 mg 3. Simvastatin 40 mg Tablet QD 4. Ferrous Sulfate 325 (65) mg QD 5. Lisinopril 10 mg Tablet QD 6. Furosemide 80 mg Tablet [**Hospital1 **] 7. Atenolol 25 mg Tablet QD Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every 4 hours) as needed. Tablet(s) 2. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day): periarea. 11. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 13. Erythromycin 5 mg/g Ointment [**Hospital1 **]: One (1) Ophthalmic QID (4 times a day). 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: MR, TR, CAD Gout CRI (2.1) SBE 2:1 heart block s/p PPM BPH HTN LE cellulitis lipids emphysema colon ca parkinsons PVD with claudication venoud stasis s/p CABG [**2106**], [**2113**] hernia repair colectomy Discharge Condition: stable Discharge Instructions: Call with fever, redness or drainage from incisions or weight gain more than 2 pounds in one day or five in one week. No baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds. Followup Instructions: Please make appointments: Dr. [**First Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 1147**] 2 weeks Already scheduled appointments: Provider: [**Name10 (NameIs) 9894**] [**Name11 (NameIs) **] 4 PAIN MANAGEMENT CENTER Date/Time:[**2124-5-5**] 10:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2124-3-8**]

Admission Date: [**2192-4-9**] Discharge Date: [**2192-4-16**] Service: [**Location (un) 259**] FIRM HISTORY OF PRESENT ILLNESS: This is a 77-year-old man with a history of chronic obstructive pulmonary disease with complaints of increasing cough, dyspnea and decreased intakes starting approximately three days prior to admission. Per his wife, he had a temperature of 100?????? in the morning and shaking chills, cough productive of copious yellow sputum. At baseline, has cough productive of white sputum. He is homebound and has had significant decline in his respiratory status over the past three months. He becomes quite dyspneic on even minimal ambulation. He uses 2 liters of oxygen at home, has a 60 pack year history of smoking and quit in [**2187**]. He reports that the severity of his chronic obstructive pulmonary disease waxes and wanes and that he does not feel worse the day of admission than during his chronic obstructive pulmonary disease exacerbations. He reports a history of multiple chronic obstructive pulmonary disease examinations at other hospitals, but that he has never been intubated before. In the Emergency Room, he was given 125 mg of intravenous Solu-Medrol and levofloxacin. In the Emergency Department, he had an electrocardiogram that initially showed sinus tachycardia, but then appeared to be atrial fibrillation in the 170s. He was given a Diltiazem bolus and started on a Diltiazem drip. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, occasionally on po steroids 2. PFTs revealing an FEV1 and FVC ratio of 80%, FEV1 52% of predicted asbestosis 3. Hypercholesterolemia 4. Head and neck cancer status post surgery and XRT in [**2178**] 5. Anxiety 6. Pneumovax in '[**86**] 7. Flu vaccine 8. Rheumatic fever as a child. No known cardiac echocardiogram prior to admission. HOME MEDICATIONS: 1. Serevent 2 puffs [**Hospital1 **] 2. Azmacort 2 puffs qd 3. Albuterol and Atrovent nebulizers 4. Librium 10 mg [**Hospital1 **] prn anxiety 5. Tylenol #3 prn neck and rib pain ALLERGIES: ERYTHROMYCIN SOCIAL HISTORY: Lives with wife in [**Location (un) 538**], 60 pack year history of smoking, quit in '[**87**], former merchant marine, question of asbestosis exposure and history of toxic DM exposure, working as an antique furniture finisher. PHYSICAL EXAM: GENERAL: Very cachectic elderly man breathing through pursed lips on admission. VITAL SIGNS: Pulse 175, blood pressure 116/74, respiratory rate 40, 98% saturation on nonrebreather. HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and reactive to light. Edentulous. Oropharynx dry. CHEST: Breathing with accessory muscles. Breath sounds very distant, scattered crackles posteriorly. HEART: Tachycardic heart sounds are very distant, unable to assess if sinus or not. Unable to assess murmurs. ABDOMEN: Thin, soft, nontender, nondistended, active bowel sounds. Stool is guaiac negative. EXTREMITIES: Thin, no edema. ADMISSION LABS AND IMAGING: Notable for a white count of 13.1 with 77% segs, hematocrit of 41.5. Chemistries unremarkable. C was 79, troponin less than 0.3. Urinalysis was negative. Arterial blood gases was 7.38, 46, 76 on 2 liters of oxygen and repeat was 7.38, 47, 50 on 1.5 liters of oxygen. Chest x-ray showed emphysema, pleural plaques, diffuse perihilar and right apical opacities which were consistent with an acute pneumonia. HOSPITAL COURSE: The patient was admitted and taken to the Medical Intensive Care Unit. In the Medical Intensive Care Unit, he was not intubated. He received antibiotics, levofloxacin for the pneumonia. He received steroids which were tapered, chest physical therapy and nebulizers with some improvement. His heart rate was controlled with Lopressor and Diltiazem which were able to be switched to po and cardiology felt he should be treated for his pulmonary process before aggressive treatment for the atrial fibrillation was started. The patient and family decided on comfort measures and he was transferred to the floor. On the floor, he remained stable with occasional runs of tachycardia, seemed to be related to albuterol nebulizers. He was able to tolerate nasal cannula oxygen and on [**2192-4-16**], his rate had gotten up to 172 but it decreased to the 120s after receiving 50 mg of intravenous Diltiazem. Repeat electrocardiogram showed that he was in atrial flutter and he was continued on po Lopressor and Diltiazem. His Lopressor dose was increased to 75 mg po bid. Palliative care consult was called and they suggested switching him to sublingual morphine sulfate elixir, as well as adding Ativan prn and Colace and Senokot. DISCHARGE PLAN: The patient is stable for transfer to [**Hospital3 2558**] for further care. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po qd 2. Levofloxacin 500 mg po qd, today is day 7 of 10. It should be stopped on [**4-19**]. 3. Salmeterol 2 puffs [**Hospital1 **] 4. Librium 20 mg po bid 5. Metoprolol 75 mg po bid 6. Diltiazem 90 mg po qid 7. Atrovent metered dose inhaler or nebulizers q4h 8. Prednisone 20 mg po qd on [**4-17**] and 8th, 10 mg po qd on [**4-19**] and 10th and then discontinue the prednisone. 9. Colace 100 mg po bid 10. Senna 2 tablets po q hs 11. Azmacort 2 puffs qid 12. Ativan 1 mg sublingual or po q6h prn 13. Morphine sulfate elixir 20 mg per cc given at 5 mg sublingual q4h 14. Morphine sulfate elixir 20 mg per cc given at 5 to 10 mg sublingual q2h prn DIET: As tolerated, supplement with Boost. FINAL DIAGNOSES: 1. Chronic obstructive pulmonary disease 2. Asbestosis 3. Pneumonia 4. Hypercholesterolemia 5. Anxiety FOLLOW UP: Patient to follow up with Dr. [**Last Name (STitle) **]. Planned patient transfer is at 4 p.m. [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2192-4-16**] 13:05 T: [**2192-4-16**] 13:14 JOB#: [**Job Number 10330**] cc:[**Hospital3 10331**]

Admission Date: [**2115-12-20**] Discharge Date: [**2116-1-19**] Date of Birth: [**2084-7-21**] Sex: M Service: [**Hospital1 **] CHIEF COMPLAINT: Requesting detox. HISTORY OF PRESENT ILLNESS: Patient is a 31-year-old male with history of heroin use times eight years who presents to the Emergency Department with request to detox from heroin. The patient has been attempting this on his own times one week. Last use was the day prior to admission. Patient also reports abdominal pain for about a week, "right in the middle". It is worse with ingestion of liquids, solids and with jarring movements causing sharp, severe waxing and [**Doctor Last Name 688**] pain. Denies any fever or chills. Denies shortness of breath. Positive mild epigastric and sternal pain post presentation to the Emergency Department. Denies palpitations. Denies sweats. Positive weight loss, cannot quantify over the last month. No dysuria. No oral or tooth pain. Patient reports that he has never used a used needle to his knowledge. Gets his needles from a needle exchange program. History of tatoos and licensed parlors. No recent sexual contacts. Negative HIV and hepatitis in the past, but cannot recall when. In the Emergency Department he is noted to have a fever of 104.0 F, white count of 17, abdominal tenderness on exam. CT Scan of the abdomen was ordered. PAST MEDICAL HISTORY: Significant for prior hospitalization at [**Hospital3 **] for unclear reasons. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is homeless, but has been staying with his parents in [**Hospital1 8**] for the last several days. IV drug use with heroin for eight years. Needles from needle exchange. Not currently sexually active. Contacts with woman in the past. No high risk contacts without condoms per patient. Positive tobacco use, one pack per day times several years. Occasional alcohol use for one to two years. FAMILY HISTORY: Diabetes in his father. PHYSICAL EXAMINATION: On admission temperature 104.0 F, pulse 114, blood pressure 126/74, respiratory rate 16, O2 saturation 98% on room air. In general ill appearing, thin, grimacing in pain. Head, eyes, ears, nose and throat exam: Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Poor dentition. No oropharyngeal lesions. Neck: Prominent carotid sensation. Positive tenderness of right anterior neck with 3 cm area of mild overlying blanchable erythema. No palpable masses. No lymphadenopathy. Cardiovascular exam: Regular, tachycardia, positive II/VI holosystolic murmur at right upper sternal border, no rubs or gallops. Lungs exam: Decreased breath sounds at left base, no dullness to percussion, otherwise clear to auscultation. Abdomen: Positive bowel sounds, tense abdomen, diffusely tender to palpation. Positive rebound. Positive voluntary guarding, no masses. Liver span about 7 cm. No [**Doctor Last Name 515**]. Spleen was not palpable. Extremities: 2+ radial, DP and PT pulses bilaterally. No lower extremity edema. Back: Positive left flank tenderness. Inguinal: Shotty inguinal lymphadenopathy bilaterally. Skin: Multiple track marks on arms, hands and feet with somewhat mild surrounding erythema. There is a 2 cm blanching erythematous patch on his right chest. Positive violaceous, tender volar distal pads on third and fourth digits to the left hand. Positive Osler nodes and [**Last Name (un) 1003**] lesion. Neurological exam: Alert and oriented times three. Cranial nerves II through XII intact. There is [**6-2**] upper extremity and lower extremity strength bilaterally. No sensory deficits. EKG: Sinus tachycardia at 110, normal axis, normal PR, acute ST-T wave changes. LABORATORY DATA ON ADMISSION: White count 17.0, hematocrit 37.7, platelets 182. INR 1.2, PTT 29.9, sodium 124, potassium 4.4, chloride 88, bicarbonate 23, BUN 19, creatinine 0.8, glucose 124. Urinalysis with small blood, trace leukocyte esterase, 100 protein, zero to two white blood cells, albumin 3.6, neutrophils 84, bands 7, 5 lymphs, 2 monos. ALT 25, AST 57, calcium 8.9, magnesium 8.1, LDH 569, alkaline phosphatase 145, phosphorus 2.1, amylase 37, T bilirubin 0.9, lipase 26. Serum tox negative. Urine tox positive for opiates, positive for Methadone. Urine culture was pending. Chest x-ray showed no evidence of infiltrates, large gastric and colonic gas, no evidence of free air. IMPRESSION: Patient is a 31-year-old male with history of heroin abuse presenting to the Emergency Department for detox with fever to 104.0 F, abdominal pain, increased white count with left shift, possible Osler nodes on exam. Admitted with likely endocarditis. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: Patient's blood cultures grew staphylococcus aureus which was Methicillin sensitive after incubation for one day in four out of four bottles. CT Scan of the abdomen showed multiple small wedge shaped perfusion defects within the kidneys bilaterally as well as multiple wedge shape and triangular low attenuation areas in the spleen consistent with septic emboli. Transthoracic ultrasound showed aortic insufficiency 1 to 2+, no definite evidence of vegetation. A transesophageal echocardiogram was performed which showed a vegetation on the aortic valve with no definite evidence of perivalvular evidence. The patient was initially started on Vancomycin, Oxicillin and Gentamycin for synergy for treatment of endocarditis. After the culture and sensitivity came back, the Vancomycin was discontinued. The Gentamycin was continued for synergy which was then discontinued four days into the hospital stay and continued on IV Oxicillin. [**Known firstname 17766**] continued to spike fevers despite the continued antibiotics and an EKG daily showed some prolongation of the PR interval, however did not show actual prolongation beyond 200 milliseconds. Due to the spiking fevers, a TEE was performed once again on [**2115-12-27**] this time showing evidence of a perivalvular abscess as well as a fistulous track between the right ventricle and the aorta. The patient was also noted to have no worsening of the aortic insufficiency. Further work up prior to replacing the aortic valve, it was felt the patient would benefit from reevaluation of all possible septic emboli and a MRI was done once again of the head which showed several septic emboli as per the MRI on admission with no definite evidence of mycotic aneurysms, however prior to undergoing surgery it was felt to be a benefit to undergo a better study in order to better evaluate for mycotic aneurysms and the patient underwent a four vessel cerebral angiogram which showed no evidence of mycotic aneurysms. As the patient also had poor dentition, it was felt that it would improve his outcome if his teeth were removed. Dental and Oral Surgery consults were obtained and the patient's 18 teeth were removed under general anesthesia. He tolerated the procedure well with no complications and is not having pain at this time from the actual procedure. Repeat imaging of the abdomen for evaluation of the septic emboli to the spleen and the kidneys revealed a splenic septic embolus which was unclear in characteristics if it was actually representing an abscess and this was further evaluated with an abdominal ultrasound which did not show any clear evidence of fluid within the mass of the spleen and likely represented an infarcted portion of the spleen. Surgical Service was consulted for possible drainage of this collection and did not feel like this would be warranted given the appearance on ultrasound. While an inpatient, the patient was also tested for HIV, hepatitis C and hepatitis B the results of which were hepatitis B was negative, HIV was negative. Hepatitis C showed evidence of antibody, however PCR for RNA is still pending at the time of this discharge, but will need to be followed as an outpatient. 2. FLUIDS, ELECTROLYTES AND NUTRITION: Sodium was noted to be significantly low on admission which improved somewhat with hydration and there was likely a prerenal component to the hyponatremia, however after adequate p.o. intake and hydration, the sodium did not significantly improve and it was noted that the Oxicillin was being given in D5 water which was then changed to normal saline and had a significant improvement in the electrolyte balance with a sodium in the 133 to 135 range. In comparison with the urine osmos and urine sodium and creatinine did show some element of SIDH as well. 3. PSYCH / ADDICTIONS: Patient is currently on Methadone maintenance for heroin withdraw and his tolerated his Methadone with very little craving or withdraw symptoms. He was initially started on large dose of Methadone which was gradually tapered down to 30 mg p.o. q. day. Patient is interested in decreasing this even further as an outpatient. 4. HEMATOLOGY: Patient's hematocrit was noted to be approximately 37 on admission which declined significantly during his hospital stay down a hematocrit of 23 to 24 at its lowest. Iron studies as well as B12, folate and hemolysis labs were all sent which showed evidence of iron deficiency anemia likely also with overlying anemia of chronic disease. There might have been some element as well as of hemolysis due to the sheering of force in the aortic valve. Was started on iron and also transfused one unit prior to being transferred to the Cardiothoracic Surgery Service. Stool guaiacs were negative with the exception of one stool guaiac which showed trace guaiac positivity. Likely as the infection subsides and with the replacement of iron, the patient's hematocrit will improve. This is the end of the dictation for the Medicine portion of this dictation summary. The rest of the course will be dictated by Cardiothoracic Surgery. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**] Dictated By:[**Name8 (MD) 4630**] MEDQUIST36 D: [**2116-1-6**] 12:56 T: [**2116-1-6**] 13:32 JOB#: [**Job Number 47073**]

Admission Date: [**2136-8-19**] Discharge Date: [**2136-8-23**] Date of Birth: [**2101-10-31**] Sex: F Service: MEDICINE Allergies: Ambien Attending:[**Last Name (NamePattern1) 13159**] Chief Complaint: DKA Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: 34F with history of insulin-dependent diabetes, cardiomyopathy, hypomagnesemia and blindness secondary to mitrochondrial myopathy presents with tachycardia and full body pain. Patient states she has not been taking her insulin for 2 weeks because she was visiting a friend. She refuses to explain further, just saying that she "didn't feel like taking it," despite having been admitted for DKA in the past. She has chronic issues with hypomagesemia which results in muscle pains, she reports taht she was having severe muscle pains and thought she likely had low magnesium, so she came to the ER. She also was having tachycardia over the past few days, especially with ambulation, and began to feel progressively weak and tired, which was another cause of her to seek care. She complains of pain in her entire body her arms. Denies fevers, chills, chest pain, palpitations, abdominal pain, nausea, vomiting. She has been urinating more frequently. In the ED, initial VS were: 173 169/105 04:40 162 153/103 28 100% 05:14 130 135/77 32 100% 05:20 8 109 129/75 28 100% 06:21 108 124/75 18 99% 06:57 98.3 07:37 131 121/72 25 99% 08:30 7 108 122/72 18 98% 09:45 3 98.4 83 120/71 13 98% Rec'd 3050 (incl IL NS w 40 kcl) last K 2.8 Up now D5NS at 125/ hr; Insulin drip Drips: Insulin drip 100units/100cc at 7 units per hour Rec'd Dilaudid 0.5mg IV x 3 last dose at 0930 w good effect Initial Glu 400s- rec'd 16 Units Humalog. Fsbs prior to drip 78. Given 1 amp Dextrose Has voided several times large amounts #18 Rac/ # 20 R ac outer aspect On arrival to the MICU, the patient says that she feels nauseous. She says that she has muscle pain in her arms, legs and some rib pain, which she describes as bone pain. She cannot pin down whether she has abdominal pain alone. She has not had any vomiting, but she says that she began to feel nauseous after she began to drink soda [**Doctor Last Name **] in the ER. Past Medical History: Diabetes mellitus, type I Hypertension Hypomagnesemia blindness Gait disorder Mitochondrial myopathy Insomnia Obstructive sleep apnea- on CPAP Social History: Lives alone, enjoys [**Location (un) 1131**] books and listening to TV shows, sister is in apartment in same building (also blind with same mitochondrial disorder). Sister's husband recently passed away. She is independent in ADLs, does not require walking assistance despite myopathy/vision deficit. Uses walking stick. Tobacco- denies Alcohol- denies Illicits- denies Family History: Father- unknown [**Name (NI) 12237**] [**Name (NI) 2320**] [**Name (NI) 12408**] mitochondrial myopathy [**Name (NI) 61697**] colon cancer Grandmother- breast cancer Father- unknown [**Name (NI) 12237**] [**Name (NI) 2320**] [**Name (NI) 12408**] mitochondrial myopathy [**Name (NI) 61697**] colon cancer Grandmother- breast cancer Physical Exam: ON ADMISSION [**2136-8-19**] Vitals: T: 98.2 BP: 129/68 P: 106 R: 18 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, edentulous. Eyes with dilated pupils, not focusing, often with eyes closed. Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, mild diffuse tenderness, obese, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, ON DISCHARGE [**2136-8-22**] PHYSICAL EXAM: VS - Temp 97.9F, BP 104/67, HR 66, RR 18, O2-sat 99% RA FSBG 105 General: Alert, awake, oriented, no acute distress, flat affect, laying in bed, pleasant, cooperative, having breakfast HEENT: Sclera anicteric, moist mucous membranes, oropharynx clear, edentulous. Eyes with dilated pupils, not focusing, often with eyes closed, there is mild horizonatal nystagmus noted, Neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, obese, bowel sounds present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation to light touch and proprioception bilaterally, no sensation to light touch at right heel Pertinent Results: ADMISSION LABS: [**2136-8-19**] 04:40AM WBC-5.1 RBC-5.47* HGB-15.9 HCT-46.1 MCV-84 MCH-29.1 MCHC-34.6 RDW-15.5 [**2136-8-19**] 04:40AM GLUCOSE-406* UREA N-11 CREAT-1.1 SODIUM-137 POTASSIUM-3.0* CHLORIDE-101 TOTAL CO2-13* ANION GAP-26* [**2136-8-19**] 07:03AM TYPE-[**Last Name (un) **] PO2-150* PCO2-24* PH-7.26* TOTAL CO2-11* BASE XS--14 [**2136-8-19**] 01:13PM LACTATE-2.8* [**2136-8-19**] 12:06PM BLOOD Osmolal-292 [**2136-8-19**] 05:52PM BLOOD Glucose-125* UreaN-5* Creat-0.7 Na-138 K-3.5 Cl-110* HCO3-18* AnGap-14 [**2136-8-19**] 07:45PM BLOOD Glucose-84 UreaN-5* Creat-0.7 Na-138 K-3.7 Cl-109* HCO3-20* AnGap-13 MICROBIOLOGY URINE CULTURE (Final [**2136-8-20**]):MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKINAND/OR GENITAL CONTAMINATION BLOOD CULTURES [**2136-8-19**]: PENDING MRSA SCREEN (Final [**2136-8-21**]): No MRSA isolated. IMAGING [**2136-8-19**]: PORTABLE AP CHEST RADIOGRAPH: The lungs are clear. No confluent opacity is identified. There is no pulmonary edema or pleural effusions. Cardiomediastinal and hilar contours are within normal limits. IMPRESSION: No acute cardiopulmonary process EKG [**2136-8-19**]: Sinus tachycardia at 160 beats per minute. Low voltage in the limb leads with much baseline artifact. There appears to be leftward axis. R wave progression is abnormal consistent with prior anterolateral myocardial infarction or lead placement. Clinical correlation is suggested. Compared to the previous tracing of [**2136-7-28**] sinus tachycardia is new and the abnormal R wave progression persists. DISCHARGE LABS: [**2136-8-23**] 09:05AM BLOOD WBC-2.8* RBC-4.71 Hgb-13.8 Hct-39.3 MCV-83 MCH-29.2 MCHC-35.1* RDW-16.2* Plt Ct-196 [**2136-8-23**] 09:05AM BLOOD PT-11.6 PTT-29.7 INR(PT)-1.1 [**2136-8-23**] 09:05AM BLOOD Plt Ct-196 [**2136-8-23**] 09:05AM BLOOD Glucose-102* UreaN-7 Creat-0.9 Na-139 K-3.3 Cl-105 HCO3-21* AnGap-16 [**2136-8-23**] 09:05AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.2* Brief Hospital Course: 34 year old female with a significant PMH for insulin-dependent diabetes, cardiomyopathy, hypomagnesemia and blindness secondary to mitochondrial myopathy presenting with hypomagnesemia and DKA likely secondary to noncompliance. # DKA: Patient was started on an insulin drip in the ED anion gap and blood sugar had resolved on arrival to the MICU. Patient tolerated a PO diet and was transitioned to subq insulin. There were no localizing symptoms concerning for infectious or ischemic causes of DKA. Given patient's history of poor control, DKA most likely secondary to non-compliance. Electrolytes were monitored every 2 hours and repleted. [**Last Name (un) **] was consulted and saw patient in MICU. Psychiatry was consulted and medication non-compliance likely [**12-29**] to severe depression. # respiratory acidosis: was most likely secondary to hyperventilation in the setting of anxiety. Patient's CO2 resolved on subsequent ABGs. # Whole Body Pain: the patient reported that she was at baseline mitrochondrial myopathy pain except that it is worsened, which may be related to dehydration and concomitant illness. There are no localizing sx on exam and her pain is diffuse. She was given minimal doses of PO dilaudid and kept on on home doses of NSAIDS and tylenol. Her home carisprodol 350 mg was continued. Her pain improved with correction of magnesium. # Depression/anxiety: Patient reporting intention of self-harm by not taking insulin. She was maintained on her home dose of fluoxetine and lorazepam. She was refusing oral medication and food intake [**12-29**] to depression. Psychiatry was consulted and recomended inpatient psychiatric admission. She was agreeable to this on discharge. # Lactic Acidosis: likely type A acidosis related to hypovolemia. Was 3.7 on admission to MICU and normalized on repeat labs after fluid hydration. # Hypomagnesemia: Patient on aggressive home repletion with magnesium gluconate 27mg (500mg) 4 tablets [**Hospital1 **] at home. She was closely monitored and repleted during admission. We did not carry this on formulary and she was treated with Magnesium oxide 400mg daily as home equivalent. She continued to have muscle pains which improved with IV Mg. # Type I Diabetes: Her HgA1c was 8.1 at PCP's office on [**7-10**], was previously 6.4 on [**2136-3-1**]. Pt reports HgA1C ranges of [**4-1**]. Patient's home regimen is insulin [**Date Range **] 37u qHS with Humalog sliding scale. [**Last Name (un) **] was consulted and gap closed she was maintained on [**Last Name (un) **] 20 units and humalog 5 units before each meal with correction 1 unit for every 50 above 150 with sugars in 120s-150s. # OSA/insomnia: patient continued on CPAP @ 9 PEEP. # Code: Full (confirmed) TRANSITIONAL ISSUES: [ ] Please attempt to keep patient on home magnesium gluconate 27mg (500mg) 4 tablets [**Hospital1 **]. If not on formulary consider giving 400mg of Magnesium oxide [**Hospital1 **]. [ ] Trend magnesium levels [ ] Insulin sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations: [**Last Name (un) **] 20 units and humalog 5 units before each meal with correction 1 unit for every 50 above 150. [ ] Encourage CPAP at 9 PEEP Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Atenolol 50 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Fluoxetine 60 mg PO DAILY 4. Glargine 37 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 5. Lorazepam 1 mg PO BID:PRN anxiety 6. Pregabalin 200 mg PO TID 7. traZODONE 25 mg PO HS:PRN insomnia 8. magnesium gluconate *NF* [**2123**] mg Oral [**Hospital1 **] 9. carisoprodol *NF* 350 mg Oral QHS 10. Lovaza *NF* (omega-3 acid ethyl esters) 1 gram Oral [**Hospital1 **] 11. Acetaminophen 650 mg PO Q6H:PRN pain not to exceed 3000 mg in 24 hours 12. Ibuprofen 400 mg PO Q8H:PRN pain do not exceed 1200 mg in 24 hours 13. Amiloride HCl 5 mg PO DAILY hold for SBP < 90 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain not to exceed 3000 mg in 24 hours 2. Amiloride HCl 5 mg PO DAILY hold for SBP < 90 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. carisoprodol *NF* 350 mg Oral QHS 6. Fluoxetine 60 mg PO DAILY 7. Ibuprofen 400 mg PO Q8H:PRN pain do not exceed 1200 mg in 24 hours 8. Glargine 20 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 9. Lorazepam 1 mg PO BID:PRN anxiety 10. Pregabalin 200 mg PO TID 11. magnesium gluconate *NF* [**2123**] mg Oral [**Hospital1 **] 12. Lovaza *NF* (omega-3 acid ethyl esters) 1 gram Oral [**Hospital1 **] 13. Senna 1 TAB PO BID:PRN Constipation 14. Docusate Sodium 100 mg PO BID 15. traZODONE 25 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: Diabetic ketoacidosis Severe Depression Hypomagnesemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent but visually impaired and requiring guidance. Discharge Instructions: Dear Ms. [**Known lastname 29571**]: It was a pleasure taking care of you at [**Hospital1 18**]. You had come into the ED because you had severe muscle pain and an increased heart rate. In the ED your sugar was found to be high and you were diagnosed diabetic ketoacidosis. You were transfered to the MICU were you were given a large amount of IV fluids and your electrolytes were repleted. Your diabetic ketoacidosis improved. You were also seen by psychiatry which felt that you were depressed and this was the reason you had stopped taking your medications. Your apetite, sugars, and pain improved throughout your stay. Your magnesium was low during your stay and we gave you oral and IV medications to make this better. Your pain also improved with administration of magnesium. We made the following changes to your medications. Please CONTINUE taking your home medications as prescribed. Please START humalog and [**Hospital1 **] as directed. Please START taking docusate sodium 100mg twice daily and Senna twice daily for constipation. Please follow-up with the appointments as outlined below. Thank you, Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2136-9-11**] at 8:40 AM With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: [**Hospital Ward Name **] [**2136-9-28**] at 7:40 AM With: DR. [**First Name (STitle) **]/DR. [**First Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: MONDAY [**2136-9-10**] at 8:30 AM With: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2159-1-25**] Discharge Date: [**2159-2-8**] Date of Birth: [**2114-8-15**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Patient is a 44-year-old gentleman with history of hypertension, diabetes, aortic root replacement x2 secondary to abscess of the aortic valve presenting to the Emergency Department on [**1-25**] with upper gastrointestinal bleed. The patient has vomited blood, had complaints of low grade temperatures, and was admitted to the MICU. The patient had been admitted prior on [**2158-9-24**] to [**2159-1-23**] for the workup of the aortic root abscess; but was subsequently discharged to rehabilitation and then again represented to the Emergency Department on [**1-25**] with the upper gastrointestinal bleed. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes. 3. Seizure disorder. 4. Neuropathy. 5. Bilateral pleural effusion. 6. Disseminated fungemia. 7. Renal tubular acidosis x1. PAST SURGICAL HISTORY: 1. Status post coronary artery bypass graft. 2. PEG placement. 3. Right hemicolectomy. 4. Left thoracotomy. 5. Aortic valve surgery x2. ALLERGIES: The patient has no known drug allergies. Upon presentation, patient's vital signs were 99.5, blood pressure 100/53, heart rate 75, respiratory rate 20. He was on SIMV mechanical ventilation with pressure support. PHYSICAL EXAMINATION UPON ADMISSION: In general, he is a young man in no apparent distress, intubated. Pupils are midline, equally reactive. Oropharynx was moist. Neck was supple, no bruits. Lungs: Crackles diffusely, decreased breath sounds bilaterally. Heart: Regular, rate, and rhythm. Abdomen is soft, nontender, nondistended. Surgical incision midline with stables clean, dry, and intact. Extremities: 3+ pitting edema, significant scrotal edema. Foley is intact. He has a left subclavian intact. INITIAL LABORATORIES: White blood cell count 17.2, hematocrit 27, platelets 183. Chem-7: 144 is the sodium, potassium 3.7, chloride 114, bicarb 21, BUN 44, and creatinine of 1, sugar of 154, lactate 1.8, INR 1.3, PTT 35.9. He had multiple blood cultures. On [**1-30**], he had a left subclavian central line culture that showed no growth. His MRSA screen on [**2159-1-29**] was negative. Stool cultures were negative on [**1-27**]. Sputum culture on [**1-25**] is negative. Blood culture on [**1-15**] negative. Urine culture on [**1-25**] was negative. He had an ultrasound of the upper extremity that showed no deep venous thrombosis on [**2159-1-30**]. During his hospital course in terms of issues: Gastrointestinal: His upper gastrointestinal bleeding was evaluated by the Gastroenterology Service. They initially did not scope the patient and given that his hematocrit stabilized. During the last couple days prior to discharge, they scoped him twice, and both times determined that he had gastritis and esophagitis in the lower [**12-1**] without any focal hemorrhage. They recommended supportive care. In terms of his presentation, a CT scan of his belly was performed which showed free air as well as bowel wall thickening around the cecum. Surgery service was consulted, and they elected to do a right hemicolectomy secondary to diverticular disease. A postoperative CT scan several days later showed no anastomotic leak. His GI course was unremarkable as examination remained nontender, nondistended. In terms of pulmonary issue, the patient was getting Zosyn and gentamicin for presumptive pneumonia. He had blood cultures which had showed sparse growth of Pseudomonas last month, but he was treated for an 11 day course. In terms of mechanical ventilation, he was on IMV with pressure support, and then weaned off to pressure support and PEEP, pressure support of 20 and PEEP of 10. Chest x-rays had already showed some failure, i.e., pulmonary edema. However, the saturations always remained stable. Cardiovascularly, he has always remained hemodynamically stable of hypertension, and Lopressor was continued. Infectious Disease: He has never spiked a fever, though his white blood cell count has been elevated as high as 30s in the low 30s. Fever never spiked. Renal wise, given his fluid status on examination, he had anasarca, diffuse edema pitting on upper and lower extremities. Given that he was diuresed with 40 mg of IV Lasix tid, and he put on -1 to 2 liters negative on the last several days of admission, and will continue to diurese him outpatient recommended. Heme wise, his hematocrit has been stable, most recently. Though his hematocrit did drop to the low 20s. He was transfused several units, and has been stable on q6 and q12h hematocrit checks. Diabetes: Has been stable. He is on regular insulin-sliding scale. Seizure disorder: He has had no apparent seizures so far. Neurologically, it has been documented that he suffered an anoxic brain event, brain damage, although he continues not to be oriented, he occasionally appears to be able to follow commands. He can track with this eyes, but he does not follow commands. Fluids, electrolytes, and nutrition: He is on tube feeds of Peptamen at 90 cc/hour, and he was full code. DISPOSITION: Back to nursing home. DISCHARGE DIAGNOSES: 1. Status post right hemicolectomy. 2. Status post upper gastrointestinal bleed. 3. Diabetes. 4. Hypertension. 5. Anoxic brain damage. 6. Status post aortic valve replacement x2. 7. Neuropathy. 8. History of renal tubular acidosis. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po bid. 2. Epogen 4,000 units subQ two times a week Tuesday and Friday. 3. Morphine sulfate 2-10 mg IV q2-4h prn pain. 4. Keppra 500 mg po bid. 5. Atrovent 1-2 puffs nebulizer q4h prn wheezing. 6. Bacitracin polymixin ophthalmic ointment apply to each eye q6h. 7. Tylenol 650 mg po q4-6h. 8. Metoprolol 25 mg po bid. 9. Tube feeds: Peptamen 90 cc/hour. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 19796**] MEDQUIST36 D: [**2159-2-7**] 13:16 T: [**2159-2-8**] 08:02 JOB#: [**Job Number 21700**]

Admission Date: [**2129-5-2**] Discharge Date: [**2129-5-5**] Service: MED This is a Discharge Summary Addendum from previous discharge summary. Regarding the patient's possible adrenal insufficiency, after discussion with the endocrinology consult and with patient's A.M. cortisol level of 12 on the morning of [**5-5**] prior to a dose of 20 mg of prednisone, it is most likely that patient is not adrenally insufficient given that she has a normal cortisol level. It was recommended by the endocrinology team that patient continue on a prednisone taper of 20 mg q day for the next day, [**5-6**], and then taper to 10 mg q day afterwards starting on [**5-7**] until patient can have a follow up appointment with the endocrinologist. At the time of this dictation an endocrine appointment is still being scheduled depending on whether the patient would like to stay close to home or whether she can return to [**Hospital1 1444**] for follow up. Patient will no longer need fludrocortisone so this was discontinued. She will need [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-stem test on her endocrine follow up appointment while she is a dose of prednisone 10 mg a day. In addition, it is important that note that patient will require stress dose steroids in the event of an infection or other stress given that she has been on high dose steroids which may have suppressed some adrenal function. So place make the correct that patient's prednisone taper will not be as dictated in the pervious Discharge Summary but will be spelled out on the . All other discharge medications are the same as previous Discharge Summary. [**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern1) 11159**], [**MD Number(1) 11160**] Dictated By:[**Name8 (MD) 5706**] MEDQUIST36 D: [**2129-5-5**] 12:19:57 T: [**2129-5-5**] 12:33:56 Job#: [**Job Number 101676**]

Admission Date: [**2115-9-11**] Discharge Date: [**2115-9-21**] Date of Birth: [**2037-10-7**] Sex: F Service: MEDICINE [**Company 191**] HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 96864**] is a 77-year-old female with a history of diabetes, hypertension, gastroesophageal reflux disease, and peripheral neuropathy recently admitted to the [**Hospital3 4527**] and found to have massive ascites and abdominal carcinomatosis on abdominal [**Hospital **] transferred to [**Hospital1 18**] for gynecologic/oncology evaluation and possible surgical staging and debulking who was then subsequently transferred to the Medicine Service for a right deep venous thrombosis and management of this due to her allergy to heparin. At the outside hospital, as mentioned before, she had massive ascites and abdominal carcinomatosis with diffuse omental studding and a CA125 of 1,200. On transfer to the Medicine Service, she was denying any complaints including shortness of breath, chest pain, fever, chills, nausea, vomiting, saying that her left leg was less full than it had been in the several days prior. She reports an allergy to heparin, although she is not sure of the specifics of the allergy, but has been told in the past not to be given heparin. After talking with the family, they state that she has denied seeing a doctor for many months but has been complaining of abdominal swelling and right-sided abdominal pain for months. They also say that she points to the region of her liver as a source of pain. While at [**Hospital3 4527**], she vomited blood and had three transfusions while admitted for maintenance of her hematocrit. Her family is also adamant that she is full code, and they reported that she had a TAH/BSO done many years ago in [**Country 10363**] and the specifics of that they are not sure of. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. COPD. 4. Gastroesophageal reflux disease. 5. Depression. 6. Osteomyelitis. 7. Peripheral neuropathy. 8. Questionable history of CVA in the past with right-sided weakness. 9. Pneumonia two months ago. 10. History of anemia with Guaiac positive stools at [**Hospital3 4527**] with an EGD and colonoscopy which were negative. She received three blood transfusions at this time. 11. TAH/BSO done in [**Country 10363**] many years ago with unclear specifics. SOCIAL HISTORY: Ms. [**Known lastname 96864**] lives at the [**Hospital 1036**] Nursing Home in [**Location (un) 620**]. She denied any tobacco, alcohol, or other drug use. Per her family, her code status is full. FAMILY HISTORY: She has one daughter who had breast cancer diagnosed at age 45. She denied any family history of ovarian or cervical cancer. ALLERGIES: She has an allergy to aspirin which causes rash and hives. She also has an allergy to heparin with unknown effects. ADMISSION MEDICATIONS: 1. Megace. 2. Nitroglycerin patch 0.1 grams q. 12 hours. 3. Zoloft 50 mg q.d. 4. Lasix 40 mg q.d. 5. Vitamin E. 6. Actos 30 mg q.d. 7. Glyburide 5 mg b.i.d. 8. Captopril 50 mg t.i.d. 9. Iron sulfate 325 mg t.i.d. 10. Ultram 50 mg t.i.d. 11. Atenolol 12.5 mg b.i.d. 12. Protonix 40 mg b.i.d. 13. Klonopin 0.5 mg t.i.d. 14. Zyprexa 2.5 mg q.h.s. 15. Lipitor 40 mg q.h.s. 16. Neurontin 300 mg q.h.s. 17. Trazodone 100 mg q.h.s. 18. Regular sliding scale with insulin. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.6, blood pressure 142-176/60s-80s, pulse 80, respirations 20, oxygen saturation of 98% on room air. General: The patient was a very pleasant elderly female, appearing her stated age, lying in bed. HEENT: The pupils were equally round and reactive to light and her extraocular muscles were intact. There was no evidence of scleral icterus. Heart: There was a II/VI systolic ejection murmur heard throughout the precordium with radiation to the carotids. Pulmonary: She had decreased breath sounds on the left, no audible wheezes or rhonchi. Abdomen: Distended, tense. She had decreased bowel sounds. She had increased venous distribution in the periumbilical region. She had no rebound or guarding. Abdomen: Nontender to palpation. Extremities: The right lower extremity was noted to be more swollen than the left. She had no palpable cords. She had 2+ dorsalis pedis pulses bilaterally, and there was no erythema or evidence of venostasis changes. LABORATORY/RADIOLOGIC DATA: On admission, the CBC revealed a white count of 11.7 with a differential showing 76.4% neutrophils, 11% lymphocytes, and 8.8 monocytes. Her hematocrit was 32.7 with an MCV of 89, platelets 366,000. Coagulations revealed a PT of 13.8, PTT 22.9, and INR of 1.3. She had normal serum chemistries. She had an ALT of 13, AST of 16, LD 306, alkaline phosphatase 57, amylase 80, T bilirubin 0.3, lipase 36, albumin 3.4. On admission to the [**Hospital1 18**], Doppler ultrasound of her right lower extremity showed a nonocclusive thrombus in the right common femoral vein and occlusive thrombus in the superficial femoral vein. The thrombus also appeared to extend into the greater saphenous vein. She had an EKG as well which showed sinus tachycardia with a right bundle branch block, and Q waves in the lateral limb leads. All of this was unchanged from previous EKG compared to [**Hospital3 4527**]. HOSPITAL COURSE: 1. HEMATOLOGIC: It was presumed and was felt most likely by Gynecology/Oncology as well as Hematology/Oncology that the mass in the patient's abdomen correlated with an elevated CA-125 of 1,200 were probably most consistent with ovarian carcinoma. This was conveyed to her and her family and she was offered surgical debulking and surgical staging by Gynecology/Oncology. It was felt necessary to medically manage her medical issues including her deep venous thrombosis by the Medicine Team with further discussion later in her admission with her family regarding possibility for surgery. Once she was medically managed and further discussions were begun, her family was very inconsistent and indecisive for plans and wishes for their mother. They became angry at one point and dissatisfied with the medical team for talking to the patient without the family present. It was explained to them, however, that Mrs. [**Known lastname 96864**] has the capacity to make decisions on her own, and her health care needs to be discussed with her as well. She was inconsistent as well throughout admission as to whether or not she wanted to undergo surgery or possible paracentesis with analysis of fluid for cytology and possible follow-up chemotherapy. At the beginning of her hospitalization, it seemed as she did wish to undergo surgery, but later throughout her admission it was clear that she was very scared of surgery and did not feel that this was the best option, and preferred paracentesis. Since no conclusion could be made or decision made by her family, it was conveyed to them that it was inappropriate for her to have an extended hospital course or hospital stay while they waited to make this decision and this decision could be made as an outpatient. Hematology/Oncology was consulted and recommended three treatment options; the first being surgical debulking and staging by Gynecology/Oncology with possible follow-up chemotherapy; the second, being abdominal paracentesis with analysis of fluid for cytology and pending the results palliative chemotherapy; the third being hospice care for Mrs. [**Known lastname 96864**]. All of these options were relayed to her family in a family meeting on [**2115-9-18**], and at this point they still felt unable to make a decision. This information was also conveyed to her primary care physician. [**Name10 (NameIs) **] of [**2115-9-23**], the patient has decided to proceed with laparotomy for staging and debulking purposes. She also was noted on admission to have a right deep venous thrombosis, and has an allergy to heparin. Therefore, she was started on lepirudin and maintained on a lepirudin drip for a goal PTT of 60-80. She received one dose of Coumadin prior to consideration of surgery, and resulted in an elevated INR to 5.6, which subsequently came down to the 2.5 range. It was unclear why her INR was persistently elevated, possibly due to malnutrition. She had LFTs checked, all of which were normal. Since she had a therapeutic INR, she was started on Coumadin with no need for overlap with the Lepirudin. HIT antibody was not checked at this time. Mrs. [**Known lastname 96864**] also has a history of anemia with iron studies consistent with anemia of chronic disease. She had been receiving iron supplementation when admitted; however, she was not discharged on iron supplementation due to inability of iron supplementation to help with anemia of chronic disease. Her hematocrit was monitored very closely. She received 1 unit of packed red blood cells on [**2115-9-18**] for a hematocrit of 25. Her hematocrit was stable after that point. 2. CARDIOVASCULAR: Mrs. [**Known lastname 96864**] has a history of hypertension and had good blood pressure control while admitted on her Captopril 50 mg t.i.d., and she was originally kept on her Atenolol 12.5 mg b.i.d., which was subsequently increased to 25 mg b.i.d. with better control of her blood pressure. There was a questionable history of coronary artery disease on admission given the Q waves in the lateral limb leads, and right bundle branch block. She underwent cardiac preoperative evaluation while admission in case of possible surgical debulking and also to better convey risks and benefits to her family. She underwent an echocardiogram which showed a mildly dilated left atrium, a normal left ventricular cavity, a normal ejection fraction, moderate pulmonary hypertension, and mild aortic stenosis. She also had a Persantine MIBI stress test which revealed no EKG changes, normal ejection fraction, and no reversible defect. It was felt that her cardiac postoperative risk for death was 10-15%. Mrs. [**Known lastname 96864**] also suffered from fluid overload and congestive heart failure while admitted. She had some oxygen desaturations and was maintained on 3 liters of oxygen by nasal cannula. She was aggressively diuresed with IV Lasix 80 mg b.i.d. for two days, with resolution of symptoms. She was diuresed until her creatinine bumped to 1.3 and then diuresis was held, and then restarted the next day at the dose of 40 mg p.o. b.i.d. Her creatinine subsequently fell to 1.0. 3. PULMONARY: Mrs. [**Known lastname 96864**] has a history of COPD, and was originally started on Albuterol nebulizer p.r.n., which were subsequently increased to a standing dose in addition to standing Atrovent nebulizers. She was also given Albuterol MDI p.r.n. She had audible wheezing and evidence of hypoxia, but improvement with her nebulizer treatments. She will be discharged with Albuterol MDI p.r.n. and strongly recommended that she have respiratory treatments with nebulizer treatments p.r.n. at the nursing home. She also had evidence of increased sputum production several days after admission and a poor quality chest x-ray. At this point, it was attempted to get sputum from induction; however, no sample was ever obtained. She remained afebrile without any clinical evidence of pneumonia. 4. ENDOCRINE: Mrs. [**Known lastname 96864**] has a history of type 2 diabetes and is maintained on Actos and Glyburide as an outpatient. While admitted, she had decreased p.o. intake, and her Actos and Glyburide were held and she was covered with a sliding scale of regular insulin. At the time of discharge, she will be restarted on her Actos and Glyburide. It was recommended that she have close follow-up at the nursing home as an outpatient for hypoglycemia given her likely decreased p.o. intake from her malignancy. 5. INFECTIOUS DISEASE: Several days into admission, it was noted that Mrs. [**Known lastname 96864**] was somnolent and it was felt that she was possibly developing an infection, and had been on Tylenol; therefore, a fever spike could not be detected. She had urine cultures, blood cultures, and an attempt at sputum culture which was never obtained. A U/A revealed signs of a urinary tract infection; however, urine culture times two came back as fecal contamination. There was a question of whether or not she might have a possible fistula between her rectum and bladder from her malignancy. She was, however, started on levofloxacin, and was discharged on five days to complete a total of a seven day course. Initial blood cultures grew one out of four bottles positive for gram-positive cocci in chains from her PICC line site. This was followed the second day with surveillance cultures which at the time of discharge had never grown anything and it was felt that this was probably secondary to contamination. 6. PSYCHIATRY: Mrs. [**Known lastname 96864**] has a history of depression and has been maintained at the nursing home on Zoloft, Zyprexa 2.5 mg q.h.s., and Klonopin 0.5 mg t.i.d. as an outpatient. These were continued while she was admitted, and several of her Klonopin doses were held for concern of excessive sedation. She was withdrawn. She also was very interactive at other periods. It was felt that she was very worried, anxious, and fearful of her diagnosis, as to be expected. DISPOSITION: Not yet determined. DISCHARGE DIAGNOSIS: 1. Presumed ovarian cancer. 2. Ascites. 3. Hypertension. 4. Diabetes. 5. Chronic obstructive pulmonary disease. 6. Depression. 7. Deep venous thrombosis. 8. Congestive heart failure. 9. Urinary tract infection. DR.[**Last Name (STitle) 2511**],[**Doctor Last Name **] 12-AHZ Dictated By:[**Last Name (NamePattern1) 14268**] MEDQUIST36 D: [**2115-9-20**] 04:52 T: [**2115-9-20**] 21:06 JOB#: [**Job Number 96865**]

Admission Date: [**2130-3-28**] Discharge Date: [**2130-3-31**] Date of Birth: [**2048-7-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Central Venous Catheter placement History of Present Illness: 81 year old male initially presented to [**Hospital1 **] [**Location (un) 620**] with chief complaint of ruq pain, fever, and hypotension. Patient was at passover [**Last Name (un) **] started c/o RUQ pain starting at noon, very minor per the patient. It did not radiate and was constant. By report CXR at [**Location (un) **] showed ?free air vs bowel. Follow-up CT was initially thought to be free air, however turned out to be bowel. On CT scan pericardial effusion was noted. Given the innability to get a RUQ u/s at [**Location (un) 620**] the patient was was given zosyn and flagyl at [**Location (un) 620**] and transfered to [**Hospital1 18**] for RUQ U/S. . He denies DOE, CP, SOB, objective chills or rigors, or sick contacts. . In the ED, initial vs were 100.2 60 89/50 20 97% 2L NC. A bedside ultrasound showed no RV collapse, patient couldn't participate in a pulsus. Most recent vitals 57 104/47 on levofed, 15 98% RA RIJ. Cardiology was called but not consulted. . On the floor, he states he is comfortable. . 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: Hearing impaired chronic 1st degree HB HOCM recurrent Afib/Aflutter, s/p DCCV [**2120-1-24**], DCCV [**2121-8-8**] bradycardia elevated PSA HTN hyperlipidemia M.R. Social History: [**Company 2318**] employee, non-smoker, non-drinker Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION PHYSICAL: General: non-verbal, A+O x3 through interpreter HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP unassessable [**1-11**] CVL Lungs: bibasilar crackles CV: distant faint SEM Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Large errythematous rash over Left knee, multiple sites of skin breakdown. . DISCHARGE PHYSICAL: VS: T98.4 BP100/54 (100-121/54-70) HR78 (76-102) RR 18 O2sat98% on RA General: well appearing elderly man in NAD, non verbal HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no cervical, submandibular or supraclavicular LAD Lungs: LLL with crackles CV: irregularly irregular, SEM, no rubs or gallops; Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ LE edema b/l; [**Male First Name (un) **] stockings on; WWP Skin: Erythematous purpuric rash over left knee Pertinent Results: ADMISSION LABS: [**2130-3-28**] 01:30AM WBC-12.4* RBC-3.35*# HGB-10.8*# HCT-30.8* MCV-92 MCH-32.3* MCHC-35.1* RDW-14.2 [**2130-3-28**] 01:30AM NEUTS-90.0* LYMPHS-6.2* MONOS-2.6 EOS-1.1 BASOS-0.3 [**2130-3-28**] 01:30AM PLT COUNT-179 [**2130-3-28**] 01:30AM PT-25.9* PTT-37.9* INR(PT)-2.5* [**2130-3-28**] 01:35AM GLUCOSE-103 LACTATE-1.7 NA+-136 K+-3.5 CL--105 TCO2-22 [**2130-3-28**] 01:35AM freeCa-1.05* [**2130-3-28**] 01:30AM UREA N-22* CREAT-0.9 [**2130-3-28**] 01:30AM ALT(SGPT)-26 AST(SGOT)-35 ALK PHOS-87 TOT BILI-0.9 [**2130-3-28**] 01:30AM LIPASE-23 [**2130-3-28**] 01:30AM cTropnT-<0.01 [**2130-3-28**] 05:28AM WBC-17.5* RBC-3.65* HGB-11.5* HCT-33.7* MCV-92 MCH-31.4 MCHC-34.0 RDW-14.3 [**2130-3-28**] 05:28AM PLT COUNT-231 [**2130-3-28**] 05:28AM BLOOD TSH-3.2 [**2130-3-28**] 05:28AM BLOOD PSA-15.2* [**2130-3-28**] 02:45AM URINE COLOR-AMBER APPEAR-Clear SP [**Last Name (un) 155**]->1.050* [**2130-3-28**] 02:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG [**2130-3-28**] 02:45AM URINE RBC-34* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [**2130-3-28**] 02:45AM URINE HYALINE-4* . DISCHARGE LABS: [**2130-3-31**] 06:55AM BLOOD WBC-8.1 RBC-3.85* Hgb-12.1* Hct-35.4* MCV-92 MCH-31.5 MCHC-34.2 RDW-14.3 Plt Ct-225 [**2130-3-31**] 06:55AM BLOOD Glucose-80 UreaN-13 Creat-0.7 Na-141 K-3.3 Cl-107 HCO3-25 AnGap-12 [**2130-3-31**] 06:55AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9 [**2130-3-29**] 02:59AM BLOOD calTIBC-164* VitB12-690 Folate-9.7 Ferritn-700* TRF-126* . MICRO: BCX [**2130-3-28**]: PENDING UCX [**2130-3-28**]: No Growth . STUDIES: [**3-27**] CT Abd/Pelvis ([**Hospital1 **] [**Location (un) 620**]): 1. LARGE PERICARDIAL EFFUSION. AN ECHOCARDIOGRAM IS RECOMMENDED TO EVALUATE FOR TAMPONADE PHYSIOLOGY. 2. TINY LAYERING STONES/SLUDGE WITHIN A NONDISTENDED GALLBLADDER. 3. LIVER HYPODENSITIES WHICH [**Month (only) **] REPRESENT CYSTS OR HEMANGIOMAS HOWEVER WHICH ARE NOT FURTHER CHARACTERIZED. MRI CAN BE CONSIDERED FOR FURTHER CHARACTERIZATION. 4. LEFT LOWER LOBE OPACITY REPRESENTING ASPIRATION/INFECTION VERSUS ATELECTASIS. 5. ENLARGED PELVIC AND PROMINENT RETROPERITONEAL LYMPH NODES. FURTHER EVALUATION IS WARRANTED AS THESE HAVE ENLARGED COMPARED WITH THE PRIOR EXAMINATION AND COULD SIGNIFY AN UNDERLYING MALIGNANCY. RECOMMEND CORRELATION WITH PSA AND CONSIDERATION TO ADDITIONAL IMAGING INCLUDING PET CT SCAN. 6. RIGHT INGUINAL HERNIA PARTIALLY CONTAINING THE ANTERIOR BLADDER WALL. 7. MARKEDLY ENLARGED PROSTATE GLAND. 8. BLADDER CALCULUS. 9. SPLENOMEGALY. . TTE [**2130-3-28**]: Conclusions The left atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Mild to moderate ([**12-11**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The pericardial effusion appears circumferential and is largely small (with a moderate sized lateral portion). There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. . CXR [**2130-3-28**]: IMPRESSION: 1. Right internal jugular line in mid-to-distal SVC. 2. Markedly enlarged cardiac silhouette, secondary to underlying pericardial effusion. . RUQ U/S [**2130-3-28**]: IMPRESSION: Cholelithiasis, without acute cholecystitis. . CT CHEST [**2130-3-19**]: IMPRESSION: 1. Severe cardiomegaly and moderately large pericardial effusion suggest tamponade physiology. 2. Severe bronchial wall thickening and mucoid impaction bilaterally indicates small airways disease. 2. Generalized ground-glass opacity, small bilateral pleural effusions, and interstitial thickening consistent with mild pulmonary edema. Brief Hospital Course: HOSPITAL COURSE: Pt is an 81M with PMH of HOCM, atrial fibrillation on Coumadin, who was transfered here from [**Location (un) 620**] for RUQ u/s in the setting of RUQ pain, fever, and hypotension. Pt was admitted to the MICU for closer monitoring given hypotension and concern for tamponade. He was placed on broad spectrum antibiotics and required brief pressors. Pressors were quickly weaned off. Pt's abdominal pain resolved after bowel movement. Pt defervesced and broad spectrum antibiotics were discontinued in favor of Levofloxacin for CAP given mucoid impaction on CT chest. He was transferred to the medicine floors where his condition continued to improve with a bowel regimen. Antibiotics were discontinued as pneumonia was felt clinically unlikely. . # Fever/Hypotension: DDx included sepsis vs. tamponade. Pt was thought to have a large pericardial effusion on CT scan. However, given pulsus of 4, this was thought to be unlikely- subsequent echo confirmed a small effusion. Given fevers there was concern for sepsis with possible sources including cholecystitis given RUQ pain, PNA, or UTI. On presentation, pt had no RUQ and abdominal discomfort overall improved after a bowel movement. RUQ demonstrated cholelithiasis but not cholecystitis. UA was clean. CAP possible though initial CXR did not show consolidation. He was placed initially on broad spectrum antibiotics. A CT chest showed mucoid impaction, and pt was switched on HOD#2 to Levofloxacin for planned 7 day course for CAP. This was discontinued after two doses as the patient clinically did not have signs of pneumonia and was doing well. Given low and then normal blood pressures, verapamil was held during this hospitalization and pt was discharged off of it. . # Pericardial effusion: Most likely chronic given asymptomatic and pulsus of only 4. Differential for etiology is broad. There was concern for malignancy given LAD on imaging. TTE was done which showed no evidence of tamponade physiology. Per cardiology, recommended follow-up in [**2-10**] weeks. TSH was checked and was normal. [**Hospital1 **] pulsus were checked in the ICU and remained <10. Pt should have further workup for evaluation of LAD. # RUQ pain: Suspect gas/constipation vs. less likely intermittent gallstone obstructions. RUQ pain resolved after large bowel movement. As above, no evidence of cholecystitis on u/s. No other obvious pathology on CT abdomen. Pt was treated with bowel regimen and symptoms improved. . # Pelvic/RP LAD: Unclear etiology, concern for malignancy. Patient also with report of recent 20 lb weight loss. No clear source on CT Chest or Abd/Pelvis. Last colon [**2130-2-3**]- evidence of internal hemorrhoids but otherwise normal. PSA is at baseline since [**2119**] per OMR; prostate biopsies in [**5-11**] were negative for malignancy. Given splenomegaly, concern for lymphoma. LDH was within normal limits. Outpatient PET scan was arranged for patient. He will need further follow up with his PCP. . # Anemia- Normocytic and new since [**2126**]. No obvious signs of bleeding. Normal [**Last Name (un) **] in [**2130-1-10**]. DDx fe deficiency vs. chronic disease (?malignancy) vs. B12/folate (less likely). B12 and folate wnl. Iron studies suggestive of anemia of chronic disease. Hematocrit trended and remained stable during this hospitalization. . # Rash: Erythematous macular, non-blanching rash over left knee of [**1-12**] month duration. Unclear etiology. Dermatology was consulted, and thought most likely purpuric rash [**1-11**] to trauma. Rash improved over course of hospitalization. Derm also recommended Amlactin cream for venous stasis rash b/l. Patient was discharged on this medication. . INACTIVE ISSUES: . # BPH: Continued finasteride. Given pericardial effusion, and concern for possible malignancy, PSA was checked and was 15.1, similar to prior values since [**2119**]. Pt should follow-up with PCP for further management. . # HOCM: Home atenolol and verapamil were held initially given concern for Sepsis. He was continued on home dose of statin. Once BP normalized, pt was started on metoprolol for titration of BP meds and rate control for afib as below. He was discharged back on his home atenolol. . # AFIB: Rate controlled on admission. He was continued on coumadin with daily PT/INR checked given antibiotics. As above, CCB and atenolol initially held given concern for sepsis. Metoprolol was started in the ICU after BP's normalized for improved titration. He was discharged back on his home atenolol. . TRANSITIONAL CARE: 1. CODE: FULL 2. HCP: [**Name (NI) **] [**Name (NI) 12982**] [**Telephone/Fax (1) 104092**] 3. FOLLOW-UP REQUIRED: CT ABD/Pelvis at [**Location (un) 620**]: A) LIVER HYPODENSITIES WHICH [**Month (only) **] REPRESENT CYSTS OR HEMANGIOMAS HOWEVER WHICH ARE NOT FURTHER CHARACTERIZED. MRI CAN BE CONSIDERED FOR FURTHER CHARACTERIZATION. B). ENLARGED PELVIC AND PROMINENT RETROPERITONEAL LYMPH NODES. FURTHER EVALUATION IS WARRANTED AS THESE HAVE ENLARGED COMPARED WITH THE PRIOR EXAMINATION AND COULD SIGNIFY AN UNDERLYING MALIGNANCY. RECOMMEND CORRELATION WITH PSA AND CONSIDERATION TO ADDITIONAL IMAGING INCLUDING PET CT SCAN. 4. PENDING ON DISCHARGE: [**3-28**] Blood Cultures x2- Pending (NGTD) Medications on Admission: ATENOLOL - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]) - 25 mg Tablet - one Tablet(s) by mouth once daily FINASTERIDE [PROSCAR] - (Prescribed by Other Provider) - 5 mg Tablet - one Tablet(s) by mouth once daily SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth once daily VERAPAMIL - (Prescribed by Other Provider) - 240 mg Cap,24 hr Sust Release Pellets - 1 Cap(s) by mouth once a day WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - one Tablet(s) by mouth once daily . Medications - OTC ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - one Capsule(s) by mouth once daily VITAMIN E - (Prescribed by Other Provider) - 400 unit Capsule - one Capsule(s) by mouth once daily Discharge Medications: 1. psyllium Packet Sig: One (1) Packet PO DAILY (Daily). Disp:*30 Packet(s)* Refills:*2* 2. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. sennosides 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*30 Tablet(s)* Refills:*0* 7. ammonium lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Please apply to the rash on your legs. Disp:*1 bottle* Refills:*1* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Abdominal Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 12982**], You were admitted to the hospital with abdominal pain. Because of your low blood pressure you were admitted to the intensive care unit and then transferred to the general medical [**Hospital1 **] when you were doing better. We believe this pain may have been related to constipation. Your CT scan of your abdomen showed enlarged lymph nodes- this will need to be evaluated further with a PET scan, which we have scheduled for you (see below). We have made the following changes to your medications: - STOP taking verapamil for your blood pressure- your blood pressure was low and then normal during your hospitalization - START taking psyillium for your bowel movements - START taking colace and senna as needed for constipation - START using AmLactin lotion for the rash on your calves It was a pleasure taking care of you. We wish you a speedy recovery. Followup Instructions: You have a PET scan scheduled for [**Last Name (LF) 2974**], [**4-14**] at 8:45 in the morning. This is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. You will need to drink a bottle of the Clear Scan Prep the night before the PET scan. The PET scan people will be sending you more information regarding the special diet that you will have to follow for dinner the night before your PET scan, and when to drink the Clear Scan prep. . Primary Care Doctor Appointment: Name: [**Last Name (LF) **],[**First Name3 (LF) **] D. Address: [**Location (un) **], [**Apartment Address(1) 8308**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 37171**] When: Thursday, [**4-6**], 1PM Completed by:[**2130-4-1**]

Admission Date: [**2180-3-8**] Discharge Date: [**2180-3-13**] Date of Birth: [**2124-4-1**] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 16920**] Chief Complaint: right breast cancer Major Surgical or Invasive Procedure: right [**Last Name (un) 5884**] flap reconstruction on [**2180-3-8**] History of Present Illness: Ms. [**Known lastname 52157**] is a 55-year-old Caucasian female who presented preoperatively in consultation for right breast reconstruction. The patient underwent right mastectomy in [**2174**] for lobular breast cancer, but deferred reconstruction at that time. She now desires reconstruction and prefers using autologous tissue in the [**Last Name (un) 5884**] flap technique. Past Medical History: right breast cancer hypothyroidism Social History: non-contributory Family History: non-contributory Physical Exam: AVSS NAD CTA b/l RRR w/ S1S2 abodmen soft, NT/ND previous right breast surgery evident with scar extremeties warm and well-perfused A + O x 3 Pertinent Results: [**2180-3-9**] 03:26AM BLOOD Calcium-8.4 Phos-4.6* Mg-1.4* [**2180-3-9**] 03:26AM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-138 K-3.9 Cl-106 HCO3-29 AnGap-7* [**2180-3-9**] 03:26AM BLOOD Plt Ct-206 [**2180-3-9**] 03:26AM BLOOD WBC-13.3*# RBC-2.99* Hgb-9.4* Hct-26.9* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.2 Plt Ct-206 [**2180-3-9**] 04:03PM BLOOD Hct-27.1* [**2180-3-10**] 04:29AM BLOOD Calcium-7.9* Phos-2.5*# Mg-1.6 [**2180-3-10**] 04:29AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-138 K-3.4 Cl-100 HCO3-34* AnGap-7* [**2180-3-10**] 04:29AM BLOOD Plt Ct-187 [**2180-3-10**] 04:29AM BLOOD WBC-9.5 RBC-2.78* Hgb-8.7* Hct-25.4* MCV-91 MCH-31.3 MCHC-34.3 RDW-13.2 Plt Ct-187 Brief Hospital Course: Ms. [**Known lastname 52157**] was admitted on [**2180-3-8**] and taken to the operating room for a right [**Last Name (un) 5884**] flap reconstruction. She tolerated the procedure well with only 150 mL of estimated blood loss. She was sent to the ICU after the procedure where she underwent frequent flap checks that revealed good doppler pulses consistently. The right aspect of the flap appeared to be somewhat congested the following morning and she was treated with leech therapy to reduce this congestion. The right aspect of her flap remained somewhat eccymotic but continued to be warm with good doppler signals. We removed her foley on POD 2 and she was able to void. She tolerated a regular diet and ambulated appropriately. She was discharged home in good condition with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 19843**] checks and dressing changes on POD 5. Medications on Admission: Levothyroxine Sodium 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). Disp:*45 Tablet, Chewable(s)* Refills:*2* 3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for spasm. Disp:*20 Tablet(s)* Refills:*0* 4. Levothyroxine Sodium 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: While taking pain medications. Disp:*60 Capsule(s)* Refills:*2* 7. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 10 days. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: s/p right [**Last Name (un) 5884**] flap reconstruction on [**2180-3-8**] right acquired breast deformity Right breast cancer Discharge Condition: Good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Take a shower immediately before dressing changes by the visiting nurse. Followup Instructions: In one week with Dr. [**First Name (STitle) 3228**]. Please call for appointment ([**Telephone/Fax (1) 98529**].

Admission Date: [**2147-3-14**] Discharge Date: [**2147-4-4**] Date of Birth: [**2091-10-7**] Sex: M Service: MEDICINE Allergies: Mycophenolate Mofetil Attending:[**First Name3 (LF) 1377**] Chief Complaint: fever, abdominal pain, diarrhea, anorexia Major Surgical or Invasive Procedure: EGD History of Present Illness: 55 male who is 9 months and 26days s/p a liver [**First Name3 (LF) **] for HCV/HCC, with mild acute rejection and recurrent HCV infection on ribavirin and interferon, who is presenting with fever and increasing nausea/emesis/diarrhea/malaise. Since discharge on [**2-9**] patient has had intermittent nausea and vomiting, the last a couple of days ago. Has had decreased PO intake d/t nausea and feeling unwell. Also with loose stills since discharge that he though was getting better but have now returned more recently, stooling 5-6 times per day, no melena or hematochezia. Increasing lethargy over the last couple of weeks. Developed a sore throat a couple of weeks ago as well in joint discomfort that has progressed now to frank swelling of feet, ankles, and hands. He relates pain/myalgias in feet, ankles, calves, ant shin, knees, hands, wrists, elbows, shoulders, forearm. Developed a fever to 102.5 over last coupe of days. No sick contacts, recent travel, abnormal foods, lives alone. No dysuria, cough. Abdominal pain slightly increased from his chronic baseline level. +HA but no neck stiffness, photophobia, vision changes. . ED course: Presenting vital signs were T 98.5 HR 125 BP 116/88 RR 16 Sat 98% RA. Labs showed a mild increase in his transaminitis, as well as a leukocytosis. Ceftriaxone 1gm, vancomycin 1gm, morphine 4mg iv x2, tylenol 1gm, oxycodone 10mg po. HR 137 when febrile to 101, HR fell to 125 with 3L NS. Blood and urine cultures were sent. UOP in ED 700cc. Past Medical History: # Hepatitis C/alcoholic cirrhosis, c/b hepatocellular carcinoma -dx [**2144-4-26**] -HCC s/p radiofrequency ablation [**2143**] -s/p liver [**Year (4 digits) **] [**2146-5-18**] with hep B core AB + liver, received HBIG and on daily lamivudine, last HBV viral load not detected [**10-3**]) -On [**9-15**] he had a liver biopsy per 3 month protocol that showed early recurrent HCV and mild acute rejection - tacrolimus increased and 500mg x 3doses of steroids -Repeat bx [**10-3**] with fibrosing cholestatic hepatitis - - started INF [**2146-10-12**], procrit [**10-3**], ribavirin [**2146-10-27**] for hepatitis C -On Save the Nephron study since [**6-3**] Viral hepatitis C - [**2147-3-9**] HCV viral load 5,750,000 (up from 3,150,000 in [**11-3**]) # Hypertension # GERD # Cholecystistitis and cholelithiasis s/p laprascopic cholecystectomy [**2145-2-10**] # Hx polysubstance abuse # Alcohol use # post [**Month/Day/Year **] DM and hypertension Social History: Pt lives alone in [**Location (un) 61729**], [**State 1727**], able to take care of his ADLs. Monogamous sexual relationship with his partner, uses [**Name2 (NI) 61730**] contraceptives. Last HIV test in [**2144-4-26**] negative, partner status unknown. Denies EtOH use, last drink was in [**Month (only) 116**] [**2143**]. Prior to that did have heavy ETOH. Denies current IVDU, states he used heroin, barbiturates, cocaine in 70s,80s, 90s. Denies current tobacco use, quit 15 years ago. Family History: NC Physical Exam: Vs- 101.1 (101.8), 113/84, 138(127-138) 20, 93%RA Gen- Ill appearing, in pain Heent- OP clear but mmm dry, PERRL, anicteric, wick in place of ear Neck- Supple, JVP flat Cor- [**Last Name (un) **] but regular rhythm, no m/r/g Chest- Crackles at bases bilaterally Abd- TTP in RLQ, mild in RUQ Ext- Joint swelling in hands with erythema, dorsal aspect of feet swollen, nonpitting, mildly erythematou, trace ankle edema, significant TTP in feet, ankles, calves and anterior shins bilaterally, no knee swelling or effusions, hip without TTP bilaterally, 1+ PE B UE/LE, no rash other than erythema in feet and hands Neuro- A&Ox3, 5/5 strength B UE/LE, 2+ DTR's patellar Skin- Multiple tatoos, scattered ecchymosis Pertinent Results: ct abd/pel [**3-15**] IMPRESSION: 1. No evidence of hepatic or intra-abdominal abscess. 2. New bilateral lower lobe consolidation in addition to previous atelectasis. 3. No change in adrenal and renal lesions. Bilateral nonobstructing renal calculi. 4. Expected appearance of liver post [**Month/Year (2) **]. [**3-16**] tte The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. [**3-20**] renal u/s IMPRESSION: 1. Nonobstructing renal calculi in the right kidney. Comparison to the [**2147-3-15**] CT, there are multiple bilateral nonobstructing renal calculi which were not visualized in this examination. 2. Splenomegaly [**3-24**] u/s GRAYSCALE AND DOPPLER ULTRASOUND OF THE LIVER: Comparison is made to the prior ultrasound dated [**2147-3-14**]. The liver is normal in echogenicity without evidence of focal lesion or intra- or extra-hepatic ductal dilatation. Portal veins, hepatic veins, and hepatic arteries are patent with appropriate waveforms. Spleen measures 16 cm. There is new right pleural effusion. IMPRESSION: Patent vessels with appropriate waveforms. Splenomegaly. New right pleural effusion. ------------------ [**3-29**] cxr IMPRESSION: 1. New right lower lobe opacification, suspicious for pneumonia in the appropriate clinical setting. Adjacent small right pleural effusion. 2. Resolving linear left basilar opacities ------------------- [**3-30**] abd u/s GRAYSCALE AND DOPPLER ULTRASOUND OF THE TRANSPLANTED LIVER: Comparison was made to the ultrasound dated [**2147-3-24**] and CT scan dated [**2147-3-15**]. There is no focal liver lesion in the transplanted liver. There is no intra- or extra-hepatic ductal dilatation. Portal vein is widely patent. There is a ring-like echogenic structure at the portal vein anastomosis. There is an anechoic tubular two-compartmental structure, which initially appeared to be bile duct, however, further scanning revealed it to be fluid accumulating along the porta hepatis at real- time scanning. Normal waveforms are seen in main portal vein, main and left hepatic arteries and three hepatic veins. There is a small amount of right pleural effusion. IMPRESSION: No intra- or extra-hepatic ductal dilatation in the transplanted liver. Tubular [**Hospital1 **]-lobed fluid tracking along the porta hepatis. Small right pleural effusion. Patent portal veins. Brief Hospital Course: 55 yo man with hx EtOH/HCV cirrhosis s/p OLT in [**5-3**], CMV donor +, recipient -, now admitted with abdominal pain, fever, myalgias, headache, cough and found to have CMV viremia with evidence of liver involvement course complicated by recurrent HCV seen on biopsy, multifactorial acute renal failure, microabscesses on biopsy concerning for ascending cholangitis. . # CMV Viremia Original CMV VL [**3-15**] 95,800 at that time started on oral valganciclovir, biopsy results on [**3-17**] confirmed liver involvement and he was switched to IV ganciclovir and completed a 2 week course. His CMV VL decreased to <600 copies on [**3-29**]. He will need to complete 6 months of oral valganciclovir 450mg daily for likely 6 months, follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] was scheduled for patient. Of note he had a negative opthalmologic examination for retinitis done by opthalmologist. . # Transplanted liver Biopsy shows trichrome stain demonstrates increased portal fibrosis with septa formation and foci of early bridging fibrosis (Stage 2-3). Additionally, marked centrivenular fibrosis without luminal occlusion is seen, indicative of a component of chronic venous outflow obstruction. Moderate portal and lobular mixed inflammation consisting of mononuclear cells and focally prominent neutrophils (some in association with bile ducts), with microabscess formation and foci of extensive hemorrhagic necrosis, predominantly involving zone 3. Scattered viral inclusions morphologically consistent with cytomegalovirus are identified within hepatocytes and rare bile ductular epithelial cells (confirmed by immunostain for CMV, with satisfactory controls). Recurrent viral hepatitis C, difficult to grade in this sample. Diagnostic features of acute cellular rejection are not identified. Biliary findings are also likely a result of the CMV and/or cytokine-mediated, but a concomitant bacterial infection, sepsis, a drug effect or biliary obstruction remain within the histopathologic differential. Given rising alkaline phosphatase concern for cholestatic fibrosis was high, he may need repeat liver biopsy in the near future given his stage 2-3 fibrosis this early into his transplantation. His Bactrim prophylaxis was switched to Dapone given his renal dysfunction, G6PD level was normal. . # Acute kidney injury Multifactorial etiology in this patient with a baseline 1-1.2, he had component of cryoglobulinemia given positive cryos on [**3-15**] and [**3-27**] with 3 an 2 percent crycrit respectively. He was started back on interferon and ribavirin on [**3-25**], ribavirin was subsequently held given rise in creatinine. His urine did not reveal proteinuria and had nonspecific granular casts. Tacrolimus nephrotoxicity was considered and his goal was reduced to [**5-3**]. His creatinine peaked at 2.1 and decreased, at discharge his creatinine was... Of note he did receive fluid challenges with no improvement in renal function given that his PO intake was poor. His Bactrim was switched to Dapone given his renal dysfunction, G6PD level was normal. . # Superimposed bacterial infection Had recurrent fevers while on treatment for CMV, biopsy revealed microabscesses concerning for ascending cholangitis. Patient is to complete 3 week course of levaquin and flagyl on [**4-6**], he did not spike any fevers while on this regimen. initially was on vancomycin for possible pneumonia, susbsequent radiograph was unrevealing. Patient had recurrent headache for which he had a negative lumbar puncture, all other cultures were negative. . # Normocytic anemia Multifactorial due to chronic disease, likely small oozing from CMV colitis (not biopsied or colonoscopy), had EGD showing gastric erosion consistent with gastritis, no CMV. On multiple myelosuppressive medications. He was transfused for hematocrit<21. Hematology reviewed smear and was not concerning for TTP. He is on Epogen during his HCV treatment. . # Inflammatory arthritis Seen by rheumatology who tapped his swollen right knee, there was no evidence of infection and the fluid was inflammatory. This was attributed to cryoglobulinemia and his myalgias and arthralgias resolved throughout his hospital course. . # Hypertension His metoprolol was increased to 75mg [**Hospital1 **] with good effect. . # Communication: Daughter (HCP): [**Name (NI) 2808**] [**Name (NI) **] [**Telephone/Fax (1) 61731**]. Medications on Admission: Lamivudine 100 mg daily Pantoprazole 40 mg daily - not taking Bactrim single strength CellCept 1 gram [**Hospital1 **] Insulin on a sliding scale (occ) Metoprolol 50 mg twice a day. Klonopin 0.5 mg as needed. Pegylated interferon alpha-2a 180 mcg subcutaneously weekly (fridays) - patient has not taken this recently, unclear for how long Filgrastim 300 mcg subcutaneously weekly - not taking recently Gabapentin 300 mg twice a day. Iron 150 mg twice a day. Epogen 40,000 units subcutaneously weekly - not taking recently Prograf 3 mg twice a day. Ribavirin 200mg [**Hospital1 **] Percocet seven and a half pills as needed for pain - per pt, but not on Dr.[**Name (NI) 948**] med list Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 7. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO TWICE DAILY (). 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 9. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 11. Peginterferon Alfa-2a 180 mcg/mL Solution Sig: One (1) Subcutaneous 1X/WEEK (SA). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 15. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 16. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 17. Outpatient Lab Work Please check cbc, chem-10, AST, ALT, Total bilirubin, LDH, INR, PT and have results faxed to Dr. [**Last Name (STitle) 497**] at ([**Telephone/Fax (1) 3618**]. These labs should be checked on Monday [**4-10**]. 18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: OLT Disseminated CMV Microabscesses in liver HCV Acute kidney injury Normocytic anemia Hypertension Discharge Condition: Stable VSS Discharge Instructions: You were admitted and found to have an extensive CMV infection in your liver as well as recurrent hepatitis C. You also had renal failure and your kidney function on discharge was still elevated. You will need to take your medications EXACTLY as you are instructed to do so. This is really important given your [**Month (only) **] is in danger. You have been scheduled appointments with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**] of infectious diseases. Take all of your medications as indicated and inform the [**Last Name (STitle) **] clinic if you have any issues obtaining your medications. If you develop any fever>101.5, abdominal pain, bleeding or any worrisome symptoms call the [**Last Name (STitle) **] clinic or present to the emeregency room. Followup Instructions: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2147-4-9**] 3:15 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-4-19**] 10:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-4-25**] 10:30 You will be contact[**Name (NI) **] by Dr.[**Name (NI) 948**] office to set up an additional appointment. If you are not you should call them by the end of this week. You should also have your labs checked on friday to make sure your blood cell counts and kidney function are stable. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]